Thrush


What is thrush?

Other names for thrush include: yeast infection; fungal infection; Candida; Candidiasis; or Moniliasis. These variations in names occur because thrush is the term used to describe an overgrowth of a strain of a yeast like fungus  called 'Candida Albicans'

Babies are not born with this yeast in their bodies and only come into contact with it from others. It is estimated that 90% of babies will have this yeast on and/or in their bodies by the time they are 6 months old.

As for the rest of us, almost everyone carries this yeast on or in his/her body. For most of us it lives quite happily in moist areas, such as our bowel, mouth, skin folds, vagina and groin and we usually don't experience any trouble from it.

However, certain conditions can allow the yeast population to explode and cause an infection, such as...

  • Taking antibiotics or steroids.
  • Taking antacids.
  • Taking oral contraceptives.
  • Getting inadequate rest.
  • Eating lots of sugary foods.
  • Stress.
  • Allergies. 
  • An injury to nipples from poor latch-on during breastfeeding.
  • Damaged skin, due to a diaper rash.

Young babies are MORE prone to a thrush than adults because of their immune system is immature. This means their bodies are unable to restrict the growth of this yeast as effectively as adults can and an infection may occur. One reason to be very careful with hygiene when caring for a very young baby is to prevent him/her from being exposed to this yeast for as long as possible.


Is thrush a serious problem?

For healthy, thriving babies a thrush infection is a minor inconvenience that may result in mild discomfort, unlike the severe pain a nursing mother may experience if a thrush infection develops her breasts.

Thrush is pftem blamed for difficult behaviors, such as irritability, wakefulness and feeding problems and yet thrush is rarely the cause of such behavior in healthy babies. (See crying baby and infant colic for common reasons for these behaviors.)

Thrush can be a serious problem for babies and adults who are immuno-suppressed, i.e. a very low functioning immune system.


Thrush in an infant's mouth

If a baby has oral thrush, there's a chance that he may also develop a yeast infection on his little bottom, because the yeast can pass from his mouth through his gastro-intestinal tract.

Signs of oral thrush

  • White or cream colored patches like milk curds can be seen on the roof of his mouth, inside his cheeks and on his tongue. These may be surrounded by red areas, or his entire tongue may have a solid white coating*.
  • Fussing, unsettled behavior during feeding (due to a sore mouth) is rare and generally only occurs if the infection is severe, i.e. if an infection reaches the stage of causing ulcerations (which seldom occurs in healthy babies even when thrush remains untreated).
  • If your baby sucks his thumb or fingers, he may also develop a yeast infection around his fingernails.

* Milk residue left after feeding is often mistaken for thrush. Milk residue is usually only found on the tongue. It's thin and wipes or rinses out of the mouth easily.

Treating oral thrush

  • Boil pacifiers, feeding equipment and teething rings etc. for 5 to 7 minutes after each use, while an infection is present.
  • Toys your baby (or other children) may chew on should be washed in hot soapy water and either bleached regularly or dried in the sun.
  • Rinse your baby's mouth out after a feeding. A few mouthfuls of water from a medicine cup will help remove the milk from his mouth. (Milk residue encourages the growth of this yeast).
  • Wash your baby's hands frequently with soap and warm water.
  • Use a natural remedy or antifungal medication as described below. Where a medication is used, wash the medicine dropper in hot, soapy water after each use.

If your baby has oral thrush, extra care should be taken to avoid a thrush diaper rash developing (which often occurs on top of other diaper rashes). If your baby is breastfed, you will also need to treat your nipples at the same time in order to reduce the risk of a thrush infection occurring on your nipples or in your breasts.


Thrush diaper (nappy) rash

The yeast that causes a thrush infection, flourishes in warm, moist environments. This makes your baby's diaper area a likely place for a thrush infection to occur. Thrush can cause a rash on your baby's genitals, buttocks or thighs.

Signs of thrush in the diaper area

A yeast diaper rash is bright pink or red with clearly defined edges. There may be small red spots near the edge. A thrush infection of the skin does not have white spots like thrush in the mouth.

Preventing and treating thrush diaper rash.

  • Change diapers as soon as you know they are wet or dirty.
  • Wash your hands with soap before and after changing diapers.
  • Take care that you don't spread the yeast, that may come in contact with your hands (as you change your baby's diaper), back into diaper rash creams.
  • While a rash is present avoid the use of diaper wipes (which can sting).
  • After a wet diaper, gently clean your baby's skin using water and vinegar or baking soda solution (described in 'Natural Remedies' below). Always clean a baby girl's diaper area from front to back.
  • After a poop, first clean off the poop and then soak his bottom in a small bath with a little baking soda (described in 'Natural Remedies' below).
  • Pat dry his skin (avoid rubbing).
  • Allow his bottom to air as much as possible by providing diaper-free time, 3 to 4 times each day.
  • Avoid using corn starch or petroleum jelly on his bottom as these can provide a food source for yeast to thrive on.
  • If you are using cloth diapers, the yeast can be passed through the laundry. Carefully follow the instruction for pre-wash diaper soaking solution (available from the supermarket). Wash cloth diapers in the hottest possible water. Add a 1/2 cup of vinegar to the final rinse and dry in the sun. If sun drying is not possible, use the hottest setting on the clothes drier.
  • Diaper rash with thrush may not clear up with the usual diaper rash treatments and you may need to use a natural remedy or antifungal medication on his diaper rash as described below.

Nipple/breast thrush

Because your baby may have the yeast in his mouth (even though he doesn't show any symptoms of an infection) any damage to your nipples during breastfeeding, such as a graze or small crack, may increase the chance of a yeast infection developing in the milk ducts of your breasts.

Although it can be painful, thrush on your nipples or in our breast should not affect your ability to breastfeed your baby.

Signs of nipple/breast thrush

  • Unusually pink or red nipples.
  • Skin can be flaky (but not always).
  • Cracked or bleeding nipples.
  • A shooting pain within the breast during feeding or may start 10 to 15 minutes after the feed has finished.

Treating nipple/breast thrush

  • Your baby will need to be treated for oral thrush even if he doesn't have symptoms, to avoid infections going back and forth.
  • Wash your hands carefully, before and after breastfeeding and after applying cream to your nipples.
  • Ensure your baby latches-on correctly to avoid further damage to your nipples. (See Breastfeeding basics for more about latch-on).
  • Try to keep your nipples as dry as possible, because moisture encourages the yeast to grow. Leave your breasts exposed to the air for as long as possible. If you can expose your nipples to sunlight, up to 10 minutes twice daily.
  • Put on a clean bra every day or more often
  • Change breast pads after every feed.
  • Bras and reusable breast pads should be soaked in a bleach solution prior to washing in hot water and dried in the sun or on a hot setting in the dryer.
  • Breast milk pumped during an active yeast infection of the breasts should be either used within 24 hours or discarded. Freezing does not kill the yeast. (Using pumped milk at a later date could result in a re-infection of your baby's mouth.)
  • Sterilize pumping equipment that comes into direct contact with your breast or your milk by boiling or breaching.
  • Treat vaginal infection if necessary.
  • Use a natural remedy or antifungal medication as described below.
  • Before breastfeeding, gently rinse off any residue of medications on your nipples.

If breast pads stick to your nipples, dampen them before removing them to avoid further damage. If your nipples are so painful that it hurts to wear clothing, breast shells* (which are not the same as nipple shields), available from a chemist or drug store, may provide some comfort. These placed inside your bra to protect anything from rubbing or sticking to your nipples.

If antifungal treatment fails to relieve your symptoms within a few days, see your doctor. Burning breast pain can also be due to a bacterial infection and you may need antibiotics.

* The aim of breast shells is to avoid anything touching tender nipples. The dome shape collects milk that may leak from your breasts. 


Treatment

Don't rely on medications alone to control your baby's yeast infection. If the source of infection is not corrected, either the infection will not clear or a thrush infection is likely to return as soon as antifungal medication has been stopped.

Because young babies have immature immune systems, along with treatment additional care needs to be taken to decrease your baby's exposure to this yeast until the time his immune system matures enough to control it, generally around the age of 6 months. (While your baby is in diapers, he will continue to be at risk of a thrush diaper rash.)

Because candida albicans will eventually become an inhabitant in your baby's body (the same as it is for the majority of the human population), where a yeast infection is mild, this means his immune system is working well enough to control the infection and antifungal medications may not be necessary. Often taking care to reduce exposure in addition to using a natural remedy to make the environment (mouth or skin) less favorable for the growth of the yeast is all that is needed.

Whether you use a natural remedy or antifungal medication or not it's important to try to exclude the source of your baby's infection. Because you can't always see the yeast that causes thrush, it can easily be carried on your hands, feeding equipment, diapers or clothing. To help to get rid of yeast (that's not always visible), you will find basic recommendations under each section above and more extreme recommendations for 'When thrush doesn't appear to get better' below.

If you are unsure whether your baby's thrush needs medications or not, see your baby's doctor and he/she will advise if treatment is necessary.


Natural remedies

Acidophalis & Bifidus

Eating natural yogurt or taking acidophalis capsules will help to colonize your body with lactobacillus acidophilus (good bacteria that will help to control the yeast in your digestive system).

Since an infant's digestive system is more sensitive, bifidus is recommended rather than acidophilus for children less than a year old. Bifidum occurs naturally in the intestinal flora of humans, including infants.

Grapefruit Seed Extract (not grape seed extract)

Also known as grapefruit seed oil, grapefruit seed extract is a broad-spectrum anti-microbial compound made from the seeds and pulp of grapefruit.

Make up a solution by adding 5 drops of grapefruit extract to 1/2 cup of cooled boiled water. This can be separated into two containers; one to wipe over your baby's mouth after feeding, using a cotton swab (it can also be used on your nipples after breastfeeding), the other portion can be used as a wash for your baby's bottom, as part of each diaper change. Use this solution at least 3 or 4 times each day and make up a fresh solution daily.

WARNING: DO NOT use grapefruit seed extract in a concentrated form.

Tea Tree Oil

Tea Tree Oil is an essential oil, which is well known for its antiseptic, antiviral and antibacterial properties. It's also good for combating yeast infections, such as thrush. For a thrush diaper rash, rinse your baby's bottom with diluted tea tree oil - 5 drops to 1/2 cup of cooled boiled water. This can also be used on your nipples and wiped off before feeding.

WARNING: Tea tree oil can be very irritating and should NOT be used in a concentrated form.

Vinegar

Other natural remedies include the use of vinegar or baking soda (sodium bicarbonate) to alter the acid balance of the environment, making it less appealing for yeast to grow.

Make up a solution of 1 teaspoon of white vinegar to 1 cup of water. (Put the solution into separate containers if you plan to use this for your baby's mouth and bottom). Use a cotton swab to wipe the solution onto your baby's mouth after feeding. This can also be used on your nipples following breastfeeding. A separate portion of this solution can be used to as a wash at diaper changes. 

WARNING: This solution can sting if thrush is severe.

In the laundry: Pour one cup of white vinegar to the final rinse of cloth diapers or clothing.

Baking soda (bicarbonate soda)

Dissolve a level teaspoon of baking soda in 1 cup of water. Use a cotton swab to wipe the insides of your baby's cheeks, gums and tongue after every feed. You can also dab this onto your nipples following feeds. Make a fresh solution every day.

Yeast diaper rash: You can use a separate potion of the same solution above as a wash during diaper changes or you can add 2 tablespoons of baking soda to a couple of inches of water in a small bath to soak your little one's bottom for a few minutes. This is generally quite soothing.

Other natural remedies used for treatment of MATERNAL thrush only include:

GARLIC
One of garlic's many healing properties is it's ability to kill yeast, bacteria and other micro-organisms. Use it in your cooking. Odorless garlic capsules are available from health food stores.

LACTIC ACID WASH
Lactic acid is unfavorable to many forms of yeast and bacteria such as candida albican. This is a relatively new product now available at chemists or drug stores. The wash (to be used externally only) contains lactic acid that help maintain the natural pH balance of the vaginal area.

SACCHOMYCES BOULARDII
Like lactobacillus, this also helps rebalance the helpful organisms in your gut flora.

CAPRYLIC ACID
This fatty acid, derived from coconut oil, has been shown to have antifungal properties.

OLIVE OIL
Olive oil contains linoleic acids, which are antifungal and may cut off the yeast's oxygen supply.

BLACK WALNUT
The green hulls containing the walnut are processed into oil which has antimicrobial properties. Black walnut is also used to treat thrush infection and can be used internally or externally. Black Walnut should NOT be taken internally if you are breastfeeding because it can stop lactation.

PAU D'ARCO TEA
Pau d'Arco is a South American tree that resists fungus growth. Pau d'Arco or Taheebo tea, are both believed to have natural fungicidal properties. Drink 2-3 cups daily.

GOLDENSEAL
Is a natural plant antimicrobial. Goldenseal can be used on the skin as a poultice but should NOT be taken internally.

WARNING: Because a product is 'natural' does not meant it is without side effects. Many natural remedies are NOT suitable for use in infants, small children OR breastfeeding mothers. Read instructions carefully and ask lots of questions at the health food store. If in doubt don't use herbal remedies.


Medications

Many antifungal medications can be purchased over-the-counter, while some more potent forms will require a doctor's prescription. Antifungal medications come in drops or gel for treating oral thrush and creams for treating thrush on the skin, i.e. nipples and bottoms.

If you use an over-the-counter medication and the thrush is not getting better after a week of treatment see your doctor.

IMPORTANT: It's generally recommended to continue treatment for 1 week after the infection appears to have cleared, to reduce the risk of reoccurrence.

Nystatin (Mycostatin®, Nilstat®)

Nystatin is the most commonly used treatment for yeast infection. Although nystatin is one the least toxic known drugs, it's effective in about 60% of cases. 

Unlike other medicines that work when swallowed, mystatin only works on surfaces it can touch. Therefore, it's very important that nystatin is applied directly to the area with thrush rather than simply tipped into your baby's mouth.

When treating with nystatin oral suspension, it's important to shake the bottle well before use. Put a small amount (one milliliter) into a small cup. Use a cotton swab to apply nystatin to all surfaces inside your baby's mouth; between his cheeks and gums, on his tongue, under his tongue, on the roof of his mouth and between his lips and gums. Then gently tip any remaining nystatin into his mouth.

When using nystatin cream on your nipples, rinse the cream off before nursing, because it tastes awful.

Miconazole (Daktrin®, Fungo®, Monistat®, Micatin®)

In Australia and Europe, miconazole antifungal cream and oral gels are available for use in a baby's mouth and on mother's nipples. Use a cotton swab to gently apply the gel to all areas of your baby's mouth.

If NYSTATIN or MICRONAZOLE is not effective intitially or the yeast becomes chronic and infects the ducts of your breast (resulting in breast pain) other antifungal medicines are available. You will need to see your doctor for advice and/or a prescription for these.

Clotrimazole (Lotrimin®, Mycelex®, Canesten®)

Although available over-the-counter, clotrimazole is a potent antifungal treatment. Creams should only be used on your nipples or your baby's bottom where nystatin or micronazole (mentioned above) have failed, and only if advised to do so by a doctor.

Fluconazole (Diflucan®)

A new and now commonly prescribed vaginal yeast medication, fluconazole given as an oral tablet, is being used to treat breast yeast in nursing mothers. This is a very strong prescription anti-fungal treatment. Although fluconazole can be used to treat thrush in infants, its use is generally reserved for severe or stubborn cases and is rarely used a first option in the treatment of thrush in infants.

Ketoconazole (Nizoral®, DaktaGOLD®) or Itraconzazole (Sporanox®)

Neither of these commonly used antifungal medications is recommended for use in children or lactating women.

Gentian Violet

Gentian Violet, a traditional remedy for yeast and other infections has around long before most modern antifungals and antibiotics. This form of treatment should only be considered if recommended by your baby's doctor. Although it is effective in the treatment of thrush there is a risk of burning your baby's mouth using this treatment.

WARNING: Although still available in many countries, Gentian Violet has been removed from the market in Australia and many European countries because it contains a material reasonably suspected of being carcinogenic.


When thrush doesn't get better

If thrush returns when treatment is completed, it's likely that the yeast is still present in the household. If this is the case, all family members may need to be treated to reduce the risk of your baby becoming re-infected. Your doctor will be the best person to advise you if this is necessary.

The yeast that causes thrush can survive for long periods in moist environments outside the body and can spread from one family member to another in this way. There are many things you can do to reduce the risk of this spread from occurring.

Basic recommendations have been made under each section for oral thrush, thrush diaper rash and nipple/breast thrush above and additional recommendations are made below. As many of the recommendations below require a lot of work, it's not necessary to go to such lengths unless your baby is troubled by recurring episodes of thrush.

  1. Good hand washing is the most important thing you can do. Encourage adults and older children to regularly wash their hands with warm water and soap, particularly before touching or playing with your baby.
  2. Wash hands before and after diaper changes, before preparing formula and before and after feeding your baby.
  3. Use paper towels for hand drying then discard, since yeast can live on a moist towel.
  4. Avoid bathing your baby with other family members.
  5. Don't share bath towels. Use the towel only once or thoroughly dry after each use.
  6. Bed linen, towels and underwear may need to be treated in order to destroy yeast spores and prevent the re-occurrence of the infection. Laundry should be washed in the hottest possible water and dried in the sun on on the hottest setting of a clothes dryer.
  7. Use an antifungal laundry detergent or add 1 cup of vinegar to the final rinse.
  8. Toothbrushes can harbour yeast. Replace each family member's toothbrush once antifungal treatment has started and again once all symptoms disappear.
  9. Toys should be washed in hot soapy water and bleached regularly. Don't permit other children to share pacifiers, feeding nipples or toys that will put into their mouth.
  10. Disinfect surfaces such as a diaper changing pad, baby furniture and toys with a 10% bleach solution.
  11. Boil pacifiers, teething rings, bottle nipples and pump parts that touch milk or breasts for 20 minutes daily until infection is gone. (Spores are heat resistant, steam sterilizing may not be enough.) After thrush is gone, discard pacifiers and buy new ones.
  12. At all times avoid putting your baby's pacifier or feeding nipple into your own mouth. (You are unlikely to get thrush from your baby because your immune system is strong, but you may spread the yeast that is present in your mouth to your baby's. As well as bacteria that causes dental decay.)

Written by Rowena Bennett
RN, RM, MHN, CHN, IBCLC, Grad Dip Health Promotion and author of 'Your Sleepless Baby: The Rescue Guide'.

© Copyright www.babycareadvice.com 2003. All rights reserved. Permission from author must be obtained to reproduce all or any part of this article. 

Added Nov 2003. Revised Aug 2008; Sept 2013.


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