IS THRUSH CAUSING MY SORE NIPPLES?

Article Update: July 2025

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Thrush (a fungal infection) was often assumed to be the cause of sudden or ongoing nipple pain and symptoms mistakenly associated with thrush included:

●  Itchy or burning nipples that look pink or fiery red (on lighter skin tones), shiny or flaky

●  Cracked or damaged nipples

● Shooting or stabbing pains in both breasts during, or especially after and between feedings

● Intense nipple or breast pain that is not improved with adjusted latch and positioning

 

NOTE: These symptoms are also related to many other conditions. 

  Oral thrush is uncommon in full term, healthy infants who are exclusively breastfed. 

 

New scientific research indicates that thrush is an exceptionally uncommon cause of breast or nipple pain [1]. More commonly, persistent or sudden nipple pain results from latching and positioning which is not deep enough nor comfortable, and other conditions like  vasospasm, dermatitis, hyperlactation (over production of milk), breast inflammation and mammary dysbiosis (an imbalance between the good and bad microbes in the breasts), etc. [2]

 

What is thrush?

Thrush is caused by Candida – which is a yeast, a type of fungus. Candida Albicans is the most common fungal commensal (meaning it is naturally present) in the human body without causing harm. It naturally resides on skin and mucous membranes, [3] therefore it is normal to find Candida Albicans in healthy breastmilk and on the skin of the nipple and areola areas. Candida Albicans form part of the protective skin mycobiomes (the fungal part of the skin microbiome). Friction, heat, moisture and changes in pH can lead to an overgrowth of Candida and inflammatory changes. These typically occur in areas where folds of skin touch, like under the breasts or in infant nappy areas, or in the infant’s mouth (usually inside the cheeks and inside the lips, on the top of the mouth and on the tongue. A white coating on the tongue alone is not a sign of thrush, as many babies have a white, milky coating on their tongues). Candida Albicans rarely invades into deep tissues, nor does it cause serious infections throughout the body; this usually only happens in immunocompromised patients (diabetics, people with obesity, HIV, or those undergoing chemotherapy). This means that “ductal thrush” (thrush inside the breast) is very unlikely.

 

What favours thrush?

Microbiome disruption and yeast overgrowth are more likely:

• When pacifiers, nipple shields, bottle teats are being used

• When silver nipple cups are used for extended periods of time

• If there has been previous steroid or antibiotic use 

• With the use of emollient, ointment or cream applications on the nipples, which may overhydrate the top skin layer, the epidermis. (In general, the use of nipple creams is not needed for breastfeeding as it comes with its own risks).
   

Is what I’m eating causing my thrush overgrowth?

There is extensive discussion about the connection between diet and candidiasis, including whether high sugar intake can cause yeast infections. Some individuals follow strict diets to limit yeast overgrowth, but scientific evidence supporting their effectiveness is limited, according to the World Health Organisation [12].

 

Is thrush contagious?

Since yeast overgrowth is a result of microbiome disruption, it is not considered to be a contagious condition [5]. Babies can get thrush in their nappy area, and women often get vaginal thrush. Both babies and adults can get oral (mouth) thrush, especially after taking certain medications, such as antibiotics or steroid asthma inhalers. Your baby’s nappy rash from thrush is not transmissible to your breast and if you have a vaginal yeast infection, that does not make it more likely to have thrush on your breasts. Vaginal thrush, thrush in the nappy area, or oral (mouth) thrush can be treated without interrupting breastfeeding.

 

While the “Art of Breastfeeding” [4] suggests that thrush can be passed back and forth between mom and baby, requiring both to be treated; other sources state there is no data to support this thinking, or that thrush is not contagious [5] and there is no reason to treat a baby’s mouth unless there are obvious signs of fungal growth [6].
 

How is thrush treated?

If you or your doctor still strongly suspect that you have a thrush overgrowth and infection, this can be treated with Miconazole gel/cream at least four times daily on the nipples after breastfeeds. This gel/cream does not need to be wiped off before the next breastfeed. Oral thrush in babies is also effectively treated with Miconazole oral gel [11].
 

Nystatin oral suspension is considered less effective than miconazole gel/cream.
 

NOTE: Gentian violet, historically used as a treatment for thrush, has been identified as a cause of concern [7]. The World Health Organization (WHO) advises against its use. Gentian violet has been reported to cause oral ulcers and if mothers were to use it on their nipples, it can cause ulcers on their nipples [8].  

 

Occasionally oral medications may need to be taken, such as a once off stat dose of 150mg of Fluconazole. Dr Pamela Douglas [9], a well-respected medical doctor and IBCLC,  recommends a once off stat dose, or three doses taken on alternate days for a week. She cautions that there is no rationale for prolonged courses of antifungals for persistent breastfeeding pain and highlights that vulvovaginal candidiasis is usually effectively treated with 150mg of Fluconazole as a single oral dose.

 

Breastmilk can also be applied to the nipple and areola areas. Breastmilk has immunoregulatory properties (i.e. breastmilk helps the immune system respond properly) and contains Lactobacillus which has an antifungal [3] effect on Candida Albicans.

 

Do I need to take any additional precautions?

If your nipple pain is truly being caused by nipple thrush, it is treatable with Miconazole gel/cream.

 

There is no evidence to support the washing of bras, pads or clothes with bleach or vinegar or other harsh detergents. There is also insufficient evidence for the use of probiotics. If you use a breastpump, routine cleaning and sterilising of pump parts as per normal is standard practice; additional sterilisation is not required. Baby toys do not need extra cleaning measures.[5]

 

Should my expressed milk be discarded?

The Academy of Breastfeeding Medicine Clinical Protocol #8 (Human Milk Storage Information) says: “If a mother has breast or nipple pain from a bacterial or yeast infection, there is no evidence that her stored expressed milk needs to be discarded” [10].
 

If it’s not thrush, what causes burning nipple pain and associated radiating breast pain between feeds?

Persistent pain is most likely due to ongoing micro-trauma and inflammation in the nipples and breasts. Anti-fungal treatments may temporarily provide pain relief even when thrush has not been the cause of the symptoms as anti-fungal treatments have some anti-inflammatory properties.  However, many mothers will return for repeat treatment because the underlying issue has not been addressed. 

 

There are other more likely causes of persistent nipple and breast pain that should be investigated first.

 

1. Latching and Positioning
   A shallow or uncomfortable latch is a frequent cause of nipple pain. When your baby isn't latched deeply, the nipple can be compressed and rubbed, leading to friction, inflammation, and damage. This can cause pain during and after feeds, sometimes even radiating deeper into the breast.

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​​​​​​​​Signs of a problematic latch might include:

• Nipples that look misshapen (after feeds), swollen, red, cracked, or bleeding. Sometimes, damage may not be visible (in other words, nipples may look normal), even if pain is present.

• Nipples appearing pink and shiny, with fine white scales. This scaling is a sign of hyperkeratosis (thickening of the outer skin layer) due to repetitive micro-trauma and overhydration [6].

• Itchiness, which results from histamine release due to inflammation [6].

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If you're struggling to achieve a deep, comfortable latch, please contact a local La Leche League Leader or a lactation consultant for support.