If you’ve ever been diagnosed with nipple thrush during your breastfeeding journey, you’re far from alone. For years it’s been one of the most common explanations given to mothers experiencing persistent nipple or breast pain, often accompanied by a prescription for antifungal cream or fluconazole tablets, sometimes multiple times over.
But the science has shifted significantly. I want to share both what the latest evidence says, and something rather personal, because my own breastfeeding experience with my youngest daughter now looks very different in the light of this new research.
What we used to think about nipple thrush
The traditional story went like this: Candida (the yeast responsible for thrush) could either transfer from a baby’s mouth to a mother’s nipples during feeding, or simply over grow on the damp and possibly damaged skin of nipples, causing a distinctive cluster of symptoms
- burning;
- shooting pain;
- itchy or flaky skin on the nipple;
- deep breast pain that continued after feeding.
The treatment was almost always antifungals for both mother and baby simultaneously, along with advice to sterilise everything the baby or nipples touched. This narrative became deeply embedded in breastfeeding support. Mothers presenting with nipple pain were routinely told it was thrush. Prescriptions were issued. Courses of treatment were repeated. And many mothers (myself included!), even when the treatment didn’t fully work, assumed the thrush had simply come back.
The clinician leading the conversation in the UK: Dr Naomi Dow
Before we get into the evidence, I want to introduce you to one of the most important voices behind this shift in the UK: Dr Naomi Dow, a GP and IBCLC based in Aberdeenshire, Scotland. I was fortunate to hear Naomi talk last year and very clearly and sensitively explain the research and why the changes in our thinking have come about.
Dr Naomi Dow has been quietly challenging the nipple thrush narrative for years, both in her clinical practice and through her work educating other health professionals. She is also a medical educator who teaches medical students, which makes her influence on the current and next generation of GPs particularly significant and valuable.
The Breastfeeding Network’s Drugs in Breastmilk service, when they published their landmark update withdrawing all nipple thrush factsheets, specifically acknowledged Dr Dow by name for “engaging in an ongoing conversation with the team and leading this shift within our services.”
Dr Dow’s core consideration, one she has made consistently across professional educational talks, podcasts and social media (you can find her at @dr_naomidow_ibclc on Instagram), is that the symptoms long attributed to nipple thrush are almost always better explained by something else; that reaching for antifungal treatment before thoroughly investigating other causes means we are overusing antifungals which can be as problematic long term as the overuse of antibiotics by creating resistance.
What the evidence is now telling us.
Here is a summary of the key studies underpinning this shift, because it is worth understanding not just what the new guidance says, but why clinicians and researchers are now so confident in saying it.
The most often cited study is Jiménez et al’s 2017 paper, Mammary Candidiasis: A Medical Condition Without Scientific Evidence? This was a large and rigorous piece of work: the Spanish research team at Complutense University of Madrid analysed milk samples, nipple swabs, and nipple biopsies from 529 women who had been diagnosed with mammary candidiasis, using multiple microscopy and culture techniques. Their conclusion was striking, yeast played, at most, a marginal role in the breast and nipple pain these women were experiencing. Instead, the evidence pointed strongly to bacteria (specifically coagulase-negative staphylococci and streptococci) as the likely agents responsible. The authors went as far as recommending that the term “mammary candidiasis” or “nipple thrush” should be retired entirely when referring to this condition.
Building on this, Australian researcher Dr Pamela Douglas published a comprehensive narrative review in 2021 in Women’s Health journal: Overdiagnosis and Overtreatment of Nipple and Breast Candidiasis. Douglas reviewed the available research on whether Candida albicans was genuinely associated with nipple and breast pain, whether fluconazole was an effective treatment, and what the human milk microbiome actually contains. Her conclusion was unambiguous: antifungal treatment is rarely indicated, and prolonged courses simply cannot be justified. She also raised an important and under-discussed concern, that topical and oral antifungals may actually disrupt the protective microbial ecosystems of both the mother’s nipple and the baby’s mouth, potentially making things worse rather than better. Her work also highlights the broader public health dimension: unnecessary antifungal use is contributing to the serious global problem of antifungal resistance.
In the same year, Dr Katrina Mitchell and colleagues published It’s Not Yeast: A Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain in Breastfeeding Medicine (Betts et al 2021). This study looked at women who had been referred with a presumed candida diagnosis that had not responded to treatment. When a thorough clinical assessment was carried out, every single woman in the cohort received a revised diagnosis, including subacute mastitis, nipple bleb, dermatitis, vasospasm, or hyperlactation. Crucially, all of them experienced resolution of symptoms once the correct diagnosis was identified and appropriate treatment started. This study is particularly powerful because it shows not just that thrush is being over-diagnosed, but that when you do look properly, you do find the real answer, and mothers do get better.
Taken together, these three studies form the scientific backbone of the guidance shift we are now seeing from the Breastfeeding Network, UNICEF UK Baby Friendly, La Leche League, and NICE. They are the reason Dr Naomi Dow and others have been able to make the case so compellingly for change.
What else could be causing the pain?
This is the really important question. If it isn’t thrush, what is it? Here are the most common causes now being highlighted by breastfeeding medicine specialists:
Suboptimal positioning and attachment – this remains the most common root cause of persistent nipple pain, and it’s also the one most likely to be overlooked if a thrush diagnosis is given too quickly. Pain caused by attachment issues can feel like burning and shooting, particularly in the early weeks. Suboptimal positioning can also contribute to the following –
- Neuropathic (nerve) pain – Likely due to misfiring or misinterpretation of nerve signals from the nipple and may follow on from suboptimal positioning and attachment. Damaged or healing nipple tissue can cause burning, shooting, or stabbing neuropathic pain that closely mimics what’s previously been described as thrush.
- Vasospasm – a brief interruption to normal blood flow in the nipple, causing colour change and often intense burning or shooting pain after feeding. It’s frequently confused with thrush and can be caused by the nipple being compressed during a shallow attachment, thus temporarily constricting blood flow, or can be associated with cold or Raynaud’s Syndrome. Warmth or medications that help with increasing blood flow (vasodilators) can be most helpful in this scenario.
Dermatitis or eczema – itchy, flaky, or shiny nipple skin is classic dermatitis, not necessarily yeast. One of the most common irritants for nipples can be lanolin, which is found in many well known nipple creams. Additionally, some topical antifungal creams can actually make dermatitis worse, which explains why some mothers felt their symptoms deteriorate with antifungal treatment. This would respond better to topical steroids instead.
Bacterial infection – more common than yeast, particularly where there is visible nipple damage, and requires a different treatment approach entirely. A damaged nipple with broken skin can allow bacteria in, which then can cause ongoing pain and challenges with healing.
My own story
I share something personal here, because I think it illustrates exactly what this new evidence is describing, and because I believe there’s real power in an IBCLC saying: ‘this happened to me too’.
When I was breastfeeding my youngest daughter, I experienced recurrent nipple pain that I, and those supporting me, believed was thrush. Having breastfed my eldest two, I knew how breastfeeding should feel but just could not achieve this with my daughter. Multiple oral assessments ruled there to be no tongue tie, I was focusing on trying to achieve optimal positioning and attachment so this left us with nipple thrush as the most likely explanation at the time. I kept treating it with antifungal medication, course after course. The pain would ease a little, then return. Dr Naomi Dow explains that this is because antifungal creams also have a slight anti-inflammatory action, which meant some temporary relief for me, but not long lasting due to actual cause not being addressed. I had never known pain like it and can vividly remember crying throughout feeds when she was 8+weeks. I also became obsessive about hand hygiene, washing my towels and bras and feeling like there was candida hiding anywhere, waiting to reproduce and take over again.
Eventually, we did achieve pain-free feeding. At the time, I attributed that to finally getting on top of the thrush with a further round of fluconazole and antifungal cream.
Now, looking back, in the light of this new evidence, I think something very different was happening. I see from photos that our daughter had a markedly recessed jaw until she was around nine to ten weeks old (I hadn’t noticed this at the time!). As her jaw developed and her attachment improved, so did the feeding. The pain I experienced, the recurrent, burning, shooting discomfort, is now far more consistent with nerve pain resulting from suboptimal attachment caused by her jaw anatomy than with a fungal infection.
I was treated repeatedly for something I probably didn’t have, while the actual cause, her jaw, and the impact it was having on her latch, wasn’t fully addressed until her anatomy changed naturally. Learning this new information was hard, not only due to reflecting on my own experience, but also due to reflecting on the support I had provided over the ensuing years to many other Mum’s with similar symptoms. There is the wonderful phrase by Maya Angelou that helps so much in these situations though
I share my story to help demonstrate how thrush was the accepted explanation at the time, and many dedicated, caring professionals were working with the best knowledge available, myself included. I also share it because I know there will be mothers reading this who have been through something similar, and who deserve to know that there may have been a different explanation for their pain; and because understanding this changes how I now support families in my work every single day.
What does this mean if you’re experiencing nipple pain right now?
First: please don’t panic, and please don’t give up.
If you’ve been told you have nipple thrush, or if you’re experiencing nipple pain that isn’t resolving, the most important step is skilled breastfeeding support, an IBCLC observing a full feed, from start to finish, in person where possible. This is what the Breastfeeding Network, NICE, and breastfeeding medicine specialists are now unanimously recommending as the first line of response to persistent breast and nipple pain.
Before reaching for antifungals, it’s worth exploring:
- How does the latch look and feel throughout the feed?
- Is there any jaw, palate, or tongue tie issue affecting how baby attaches?
- Could the pain be vasospasm or nerve pain from sub-optimal positioning and attachment?
- Is there any sign of a skin condition like dermatitis?
- Has anything changed recently, a growth spurt, a new position, started pumping?
A note on how this might feel to read
If you’ve previously been diagnosed and treated for nipple thrush, especially if you were treated repeatedly, this may be an uncomfortable read. You were not let down by carelessness. You were supported by people working with the knowledge they had at the time. The science has moved on, and that’s actually a hopeful thing, it means the support available to mothers now is better, and more targeted, than it has ever been. We will continue to adapt and grow as we learn more too.
If you’re struggling with nipple or breast pain, I’d love to help. As an IBCLC and Registered Midwife, skilled assessment of your feeding is always my starting point. Get in touch here or book feeding support directly.
Useful links for further reading
Pamela Douglas – Overdiagnosis and overtreatment of nipple and breast candidiasis