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Can I treat deep nipple thrush?

QA breast-feeding mother has asked for an oral antifungal to clear internal thrush in her nipples, which are still very painful although there is little to see. Is any antifungal licensed for this?

AA clinical diagnosis of 'internal thrush' is made with increasing frequency by non-medical staff. No diagnostic tests exist and the condition may not even exist.

Suffering from 'internal thrush' is said to be more likely after antibiotic use, or if there is poor positioning with a history of cracked nipples, or if the woman has a history of the condition. The condition produces no pyrexia and no redness of the breast; the areolae may show no colour loss or may be red or shiny. The predominant symptom is pain that gets worse after a breast feed and increases for up to two hours.

The differential diagnosis includes a poor feeding position.

Recommended treatments include careful attention to hygiene, local antifungal therapy with miconazole cream, or systemic antifungal treatment. Opinion differs on whether the asymptomatic neonate should be concurrently treated.

Nystatin is the only antifungal licensed for use in lactating women, and although gut absorption is poor it is possible sufficient is absorbed to be effective. Oral nystatin 500,000 units, every six hours for 10 to 14 days, is recommended before persistence of symptoms is considered a treatment failure or the result of a misdiagnosis.

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