”It’s Not Thrush!” Challenging the Candida Narrative Dr Naomi Dow Report Compiled By Sue Jameson

Dr Naomi Dow with Sue Jameson

This presentation was given by Dr Naomi Dow at LCGB Conference in Birmingham in September 24. Dr Dow is a GP and IBCLC in Aberdeen in Scotland and provided much food for thought with her forensic examination of the evidence surrounding current management of thrush.
Learning objectives

• Outline why the nipple and breast are not a typical site for Candida infection.
• Describe the harms associated with mis diagnosing and treating nipple/breast thrush.
• Name conditions that may be confused with nipple/breast thrush, and outline their correct
  management.

She opened with a statement about adult learners – which most of us will identify with – that we are often resistant to change! It takes a lot to move us from our dearly held notions and theories. She asked us to approach this new consideration of thrush with:

• Humility
• Adaptability
• The ability to forgive
• To consider the room at that moment as a psychologically safe space to explore and learn new things.

Most breastfeeding supporters and health professionals have been taught about thrush. Nipple or breast thrush has existed as a concept for decades within the lactation world, and remained largely unchallenged.

It is a label frequently attached to lactating individuals who have symptoms such as shooting pains or skin changes.

Lactation work is a caring role and Dr Dow reiterated that it doesn’t make us feel good to think we could have done better. She asked us to be kind to ourselves and not beat ourselves up for things we may have done, as this is not a good space for personal growth.

When a diagnosis of nipple or breast thrush is made, the parent and nursling are typically advised to be treated with antifungal medications, and for strict hygiene measures to be adhered to. But how much of this is actually evidence-based?

The role of confirmation bias was examined – we look for things that validate and verify what we already know.

She cited the work on Foetal Blood Sampling as an example of a practice that was shown to confer no benefit and even lowered APGAR scores. It is no longer routine practice. With HRT the huge upswing in women availing of these treatments was as a result of newer information.

Where we were heading was the possibility of considering the very existence of nipple thrush. Some facts:

• There are over 200 types of Candida. C Albicans is the one most familiar to us.
• It is a normal skin flora and lives quite happily as part of our microbiome
• It has been known about for a long time. Hippocrates described it as a ‘disease of the diseased’
• It is generally only seen systemically where there is a severely immunocompromised individual
• It is not infectious like herpes or flu and as such is not transmitted from person to person.

The evidence for this last statement, which drew gasps from the audience, is from BASH – the British Association for Sexual Health and HIV, which states that there is no need to treat asymptomatic partners. They found no evidence of transfer from infected party to others. So if the pain and other symptoms that our clients are experiencing are not thrush, what are they? Dr Dow covered a lot of research studies which identified the main cause of extreme pain as originating from the nerves of the breast. Hence shooting pains etc. A number of studies she cited treated thrush-like symptoms with a medium strength hydrocortisone ointment and saw resolution in a short time frame.

She challenged us to really look at the evidence for thrush when in her, and many others, opinions, this could infact be dermatitis caused by all the things we associate with thrush – occluded skin, heat, friction, loss of skin integrity, damaged nipples, and red flakey patches.

Oestrogen is also needed for thrush to proliferate and this is in short supply during the post partum period. Ref: Douglas et al 2022; Rethinking lactation related nipple pain

Looking back historically, the first papers published in 1979, and many more published since are contradictory and do not stand up to scrutiny, so why do certain theories persist? The following are just some of the reasons uncovered:

• Medical misogyny
• Industry does not prioritise Women’s health conditions
• Successful lactation makes no money

The following research papers were evaluated:

• 2002 Carmichael & Dixon – this paper cast doubt on the existence of nipple thrush
• 2009 Hale & Colleagues – used 16 mothers and 18 controls.
• 2013 Amir et al - the Castle Study
• 2017 Jiminez et al
• 2021 Betts et al

No one disputes that oral thrush exists in infants. The dispute is over the potential for transfer to the nipple. All the studies above measured and swabbed using different methods and some scrubbed nipples with detergent before swabbing. Others rinsed in 500mls sterile water.
As a health professional Dr Dow questioned the prolonged treatment regimes mothers have often gone through to try to get rid of systemic thrush in particular. Usually if a treatment isn’t working you try another medication. Wrong diagnosis equals wrong treatment. Overuse of Fluconazole leads to resistance and in those immunocompromised individuals this can be critical.

Sore nipples should be examined carefully and swabs will really only be a choice is there is suspected Herpes or viral infection. So how do we proceed?

• Treatment options start with good breastfeeding management of position and attachment.
• Dermatitis should always be considered, where skin changes are present.
• Ointments and unguents may cause sensitivity
• Appliances such as silver cups, milk collectors etc may interact with skin, cause excessive
  masceration of skin submerged in milk for long periods of time
• Check fitting of pump flanges plus frequency and duration of pumping.

If your client appears 9 times with recurrent thrush – it isn’t! Look again.

I look forward to hearing more on this fascinating topic from Dr Dow in the future.

L-R Sue Jameson,Nicola O’Byrne, Pauline McLoughlin Caoimhe Whelan, Naomi Hurley, Ciara Butler

Complied by: Sue Jameson, IBCLC

Sue did receive a bursary from ALCI for this report. ALCI Council would like to thank Sue for her report.

Dated: 10 October 2024. 

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