S150 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004
Problems during lactation Giugliani ER
affect the lactiferous ducts, and often occurs in the presence of moist nipples (candida interacts with carbohydrate- containing substrates) and of lesions. Vaginal candidiasis, use of antibiotics, oral contraceptives and steroids and use of contaminated pacifiers increase the risk of breast candidiasis.19 Usually it is the infant who transmits the fungus, even if no symptoms are present.
Candida infection often is characterized by itching, burning sensation and twinges in the nipples, which persist after breastfeeding. The nipples usually have a reddish and shiny appearance. Some mothers complain of burning and twinges in the breasts. The infant usually has oral white patches, which should not be mistaken for milk patches (the latter of which are removed without leaving a bloody area).
Prevention
As the fungus grows in a moist, warm and dark environment, maintaining the nipples dry and exposing them to air, and also exposing them to light for some minutes every day, are preventive measures against the development of candida infection.
Treatment
Mother and infant must be treated simultaneously, even if the infant does not present with signs of candidiasis. Treatment is initially topical and includes nystatin, clotrimazole, miconazole or ketoconazole for two weeks. Women can apply the cream after each breastfeeding and do not have to remove it before the next breastfeeding. A large number of candida species are resistant to nystatin. Gentian violet 0.5 at 1% can be used on the nipples/areolas and in the mouth of the infant once a day for three to four days. If topical treatment is not efficacious, the use of systemic oral fluconazole is recommended for 14 to 18 days.3,20
In addition to the specific treatment against the fungus, some general measures are useful during treatment, such as rinsing the nipples and air-dry them after breastfeedings and expose the nipples to sunlight for at least some minutes every day. Pacifiers and bottle nipples are an important source of reinfection, therefore, if it is not possible to eliminate them, they should be boiled for 20 minutes, at least once a day.3
Raynauds phenomenon
Raynauds phenomenon, an intermittent ischemia caused by a vasospasm that often occurs in the fingers and toes, can also affect the nipples. In general, it occurs in response to cold temperature exposure, abnormal compression of the nipple in the infants mouth or severe nipple trauma. However, the cause can not always be identified. Vasospasms may cause nipples to become pale (due to the lack of blood irrigation) and often are very painful. They can appear before, during or after breastfeedings, but it is more common for them to occur
after breastfeedings, probably because, in general, the air is cooler than the infants mouth. Many women report a twinging pain or burning sensation when the nipple is pale, and therefore, this condition often is mistaken for candidiasis, although fungal infection itself can lead to Raynauds phenomenon. Spasms, with a characteristic pain, last from seconds to minutes, but the pain can last for one hour or more. Usually a sequence of spasms occurs, with short intervals in-between. Some medications such as fluconazole and oral contraceptives can aggravate vasospasms.21
Treatment
The management consists in treating the basic cause that produces the vasospasm in the nipple. Warm compresses can alleviate the pain. When pain is severe and does not improve with the afore-mentioned measures (which is rare), some medications can be used, although there are no studies that scientifically confirm this recommendation. Among these medications, there are nifedipine (5 mg, three times a day for one to two weeks or 30 mg once a day for the slow-releasing formulation), vitamin B6 (200 mg/day, once a day, for 4 to 5 days and later 50mg/day for another 1 to 2 weeks), calcium supplementation (2,000 mg/day), magnesium supplementation (1,000 mg/day) and ibuprofen.21,22
Plugged ducts
Lactiferous ducts are plugged when the milk produced in a certain breast area does not drain properly for some reason (solid obstruction is not necessary). This often occurs when the breast is not properly emptied, which may occur when breastfeeding is infrequent or when the infant has a poor suck. It may also happen when there is local pressure on some area, for instance, a very tight bra, or as a consequence of the use of creams on the nipples.
Plugged ducts are typically characterized by the presence of sensitive and painful breast lumps in a mother without any other breast disease. There may be pain, heat and erythema in the affected area, not accompanied by high-grade fever. Sometimes, this condition is associated with a small, almost imperceptible, white spot at the tip of the nipple, which may hurt a lot during breastfeeding.4
Prevention
Any measure that facilitates the complete emptying of the breast can prevent the occurrence of plugged ducts. Thus, a proper nursing technique and frequent breastfeedings minimize this complication, as well as wearing a bra that does not interfere with milk drainage and avoiding the use of unnecessary creams on the nipples.
Treatment
In the presence of plugged ducts, the following measures are necessary: