Ausr NZ J Obsret Gynaecol 1991: 31: 4: 378
Nipple Pain, Mastalgia and Candidiasis in the Lactating Breast Lisa H. Amir, MBBS and Shyrla Pakula, MBBS Family Planning Association, Richmond, Victoria EDITORIAL COMMENT: Weaccepted thispaperforpublication because we thought it would interest readers and probably help their patients. The authors did not obtain confirmatory evidence of infection with Candida in Case 2 which is a pity, especially as the condition did not respond mpidly to nystatin and gentian violet. The editorial committee does not endorse the comments regamling the usefulness of dietary measures in the control of candidiasis. We would be interested to publish a study of a larger series of lactating women with these symptoms, with bacteriologicaldiagnosis, and treatment by a single antifingal agent if C albicans is isolated. Since the patients took so long to respond to treatment, it could be that an orally active antiyungal agent would achieve a superior therapeutic result. Author's response: It may well be that an omlly active antifungal agent would achieve a superior thempeutic result, but the only such agent available in Awtmlia at present is ketoconazole which is excreted in breast milk and is not recommended for use in lactating mothers. It is also contraindicated in pregnancy because it is temtogenic. and use in children is not recommended according to the manufacturers, as stated in MIMS 1991. Thus, we are limited to using nystatin as an oral agent in mothers or infants. or miconazole gel as a topical treatment for oral candidiasis in the infant; nystatin is not absorbed into the blood stream or excreted in breast milk, and the status of miconazole in relation to lactation is not understood, although it is considered safe wen for newborn infants. There is also some difficulty in avoiding use of gentian violet as a topical nipple treatment in nipple thrush because we have experienced some degree of sensitivit-vto nystatin, miconazole and clotrimazolecreams or ointments, probably due to the vehicle rather than the thempeutic agent. This is why we have decided to sta-v with gentian violet, fully aware of the animal studies which suggest it to be carinogenic in mice; W P have not found any allergic reactions in over 300 users. Thus, a studv in which onlv one antifungalagent was used might be difficultto xt un since application of some antifungal substance to the nipple seems necessary to clear symptom. We think that we are dealing with a condition which usually dweloi>.sover a period of seveml weeks, and which may need a similar time to wsolve.
Summary: During lactation, persistently sore nipples or shooting breast pain in the absence of local or systemic signs may be symptoms of C alhicarrs infection of the nipples and/or breast ducts. The nipple may be erythematous or fissurcd. but the appearance does not resemble oral or vaginal candidiasis. Case I is a woman with sore nipples following a course of antibiotics. Case 2 is a woman with severe shooting breast pain which was worsened by antibiotic treatment. Treatment included topical and oral antifungal treatment for the mother in conjunction with an 'anti-candida' diet. The infant's mouth was also treated to prevent reinfection. It is well-recognized that infection with Candida albicansis a very common problem in the child-bearing years. Candidal vulvovaginitis in the pregnant woman and oral thrush in the infant are easily diagnosed. What is not widely known is that the lactating breast and nipple are also common sites for candidal infection, Address for correspondence: Dr.S. Pakula. 178 Orrong Road, Caulfield, Victoria, 3161.
often presenting as sore nipples with or without severe breast pain, with few clinical signs (I). Calbicans is a normal part of the saprophytic microflora of the healthy gut and behaves as an opportunistic pathogen. Generally, infections by candida cpccies d o not arise unless the host is debilitated o r damagcd in some way, or lies within the extreme o f a phyciological norm, such as the state of being newly-horn or pregnant (2). Candidiasis is a condition where the 'soil' niuct he suitable in order for the opportunistic 'seed' to flourish.
LISAH . A M I R AND SHYRLA PAKULA
The mother-infant dyad is highly susceptible to infection by C albieans. In addition to the physiological factors, mechanical and iatrogenic factors are common. Nipples may be damaged at the initiation of lactation if the importance of correct positioning and latchingon are not appreciated; nursing pads and bras may serve to further damage the nipples by local occlusion and maceration; antibiotics are widely prescribed for women postpartum for mastitis, urinary tract and vaginal infect ions. Following are 2 case reports, the first showing that candidiasis can be a cause of nipple pain, the second showing it as a cause of breast pain. Case I: Sore nipples A 25-year-old woman presented with sore nipples when her baby was 4 months old. She had had an uneventful pregnancy followed by normal vaginal delivery at term. At 3 months postpartum she developed a painful red area on the right breast and her local doctor diagnosed mastitis for which he prescribed penicillin and cessation of breastfeeding. She was reluctant to wean as the baby was thriving and they were both enjoying the nursing relationship. While she was taking the antibiotics, the baby developed thrush in its mouth and on the skin of the nappy area. Nystatin oral drops were prescribed for the oral thrush and clotrirnazole cream for the mother’s nipples. The signs of thrush resolved. Her past history included an episode of vaginal thrush prior to her pregnancy. Two weeks later, her left nipple became tender and developed a crack which persisted for 2 weeks before she presented; the nipple was tender to touch and very painful while feeding. There was no breast pain. On examination, there was a fissure on the upper outer region of the left areola, and a dry, flaky area on the same region of the right areola. The baby had no sign of thrush. A swab was taken and cultured on Sabouraud dextrose agar medium. Subsequently, C albieans was isolated, but the results were not available for some days. The initial diagnosis was nipple trauma and general treatment measures were commenced. This included the use of hindmilk on the nipples after feeding, varying the position of the baby at the breast, and using breast she& to dlow circulation of air around the nipples. The patient was happy to try these measures and review the situation in a few days’ time. She phoned 2 days later to say that the local Maternal and Child Health nursehad found thrush in the baby’s mouth. The baby had earlier been diagnosed as having otitis media by the local doctor and had been commenced on acourse of cotrimoxazole When the mother was reviewed 7 days after initial consultation, she complained that the nipples were itchy as well as more painful. On examination, both nipples were erythematous. A clinical diagnosis of candidiasis of the nipple was made. Management was miconazole oral gel on the nipples and in the baby’s mouth 4 times daily; nystatin, 2 tablets 3 times daily and an anti-candida diet which
319
restricted refined carbohydrates, yeastcontaining foods and yeast products, including alcohol (4). Clinically, there was little change noted in the following week, during which the baby continued its course of antibiotics. The next week, the nipples were not so painful, and on examination were only mildly erythematous. Improvement continued gradually, and breast feeding was not interrupted. Nystatin tablets were withdrawn over a period of 2 weeks once the nipple pain resolved. Case 2: Mastalgia and nipple sowness
A 34-year-old woman presented complaining of ongoing problems with sore nipples and severe, burning breast pain which occurred after a feeding and lasted for at least 10 minutes. She had a past history of repeated antibiotic use for recurrent tonsillitis and recurrent urinary tract infections. At age 20 she had a foot injury for which she was prescribed 6 weeks of an oral corticosteroid. At the time of the initial presentation she was the mother of a 4-year-old son whom she had breastfed for 11 months with no problems, and a 4-month old baby. She had suffered 2 miscarriages in between. She had consumed a diet high in refined carbohydrate during the pregnancy. Delivery was uneventful. Lactation was established and the baby thrived. Over the next 2 months the only problem was nipple soreness which was treated with infra-red lamp, pawpaw ointment, tincture of benzoic compound and exposure to sunlight, with no lasting effect. The breast pain started 9 weeks postpartum. She was diagnosed as having mastitis and was prescribed amoxycillin. Soon after beginning the course, the pain intensified, shooting from medial to lateral aspects in both breasts. The dose of amoxycillin was then doubled after which the pain became unbearable, Flucloxacillin was added, with no improvement. At presentation the nipples were noted to bedry, flaky and tender to very soft touch. The baby showed no clinical evidence of oral or skin candidiasis. Diagnosis of candidiasis of nipple and breast was made and a treatment regimen given, as follows: Nystatin capsules, 2 orally 3 times daily, Lactobacillus acidophilus capsules, 1, 3 times daily, 0.5% aqueous gentian violet applied to nipples twice daily and nystatin drops for the baby, I m14 times daily. An anti-candida diet was also recommended. After the first week of the treatment the nystatin dose was increased to 3 capsules thrice daily because of lack of noticeable improvement. During the next week the nipple and breast pain subsided. After 2 weeks, the burning pain was gone and the patient felt much better in herself. There was still some nipple pain. Nystatin was continued at 2 capsules thrice daily and the number of feedings was reduced to 5 a day. Over the next month symptoms remained tolerable, but cessation of nystatin was followed by recurrence of nipple pain, and likewise gentian violet still had to be used from time to time for the left nipple which would otherwise crack. Two months later she again developed mastitis and was
380
treated with flucloxacillin. The initial symptoms flared again and were brought under control with nystatin. The patient was able to control her symptoms on 1 capsule of nystatin thrice daily and gentian violet applied to the left nipple once a day. Generally she found that the symptoms were aggravated by stress at work or home and dietary indiscretion. She weaned at 11 months.
DISCUSSION When a lactating woman presents with breast or nipple pain, a careful history and examination, including observation of a feeding are required. It is important to ensure that the baby is correctly positioned or ‘fixed’ at the breast, i.e. that the baby’s mouth is correctly juxtaposed to the nipple. The baby should be facing the breast, mouth wide open and lips flanged outwards. The initial placement of lip and gum should be well below the nipple (5). Normal breast feeding should not cause pain or discomfort. Both the nipple pain and the breast pain associated with candidiasis are usually described by the patient in the strongest terms, with words such as ‘agonising’ or ‘excruciating’ often being used. The nipple may look normal, or there may be some erythema, flakiness of nipple or areolar skin, or shininess; there may be some itch. The nipples will be tender to very light touch. Occasionally there is a fissure which may contain creamy exudate, which is candida colonization. There have been several case reports of infection by C ulbicuns of lactating nipples in the literature. The pathway of infection is usually postulated as originating in the mother’s vagina, passing to the infant’s mouth during delivery and then to the mother’s nipple (6). When candidiasis occurs in the older child it is often following the use of antibiotics (7). The potential for candidiasis to interfere with breast feeding has been emphasized in a recent report and the point made that ‘Candidiasis may be a more common but unrecognized infection in the breast feeding mother and infant’ (8). Nipple thrush can be treated topically with 0.5% aqueous gentian violet applied on a cotton bud to the nipples, or miconazole gel. On the nipple, miconazole appears to be better absorbed and more effective than clotrimazole Gentian violet has been an effective treatment for thrush for many years, but recent studies have found that it is a potential animal carcinogen; thus its use is now under review (9). The baby’s mouth should be routinely treated because C ulbicuns can frequently be cultured from the mouths of asymptomatic babies (10). Treatment will thus avoid the ‘ping-pong’ effect, where the untreated infant reinfects the mother (11). Other clinical manifestations of candidiasis must be treated as appropriate. The mother in the second case report described the symptom which is almost pathognomonic of candidiasis in the lactating breast, namely burning pain shooting through the breast (1,12,13). This pain is worse after feedings and may last for minutes or hours; it may wake the patient from sleep. Whatever triggered the original
breast pain, there is little doubt that the pain was aggravated by the antibiotics which were prescribed for wrongly diagnosed ‘mastitis! It must be made clear that not all painful lactating breasts are afflicted by mast itis; the absence of fever and local or systemic signs would certainly make a diagnosis of mastitis questionable. This woman’s past history of repeated antibiotic use in childhood and adolescence plus the short course of oral steroids would render her vulnerable to candidiasis by affecting her flora and her immunity, as mentioned earlier in this article. Her high intake of refined carbohydrate during the pregnancy would also have supplied an excellent substrate for intestinal C ulbicuns. The pathogenesis of the breast pain is unclear. Shooting pain suggests that there is duct involvement; but if the breast pain is caused by candidiasis of the ducts, it is not clear how oral nystatin works to clear it. Nystatin is poorly absorbed into the blood stream and is therefore not secreted in the breast milk at normal doses. One hypothesis is that, in clearing the overgrowth of candida in the bowel, the major reservoir is eliminated, and the general population of the candida declines by a process of attrition. Also contentious is the role of diet and Lacrobmillus ucidophilus in candidiasis. There is empirical evidence which strongly supports the importance of diet in candidiasis (14). There are many stories of pain recurrence or aggravation when the woman indulges in alcohol or refined carbohydrate: often. the patient cravcs sweet foods. The role of L. ucidophilus is less clear. It probably provides replacement flora whcn C ulbicuns is eliminated. Case 2 is an extreme example of a common prohlcm which must be recognized by doctors in ordcr to avoid a great deal of distress in nursing mothers. Thc patient was unable to cease nystatin treatmcnt without a rccurrence of symptoms.
Refemnces I. Lawrence RA. ~reastfccding.a guide lor the medical profewon. 3rd ed. St. I.ouis: C T htoshj C’o, IYWY: 211. 2. Hurlg R. Dc Inurnis J. hlulhall A. Yiipsts a$Human and h t m a l Pathogens. In Row AH and Harriwn JS fed%).The Yeasts, VOI 1. 2nd ed, London: Academic Pms. 1987; p22Y. 3. Odds FC. Candida and Candidasis. A roim and hihlio)rraph> 2nd Ed. London: Raillerc Tindal 1988. p9-4. 4. Turner R. Simonxn E. Candida (’an be katen! Corio. Oidium
Books. 1988. 5. Woolridge MW. Aetiology of sore nipples. Midwifer) 1986; 2: 172-176. 6. Mukherjee SC.Moniliasic Breast: J Indian h k d h s w c IW: 43. II: 536-538. 7. Chetty G N . Sehi G S . Kamalarn A. Thamhiah AS. C‘andtdo\l\ in Molher and Child: Xtyhosen, 198O: 23: 10: 580-!82. 8. Johnstone HA. Marcinak JF.
Nipple Pain, Mastalgia and Candidiasis in the Lactating Breast Lisa H. Amir, MBBS and Shyrla Pakula, MBBS Family Planning Association, Richmond, Victoria EDITORIAL COMMENT: Weaccepted thispaperforpublication because we thought it would interest readers and probably help their patients. The authors did not obtain confirmatory evidence of infection with Candida in Case 2 which is a pity, especially as the condition did not respond mpidly to nystatin and gentian violet. The editorial committee does not endorse the comments regamling the usefulness of dietary measures in the control of candidiasis. We would be interested to publish a study of a larger series of lactating women with these symptoms, with bacteriologicaldiagnosis, and treatment by a single antifingal agent if C albicans is isolated. Since the patients took so long to respond to treatment, it could be that an orally active antiyungal agent would achieve a superior therapeutic result. Author's response: It may well be that an omlly active antifungal agent would achieve a superior thempeutic result, but the only such agent available in Awtmlia at present is ketoconazole which is excreted in breast milk and is not recommended for use in lactating mothers. It is also contraindicated in pregnancy because it is temtogenic. and use in children is not recommended according to the manufacturers, as stated in MIMS 1991. Thus, we are limited to using nystatin as an oral agent in mothers or infants. or miconazole gel as a topical treatment for oral candidiasis in the infant; nystatin is not absorbed into the blood stream or excreted in breast milk, and the status of miconazole in relation to lactation is not understood, although it is considered safe wen for newborn infants. There is also some difficulty in avoiding use of gentian violet as a topical nipple treatment in nipple thrush because we have experienced some degree of sensitivit-vto nystatin, miconazole and clotrimazolecreams or ointments, probably due to the vehicle rather than the thempeutic agent. This is why we have decided to sta-v with gentian violet, fully aware of the animal studies which suggest it to be carinogenic in mice; W P have not found any allergic reactions in over 300 users. Thus, a studv in which onlv one antifungalagent was used might be difficultto xt un since application of some antifungal substance to the nipple seems necessary to clear symptom. We think that we are dealing with a condition which usually dweloi>.sover a period of seveml weeks, and which may need a similar time to wsolve.
Summary: During lactation, persistently sore nipples or shooting breast pain in the absence of local or systemic signs may be symptoms of C alhicarrs infection of the nipples and/or breast ducts. The nipple may be erythematous or fissurcd. but the appearance does not resemble oral or vaginal candidiasis. Case I is a woman with sore nipples following a course of antibiotics. Case 2 is a woman with severe shooting breast pain which was worsened by antibiotic treatment. Treatment included topical and oral antifungal treatment for the mother in conjunction with an 'anti-candida' diet. The infant's mouth was also treated to prevent reinfection. It is well-recognized that infection with Candida albicansis a very common problem in the child-bearing years. Candidal vulvovaginitis in the pregnant woman and oral thrush in the infant are easily diagnosed. What is not widely known is that the lactating breast and nipple are also common sites for candidal infection, Address for correspondence: Dr.S. Pakula. 178 Orrong Road, Caulfield, Victoria, 3161.
often presenting as sore nipples with or without severe breast pain, with few clinical signs (I). Calbicans is a normal part of the saprophytic microflora of the healthy gut and behaves as an opportunistic pathogen. Generally, infections by candida cpccies d o not arise unless the host is debilitated o r damagcd in some way, or lies within the extreme o f a phyciological norm, such as the state of being newly-horn or pregnant (2). Candidiasis is a condition where the 'soil' niuct he suitable in order for the opportunistic 'seed' to flourish.
LISAH . A M I R AND SHYRLA PAKULA
The mother-infant dyad is highly susceptible to infection by C albieans. In addition to the physiological factors, mechanical and iatrogenic factors are common. Nipples may be damaged at the initiation of lactation if the importance of correct positioning and latchingon are not appreciated; nursing pads and bras may serve to further damage the nipples by local occlusion and maceration; antibiotics are widely prescribed for women postpartum for mastitis, urinary tract and vaginal infect ions. Following are 2 case reports, the first showing that candidiasis can be a cause of nipple pain, the second showing it as a cause of breast pain. Case I: Sore nipples A 25-year-old woman presented with sore nipples when her baby was 4 months old. She had had an uneventful pregnancy followed by normal vaginal delivery at term. At 3 months postpartum she developed a painful red area on the right breast and her local doctor diagnosed mastitis for which he prescribed penicillin and cessation of breastfeeding. She was reluctant to wean as the baby was thriving and they were both enjoying the nursing relationship. While she was taking the antibiotics, the baby developed thrush in its mouth and on the skin of the nappy area. Nystatin oral drops were prescribed for the oral thrush and clotrirnazole cream for the mother’s nipples. The signs of thrush resolved. Her past history included an episode of vaginal thrush prior to her pregnancy. Two weeks later, her left nipple became tender and developed a crack which persisted for 2 weeks before she presented; the nipple was tender to touch and very painful while feeding. There was no breast pain. On examination, there was a fissure on the upper outer region of the left areola, and a dry, flaky area on the same region of the right areola. The baby had no sign of thrush. A swab was taken and cultured on Sabouraud dextrose agar medium. Subsequently, C albieans was isolated, but the results were not available for some days. The initial diagnosis was nipple trauma and general treatment measures were commenced. This included the use of hindmilk on the nipples after feeding, varying the position of the baby at the breast, and using breast she& to dlow circulation of air around the nipples. The patient was happy to try these measures and review the situation in a few days’ time. She phoned 2 days later to say that the local Maternal and Child Health nursehad found thrush in the baby’s mouth. The baby had earlier been diagnosed as having otitis media by the local doctor and had been commenced on acourse of cotrimoxazole When the mother was reviewed 7 days after initial consultation, she complained that the nipples were itchy as well as more painful. On examination, both nipples were erythematous. A clinical diagnosis of candidiasis of the nipple was made. Management was miconazole oral gel on the nipples and in the baby’s mouth 4 times daily; nystatin, 2 tablets 3 times daily and an anti-candida diet which
319
restricted refined carbohydrates, yeastcontaining foods and yeast products, including alcohol (4). Clinically, there was little change noted in the following week, during which the baby continued its course of antibiotics. The next week, the nipples were not so painful, and on examination were only mildly erythematous. Improvement continued gradually, and breast feeding was not interrupted. Nystatin tablets were withdrawn over a period of 2 weeks once the nipple pain resolved. Case 2: Mastalgia and nipple sowness
A 34-year-old woman presented complaining of ongoing problems with sore nipples and severe, burning breast pain which occurred after a feeding and lasted for at least 10 minutes. She had a past history of repeated antibiotic use for recurrent tonsillitis and recurrent urinary tract infections. At age 20 she had a foot injury for which she was prescribed 6 weeks of an oral corticosteroid. At the time of the initial presentation she was the mother of a 4-year-old son whom she had breastfed for 11 months with no problems, and a 4-month old baby. She had suffered 2 miscarriages in between. She had consumed a diet high in refined carbohydrate during the pregnancy. Delivery was uneventful. Lactation was established and the baby thrived. Over the next 2 months the only problem was nipple soreness which was treated with infra-red lamp, pawpaw ointment, tincture of benzoic compound and exposure to sunlight, with no lasting effect. The breast pain started 9 weeks postpartum. She was diagnosed as having mastitis and was prescribed amoxycillin. Soon after beginning the course, the pain intensified, shooting from medial to lateral aspects in both breasts. The dose of amoxycillin was then doubled after which the pain became unbearable, Flucloxacillin was added, with no improvement. At presentation the nipples were noted to bedry, flaky and tender to very soft touch. The baby showed no clinical evidence of oral or skin candidiasis. Diagnosis of candidiasis of nipple and breast was made and a treatment regimen given, as follows: Nystatin capsules, 2 orally 3 times daily, Lactobacillus acidophilus capsules, 1, 3 times daily, 0.5% aqueous gentian violet applied to nipples twice daily and nystatin drops for the baby, I m14 times daily. An anti-candida diet was also recommended. After the first week of the treatment the nystatin dose was increased to 3 capsules thrice daily because of lack of noticeable improvement. During the next week the nipple and breast pain subsided. After 2 weeks, the burning pain was gone and the patient felt much better in herself. There was still some nipple pain. Nystatin was continued at 2 capsules thrice daily and the number of feedings was reduced to 5 a day. Over the next month symptoms remained tolerable, but cessation of nystatin was followed by recurrence of nipple pain, and likewise gentian violet still had to be used from time to time for the left nipple which would otherwise crack. Two months later she again developed mastitis and was
380
treated with flucloxacillin. The initial symptoms flared again and were brought under control with nystatin. The patient was able to control her symptoms on 1 capsule of nystatin thrice daily and gentian violet applied to the left nipple once a day. Generally she found that the symptoms were aggravated by stress at work or home and dietary indiscretion. She weaned at 11 months.
DISCUSSION When a lactating woman presents with breast or nipple pain, a careful history and examination, including observation of a feeding are required. It is important to ensure that the baby is correctly positioned or ‘fixed’ at the breast, i.e. that the baby’s mouth is correctly juxtaposed to the nipple. The baby should be facing the breast, mouth wide open and lips flanged outwards. The initial placement of lip and gum should be well below the nipple (5). Normal breast feeding should not cause pain or discomfort. Both the nipple pain and the breast pain associated with candidiasis are usually described by the patient in the strongest terms, with words such as ‘agonising’ or ‘excruciating’ often being used. The nipple may look normal, or there may be some erythema, flakiness of nipple or areolar skin, or shininess; there may be some itch. The nipples will be tender to very light touch. Occasionally there is a fissure which may contain creamy exudate, which is candida colonization. There have been several case reports of infection by C ulbicuns of lactating nipples in the literature. The pathway of infection is usually postulated as originating in the mother’s vagina, passing to the infant’s mouth during delivery and then to the mother’s nipple (6). When candidiasis occurs in the older child it is often following the use of antibiotics (7). The potential for candidiasis to interfere with breast feeding has been emphasized in a recent report and the point made that ‘Candidiasis may be a more common but unrecognized infection in the breast feeding mother and infant’ (8). Nipple thrush can be treated topically with 0.5% aqueous gentian violet applied on a cotton bud to the nipples, or miconazole gel. On the nipple, miconazole appears to be better absorbed and more effective than clotrimazole Gentian violet has been an effective treatment for thrush for many years, but recent studies have found that it is a potential animal carcinogen; thus its use is now under review (9). The baby’s mouth should be routinely treated because C ulbicuns can frequently be cultured from the mouths of asymptomatic babies (10). Treatment will thus avoid the ‘ping-pong’ effect, where the untreated infant reinfects the mother (11). Other clinical manifestations of candidiasis must be treated as appropriate. The mother in the second case report described the symptom which is almost pathognomonic of candidiasis in the lactating breast, namely burning pain shooting through the breast (1,12,13). This pain is worse after feedings and may last for minutes or hours; it may wake the patient from sleep. Whatever triggered the original
breast pain, there is little doubt that the pain was aggravated by the antibiotics which were prescribed for wrongly diagnosed ‘mastitis! It must be made clear that not all painful lactating breasts are afflicted by mast itis; the absence of fever and local or systemic signs would certainly make a diagnosis of mastitis questionable. This woman’s past history of repeated antibiotic use in childhood and adolescence plus the short course of oral steroids would render her vulnerable to candidiasis by affecting her flora and her immunity, as mentioned earlier in this article. Her high intake of refined carbohydrate during the pregnancy would also have supplied an excellent substrate for intestinal C ulbicuns. The pathogenesis of the breast pain is unclear. Shooting pain suggests that there is duct involvement; but if the breast pain is caused by candidiasis of the ducts, it is not clear how oral nystatin works to clear it. Nystatin is poorly absorbed into the blood stream and is therefore not secreted in the breast milk at normal doses. One hypothesis is that, in clearing the overgrowth of candida in the bowel, the major reservoir is eliminated, and the general population of the candida declines by a process of attrition. Also contentious is the role of diet and Lacrobmillus ucidophilus in candidiasis. There is empirical evidence which strongly supports the importance of diet in candidiasis (14). There are many stories of pain recurrence or aggravation when the woman indulges in alcohol or refined carbohydrate: often. the patient cravcs sweet foods. The role of L. ucidophilus is less clear. It probably provides replacement flora whcn C ulbicuns is eliminated. Case 2 is an extreme example of a common prohlcm which must be recognized by doctors in ordcr to avoid a great deal of distress in nursing mothers. Thc patient was unable to cease nystatin treatmcnt without a rccurrence of symptoms.
Refemnces I. Lawrence RA. ~reastfccding.a guide lor the medical profewon. 3rd ed. St. I.ouis: C T htoshj C’o, IYWY: 211. 2. Hurlg R. Dc Inurnis J. hlulhall A. Yiipsts a$Human and h t m a l Pathogens. In Row AH and Harriwn JS fed%).The Yeasts, VOI 1. 2nd ed, London: Academic Pms. 1987; p22Y. 3. Odds FC. Candida and Candidasis. A roim and hihlio)rraph> 2nd Ed. London: Raillerc Tindal 1988. p9-4. 4. Turner R. Simonxn E. Candida (’an be katen! Corio. Oidium
Books. 1988. 5. Woolridge MW. Aetiology of sore nipples. Midwifer) 1986; 2: 172-176. 6. Mukherjee SC.Moniliasic Breast: J Indian h k d h s w c IW: 43. II: 536-538. 7. Chetty G N . Sehi G S . Kamalarn A. Thamhiah AS. C‘andtdo\l\ in Molher and Child: Xtyhosen, 198O: 23: 10: 580-!82. 8. Johnstone HA. Marcinak JF.
