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PHYSICAL HEALTH - CLINICAL GUIDELINEThe Identification and Management of Candida Albicans (Thrush) in the Breastfeeding Mother and their BabyNOTE: This policies’ format is still based on the Gloucestershire Care Services NHS Trust original and the trust details have been adjusted to reflect the merger of GCS and 2G and creation of Gloucestershire Health and Care NHS Foundation Trust. Staff should continue to use this Policy until it has been reviewed and updated to reflect any changes due to the merger.Guideline NumberCLG010Version: V2.2Purpose:To provide staff with up to date information on the Identification and Management of Candida Albicans (Thrush) in the Breastfeeding Mother and their BabyConsultation:Public Health Nursing, CYPS Clinical Governance Committee Clinical Policy Group, Head of Medicines Optimisation & Non-Medical Prescribing LeadApproved by:Clinical Policy Group / Integrated Governance & Quality CommitteeDate approved:October 2018Author:Emma Cronin-Preece – Infant Feeding Lead Specialist Health VisitorDate issued:October 2018Review date:August 2021Audience:Public Health Nursing StaffDissemination:The document will be disseminated via the Locality Leadsto the Public Health Nursing TeamsQuality and Equality Impact AssessmentThis guideline has been subjected to a Quality and Equality Impact Assessment. This concluded that this guideline will not create any adverse effect or discrimination on any individual or particular group and will not negatively impact upon the quality of services provided by the Trust.Version History VersionDateReason for ChangeV2October 2018Updated GuidelineV2.1January 2020Trust Name changed and GHC Logo addedV2.2July 2020Transferred to new Trust Template and updated Trust Name and details following merger of trustsTABLE OF CONTENTSSectionPage1Introduction32Purpose33Scope34Duties3-45Guideline Detail4-96Definitions97Process for Monitoring Compliance9-108Training109References, Bibliography & Acknowledgements10-12ABBREVIATIONSAbbreviationFull DescriptionGHCGloucestershire Health and Care NHS Foundation TrustGPGeneral PractitionerPHNSPublic Health Nursing Service1.INTRODUCTION 1.1Candida Albicans, more commonly known as ‘thrush’, is one of the most painful breastfeeding conditions, which if not treated promptly and successfully can lead to early cessation of breastfeeding. Breastfeeding provides many health benefits for mother and baby, and early recognition and treatment of thrush of the nipple and/or breast is essential to protect breastfeeding and avoid early cessation.1.2This guideline needs to be used in conjunction with the following organisational documents:Infant Feeding PolicyClinical Record Keeping Standards PolicyInfection Control Guidelines – Hand DecontaminationConsent to Examination and Treatment Policy2.PURPOSE2.1These guidelines aim to assist health practitioners with the accurate diagnosis and treatment of thrush in the breastfeeding mother and her baby.3.SCOPE3.1Public Health Nursing Staff.4.DUTIES4.1General Roles, Responsibilities and AccountabilityGloucestershire Health and Care NHS Foundation Trust (GHC) aims to take all reasonable steps to ensure the safety and independence of its patients and service users to make their own decisions about their care and treatment.In addition GHC will ensure that:All employees have access to up to date evidence based policy documents.Appropriate training and updates are provided.Access to appropriate equipment that complies with safety and maintenance requirements is provided.Managers and Heads of Service will ensure that:All staff are aware of, and have access to policy documents.All staff access training and development as appropriate to individual employee needs.All staff participate in the appraisal process, including the review of competencies.Employees (including bank, agency and locum staff) must ensure that they:Practice within their level of competency and within the scope of their professional bodies where appropriate.Read and adhere to GHC policyIdentify any areas for skill update or training required.Participate in the appraisal process.Ensure that all care and consent complies with the Mental Capacity Act (2007).4.2Roles, Responsibilities and Accountability Specific to this GuidelinePublic Health Nursing Teams, midwives and general practitioners (G.P’s) are the health professionals most frequently involved with supporting breast feeding mothers. When a breastfeeding mother and baby are identified as having a thrush infection it is the responsibility of the health professional to ensure the mother receives prompt and appropriate treatment of the condition, to minimise pain and the risk of early cessation of breastfeeding. Topical treatments may be prescribed by a Nurse Prescriber, but if a systemic treatment is required for an un-resolving infection or infection of the milk ducts, referral to a doctor will be required.5.GUIDELINE DETAIL5.1Thrush is a very painful condition if acquired when breastfeeding. This fungal infection usually starts suddenly after some days or weeks of pain free breastfeeding, or after a course of antibiotic medication.5.2Signs of thrush in the mother:Pink / Red shiny areolaPermanent loss of colour in the nipple or areolaCracked nipples which do not heal in spite of good positioning and attachmentWhite plaques on the folds of the nipple or areola skinNipples and areolas may on occasion look normalSymptoms of thrush in the mother:Itchy nipples, very sensitive to any touch, even to loose clothing. It may be unbearably painful for the mother to take a showerBurning sensation in the nipplesSevere pain when the baby initially latches onto the breastPain becomes progressively worse with each re-latchingNipple pain which intensifies as a breastfeed progresses and may last for up to an hour after the feed (this is unlike incorrect attachment nipple pain, where the pain stops when the feed stops)Shooting pains in the breast after breast feeding, may be severePain in both breastsCulturing of mother’s milk or taking swabs (which can detect bacterial or candida growth) of the nipple or areola or taking a swab of the baby’s mouth can be useful.5.3Signs of thrush in the babyCreamy white patches in the baby’s mouth or on the tongue, which do not rub off easily. Sometimes seen far back in the mouth, in the cheeks or on the inside of the lips. If they are rubbed off the base is raw and may bleed.A white sheen on baby’s tongue or lips.Baby is fidgety during feeds, pulls off or away from the breast while feeding and seems unhappy or uncomfortable. (Baby’s mouth may be sore)Baby may have a nappy rash, red spots or soreness in the nappy area that is difficult to heal.Anal thrush can at first seem to be nappy rash; however it does not respond to the usual nappy rash ointments and presents itself as a very red, shiny rash that radiates outwards from the anus.5.4Other causes of nipple pain:It is important to exclude other causes of nipple pain before treating for Thrush (The Breastfeeding Network 2015)Ineffective attachmentEczemaDermatitis (including reactions to nipple creams, breast pads)Tongue-tieWhitespot or BlebRaynaud’s syndromeBacterial infection (may be present at the same time as thrush)As well as listening to what the mother says, her nipples and her baby should be examined, and a feed observed, to ensure that ineffective attachment to the breast is not the cause of the pain.Thrush is often mistakenly diagnosed when ineffective positioning and attachment are the cause of pain, resulting in inappropriate exposure to drugs and delay in the resolution of the true cause of nipple pain.5.5Deep breast pain, whenever it occurs, is more likely to be due to ineffective/inefficient milk removal, usually by an ineffectively attached baby, than by ascending, ductal thrush. (See below for guidance on ductal thrush). Deep breast pain is unlikely to be due to ductal thrush in the absence of topical thrush. In the presence of topical thrush, if the mother’s nipples and /or baby’s mouth is sore, attachment may be ineffective, and this may give rise to deep breast pain. Achieving effective attachment and positioning and/or milk removal by expression may relieve deep breast pain, and negate a diagnosis of ductal thrush.5.6Treatment - There is accumulating evidence that Azole antifungals are more effective than Nystatin in treating topical thrush.Only one, Miconazole, is licensed for use both on the skin and as an oral preparation for babies. Miconazole oral get is only licensed over 4 months but can be prescribed b y a Doctor with Clinical Reasoning and clear instructions for administration to the parent/carer , and if the baby is preterm caution should be exercised and the licence may be over 5 – 6 months (BNF. 2018) It is imperative that both mother and baby are treated simultaneously, even when there are no signs of thrush in the baby’s mouth, otherwise the infection will continue to pass between mother and baby, baby and mother. Babies frequently show no signs of oral thrush, even though their mothers have the ical treatment for motherMiconazole Cream (Daktarin) 2% is the first choice of anti-fungal cream. A smear is applied to the nipple and areola after each feed. There is no need to wash this off, but if any cream can be seen prior to feeding it should be gently wiped away.It is necessary to apply the cream after each feed in order to keep it in contact with the skin long enough for it to be effective, as the small amount the mother applies to her nipple after a feed will be absorbed over time by her breast pad or clothing.For nipples which are very red and inflamed a mild steroid cream can be used to facilitate healing. Miconazole 2% plus Hydrocortisone 1% (Dactacort?) may be useful.It is important that the treatment for nipple thrush is continued for 10 days after freedom from symptoms, otherwise thrush may return.Miconazole gel and Nystatin suspension are not pharmacologically designed to penetrate the skin of the nipple and are unlikely to be effective. Clotrimazole cream is not as effective a treatment of nipple thrush and some mothers have reported allergic reactions to 1% Clotrimazole cream.Repeat prescriptions may be required to eliminate thrush infections, as it can take weeks to get rid of the infection.If a mother continues to feel pain deep within the breast for long periods after feeds, which has not been helped by adjustment of positioning and attachment, the thrush may have entered the milk ducts and oral systemic treatment will be required in addition to topical treatment of mother and baby. (See systemic treatment below).Treatment of the babyThere is evidence that the use of miconazole gel is preferable to nystatin suspension with greater efficacy within a shorter period of time. This should be used to cover all surfaces of the baby’s mouth, preferably using a clean fingertip. The intention should be to smear the gel around the mouth, after feeding, to keep the gel in contact with the baby’s mouth for as long as possible, rather than to encourage the baby to swallow it.The gel is not licensed for use in babies less than 4 months of age, or during the first 5-6 months of life of an infant born pre-term. This appears to be due to the risk of choking rather than concern with the drug itself. GP’s prescribing Miconazole oral gel for babies under 4 months old should ensure the carer knows to apply the gel in a small amount after feeding with a clean fingertip. Neither the gel nor the finger should touch the back of the baby’s throat. The responsibility for the use of Miconazole oral gel in a baby under 4 months of age remains with the prescriber.The recommended dose for neonates is 1mL x 4 times a day, and from 1 month – 2 years of age 2.5mL x 2 a day. (24mg Miconazole/mL) However a small amount applied with a clean fingertip, four times a day, is in line with recent efficacy studies, and is likely to keep the gel in contact with the oral mucosa for longer than larger but less frequent doses. (Appendix 2).In Nystatin suspension (100,000 units /mL) for the treatment of oral thrush. However this product is licensed for use in babies over a month old. The dose of Nystatin suspension recommended is 100,000 units x 4 times a day. If it is measured onto a spoon rather than using a dropper it may be applied in a similar way to Miconazole gel with a clean fingertip, and stay in contact with the mucosa for longer, rather than being administered by dropper and rapidly swallowed by the baby.Ductal ThrushIf a mother continues to feel pain deep within the breast for long periods after feeding, that has not been helped by improvement of the attachment of the baby to the breast, the thrush infection may have entered the milk ducts.Symptoms of ductal thrushPain:PersistentSevereBurningRadiating throughout the breasts Shooting through the breasts and into the backTypically during and after feeds(In spite of efforts to improve attachment)Systemic treatment for ductal thrushAlthough there is little research evidence, there is growing anecdotal experience that treatment with oral Fluconazole is effective and mothers are enabled to continue pain free breastfeeding. Without treatment very few women are able to deal with the severity of pain from thrush, and are forced to cease breastfeeding prematurely.Fluconazole is not licensed for lactating women. (The manufacturers of Fluconazole are unlikely to apply for such a licence due to the prohibitive costs and recent availability of a generic product). Practitioners are thus required to take full liability for use, and breastfeeding women who buy Fluconazole over the counter would share liability for its non- licensed use with the pharmacist.It is however widely prescribed for use in lactating women, particularly in North America, and is listed for use in lactating women by WHO. There is growing evidence that it is a safe and effective form of treatment and using it enables women to continue breastfeeding.Fluconazole is licensed for oral use in infants over six months of age. The amount of Fluconazole that transfers via the breastmilk to the baby is 0.6mg/kg/day and the recommended paediatric dose is 6mg/kg/day.In babies less than 6 weeks the half-life is 88 hours and could theoretically lead to accumulation above the recommended paediatric dose in the baby.The baby (more than 6 weeks old) will still need separate oral therapy and cream for napkin rash, to be effectively treated, due to the low dose passing through the milk not being at therapeutic levels.Nystatin tablets 500,000 units have been used as an alternative oral treatment for the lactating women with suspected ductal thrush, but the poor absorption from the gut results in delay in achieving resolution of symptoms and re-occurrence of thrush is more likely. (Nystatin also has no specific licence for use in lactating women).When using oral treatment it is still important to continue to apply cream to the nipples after every feed, and to treat the baby’s mouth four times daily.Once treatment starts with fluconazole, pain will normally ease within 2 to 3 days.Residual pain after treatment is sometimes reported. If the pain is severe, a longer course or higher dosage of Fluconazole may be required.Paracetamol and/or Ibuprofen may be taken by breastfeeding mothers for relief of pain.5.7Other ConsiderationsThrush can survive outside the body for at least 24 hours, in moist warm conditions. It can survive on clothing even when laundered at 50oC. It can survive in hand creams (and other oil-in-water emulsions), eye make-up and toothbrushes.Non-disposable items that come into contact with the mother or baby should be boiled for at least 10 minutes; steam sterilised or soaked in Milton or a similar solution, as directed, daily.Mothers should be advised that:Thrush can be passed between the mother and baby - and other family membersProbiotics can help to restore ‘good’ bacteria e.g. Acidophilus capsulesand can help to keep thrush under control (available from health food stores or chemists)Painkillers may be needed to help cope with the pain.(paracetamol or ibuprofen is recommended)Thorough hand washing is recommended after applying medication and following each nappy changeA separate towel should be used for each person in the family and it should be changed dailyClothes in contact with the breasts should be machine washed at a temperature of at least 60oCIf the baby is also sucking on a dummy, bottle teat, nipple shield or plastic toys, these will also need to be carefully washed and sterilised.Expressed breast milk should not be saved, as it may cause re-infection of baby and motherAnecdotally some mothers find reducing the level of sugar and yeast in their diet helpsSummary The diagnosis of candidial infections of the breast is difficult. Some authorities recommend that swabs of the nipple and baby’s mouth be taken for culture and sensitivity, however other authorities disagree, as even when thrush is present results are often negative. However if baby has signs of a candidial infection it is more likely that mother will have the same causative organism causing her pain.If thrush is suspected, having ruled out other causes of nipple and/or breast pain, both mother and baby should be treated effectively and concurrently.Treatment of choice for topical thrush is:Miconazole (Daktarin) cream 2% applied sparingly to the mother’s nipples after every feed. Any excess to be wiped NOT washed off prior to feeding.Miconazole* (Daktarin) oral gel 2% should be applied with a clean fingertip, to cover all surfaces of the baby’s mouth four times a day.Miconazole cream (Daktarin 2%) should be applied to the baby’s bottom to treat candida napkin rash or if the baby has a sore bottom that is not responding to other treatment.To prevent re-infection, both mother and baby need to be treated simultaneously, even if only one shows symptoms of thrush.Treatment for both mother and baby should continue for at least 10 days after the symptoms have cleared, although symptoms should be resolving within 2- 3 days.(Treatment for Thrush must be prescribed by the Health Visitor or Doctor when baby is under 6 months old; when clinically indicated, a mother can buy treatment for Thrush over the Counter when baby is over 6 months old).The treatment of choice for systemic (ductal) thrush should be:Oral Fluconazole, Please refer to the Breastfeeding Network for further information: topical treatment as listed above should continue concurrently.Fresh expressed breastmilk and frozen expressed breastmilk during Thrush treatment can be given to baby, however when Thrush treatment is complete any remaining breastmilk should be discarded Albicans is a diploid fungus (yeast like) organism found in small amounts in the normal human intestinal tract. It is a causal agent of opportunistic oral and genital infections in humans.7.PROCESS FOR MONITORING COMPLIANCE7.1As part of clinical record keeping audit – those records with breastfeeding mother and baby demonstrating assessment, advice and treatment as per guidelines.7.2Non-Medical Prescribing activities will be audited regularly, and a subsequent report will be generated for discussion and scrutiny. The audit will include:NMP activity.Where, what & when.Cost implications.Qualitative factors.8.TRAINING8.1Training on the recognition, care and treatment of mothers and babies with Thrush will be included in the infant feeding training provided to midwives and PHNS by the infant feeding lead Specialist Health Visitor (GHC) / infant feeding lead Specialist Midwife (Hospitals) at the Joint Initial Full 2-day Training and at the Joint Annual Update Training to ensure continuity of care for Mothers. Training will be offered to G.P’s, and all G.P’s will be provided with written information on the recognition and treatment of Thrush in mothers and babies, by access to this Policy via G-Care website and the written information on G-Care for Doctors as written by the Infant Feeding Lead Specialist Health Visitor.9.REFERENCESAmir L. 1991. Candida and the lactating breast: predisposing factors. J Hum Lact, 7 (4); 177-181Amir L, Hoover K. 2002, Candidiasis and Breastfeeding, LLLI SchaumbergBFN (2015) Differential Diagnosis of Nipple Pain The Breastfeeding Network [Date last accessed 26.08.2018]BFN (2017) Thrush and Breastfeeding The Breastfeeding Network [Date last accessed 26/08.2018]BNF (2018) Miconazole. National Institute for Health and Care Excellence [Date last accessed 17.09.2018]JonesW. Sachs M. 2003. (revised 2009)KellyMom (2018) I have Thrush. Can I give baby my expressed breastmilk? [Date last accessed 26.08.2018]Odd FC. 1988. Candida and Candidosis: A review and bibliography.2nd.Edn. Balliere Tindall, London. p 119-120Hoppe JE, et al. 1997. Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomised multicentre study of miconazole gel vs. nystatin suspension. Paed Infect Dis 16:288-93Hoppe JE, Hahn H. 1996. Randomised comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group. Infection Mar-Apr; 24(2): 136-9BPF for children (2009) page 666, Pharmaceutical Press. LondonWHO 2002. Breastfeeding and Maternal Medication Recommendations for Drugs in the Eleventh WHO Model List of Essential Drugs Downloadable from: [Date last accessed 26.08.2018]Amir L, Hoover K. 2002, Candidiasis and Breastfeeding, LLLI Schaumberg.Hale T. 2012, Medications and Mothers Milk (15th Ed), Hale Publications. Texas.Lawrence R. 1998, Breastfeeding: a guide for the medical profession (5th Ed), MosbySally Inch (2009) Prescribing Points. Treatment of Thrush in the breastfeeding Mother and Baby. Oxford.Bibliography:Bristol NHS. (2010) Guidelines for the management of Thrush in the breastfeeding mother and her baby. Available to download at: information on identifying and treating thrush, as well as further references, can be obtained from The Breastfeeding Network. The Essential Guide to the Public Sector Equality Duty (Equality and Human Rights Commission November 2012)Essence of Care Benchmarks (DH, 2005) Essential Steps to Safe Clean Care (DH, 2007)Quality Improvement in Healthcare (2nd Edition) Stanley Thornes, Cheltenham (Parsley, K and Corrigan, P 1999)The Royal Marsden Hospital Manual of Clinical Nursing Procedures (9th Edition) Blackwell Sciences, Oxford (Lister, S and Dougherty, L 2004)An Organisation-wide Policy for the Development and Management of Procedural Documents (NHSLA, 2008)The Equality Act (2010) ................
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