Nipple and breast thrush

Comment from expert advisory group

The use of all-purpose nipple ointment is not recommended as treatment option.
It is important to treat both the mother and baby if a breast-fed baby has oral thrush but the mother has no symptoms. Similarly, if mother has symptoms, treat breast-fed baby also even if no signs of thrush in baby’s mouth.
Second line systemic fluconazole should only be used in exceptional circumstances and under medical supervision for deep candida mastitis which is very rare.
There is a significant risk of drug interactions and caution must be exercised when using fluconazole.

Treatment

Drug	Dose	Duration	Notes
1st choice options
Miconazole Cream for mother	Apply cream to nipple and areola	See Notes	Apply after every feed. Continue for at least 7 days after symptoms have cleared.
Nystatin 100,000 units/ml oral suspension for baby	Neonate: birth to 1 month: 1mL dropped into the mouth every 8 hours after feeds Infant: 1 month to 2 years: 1-2mL dropped into the mouth every 6 hours after feeds	See Notes	Duration usually 7 days (48 hours after lesions have cleared). If signs and symptoms persist beyond 14 days, re-evaluate.
Miconazole 20mg/mL oral gel for baby	Neonate: 1ml two to four times daily after feeds* 2-3 months: 1.25ml to be applied four times daily after feeds* ≥4 months: 1.25ml to be applied four times a day after feeds* The dose should be divided into smaller pea-sized portions; gel should be smeared in baby’s mouth after feeds with a clean finger, ensuring there are no clumps of gel in the mouth	See Notes	*Unlicensed use in infants <4 months due to choking risk. Lower age limit increased to 5-6 months for infants who are pre-term or exhibiting slow neuromuscular development. If prescribed for infants < 4 months, ensure counselling on administration provided. The gel should not be applied to the back of the throat due to possible choking. Gel should never be given by spoon or syringe. Continue for at least 7 days after lesions have cleared.
2nd choice options
Fluconazole			Should only be used in exceptional circumstances and under medical supervision for deep candida mastitis which is very rare. There is a significant risk of drug interactions and caution must be exercised when using fluconazole.

Patient Information

Further information on thrush while breast feeding can be found on the HSE My Child website.
Further information on Antimicrobials and Breast-feeding can be found on the Mother to Baby website (USA) (Search or Use Browse by Medications category).

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Dosing in children quick reference dosage/weight guide
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed Mary 2022, with minor edit in February 2023