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 *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. 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