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Lactation Information and Discussion <[log in to unmask]>
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Sun, 7 Apr 2002 18:55:40 +1000
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Dear All,

I am off Lactnet more than I am on, thanks to an overwhelmingly busy life.
However, I feel that I should post this to the group immediately: please
copy me personally if you wish me to read your responses. I hope someone can
validate or disprove the following hypothesis, while acknowledging its
origins. I consider this the first formal publication of the idea!!!

Anyone working in this field knows that severe mastalgia, with pain
radiating through the breast and even to the spine, can be associated with a
history of thrush. But much as I like Kay Hoover's excellent colour
publication, and accurate as her descriptions of this pain are,  I have
never believed in "thrush in the breast" as an explanation. It seemed to me
illogical and unphysiological to think that thrush could get into and
survive in healthy breast tissue, especially ductal tissue with its exposure
to the free flow of anti-biotic breastmilk. Yet many people talk of thrush
in the ducts, or invasive thrush, and major anti-fungals have been
prescribed, often for lengthy periods, and sometimes with little effect,
although in other cases the drugs seem to work well and speedily.

In teaching students about "breast thrush" I have always emphasized that I
do not believe that thrush can survive in the ducts of a healthy lactating
breast, and argued that the description of pain given by the mother is
exactly that of nerve pain. (Having shingles reinforced that notion!) I
speculated that previous trauma to the breast and nipple - usually
originating in poor positioning and/or attachment - had allowed thrush to
get a foothold in the external skin layers of the nipple face, where
unmyelinated nerve endings respond with acute pain. (I consider it important
to eradicate thrush from the nipple face and find gentian violet - always
only .5% - the most efficient means of doing this.) I had wondered whether
complete eradication of epithelial thrush  was achieved by the now usual
topical treatments, which I believe do not penetrate nipple skin crevices
and skin layers as effectively as generous amounts of liquid GV. I
emphasized that irritated/damaged nerve endings could cause radiating pain
such as the mothers describe, which retreats little by little over time as
inflammation of the nerve endings declines.

Last week as I said this sort of thing to a class, Dr. Kathy Cook, a
re-certifyine IBCLC ob/gyn, suddenly saw a bright light and commented that
in fact I was describing chronic nerve pain such as she routinely treated
with tiny doses of  anti-depressants (amitryptilin and Tegretol) in the
vulval clinic where she had been working. Other students then thought of
many other situation where chronic nerve pain has identical characteristics
and is treated by nerve re-education in that way. The important point is
that there is no need for ANY infection to be present for this pain to be
present and persistent.

What we are describing as breast thrush could thus be a conditioned reflex
response, in which the body has come to associate feeding stimuli with pain.
Conditioned reflex association is an explanation that I have discussed in
Breastfeeding Matters (1998) for those cases of vasospasm which are not
simply due to cold or compression. But I had not thought of it in this
context of thrush and breast pain, until Kathy's comment. There may be no
thrush present anywhere by the time the nerves are jangling: simply a body
memory of how painful it all was when the nipple was damaged and inflamed.

Why might some of this mastalgia respond to anti-fungal medications? Tom
Hale can probably add to this, but here is a start. Drugs often have more
than one action. The penicillins are not only anti-biotic, for example, but
enhance phagocytic clearance in mastitis (discussed in BFM 1998 also).
Perhaps the anti-fungals prescribed with apparent success for mastalgia are
simply working another way, via some other anti-inflammatory pathway, to
reduce nerve sensitivity or cerebral perception of pain. Or perhaps it is
coincidence that the pain clears while mothers are taking the anti-fungals.
And perhaps in some cases there are still viable thrush colonies which are
still affecting nerve endings on the nipple face and which are destroyed by
the drug. (The length of time some people expect fissures to take to heal
always suggests persistent thrush to me: once positioning and attachment are
fixed, I expect fissures to heal in 24-48 hours, and when they do not,
suggest a GV dose just in case of thrush delaying healing. All that is in
BFM as well, in the chapter on nipple problems). All are possible
explanations. No doubt you will think of others.

Has anyone previously concluded that "breast thrush" is in fact chronic
nerve pain and I have missed seeing it in the literature (quite possible
given my life!) Does this fit with others' experience? Are there LCs out
there who could work with pain clinics to investigate this and find the
optimal doses and drugs? Tom, can you comment? How nice if we did not need
all that fluconazole?!

I am just thrilled to have  a reasonable explanation that also offers some
hope of a sensible treatment. I have urged Kathy Cook to write this up for
publication asap, so that it can be tested.

BTW, I dislike the idea of concurrent use of topical steroids with
antibacterial and antifungal treatments. Again, suppressing inflammation
should make the nipple feel better immediately, and if the mother is
desperate can be a last resort. But suppressing inflammation locally or
centrally when that is a necessary healing mechanism, and leaving the nipple
and breast skin immuno-suppressed to any degree seems a bad idea to me.
Given that breastmilk has major anti-inflammatory components, to the point
where one mother who used it on herpes lesions noticed an immediate effect,
I'd prefer to use breastmilk as the anti-inflammatory of choice. The single
worst case of thrush I ever saw was a mother who had used and abruptly
discontinued Kenacomb, a cocktail cream with steroids as well as anti-biotic
factors: sterilising the skin resulted in a hideous outbreak of thrush as
residual spores germinated on immunosuppressed skin.


Back to a BFHI assessment report...


Maureen Minchin IBCLC

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