Nipple and breast thrush in breastfeeding mothers

Comment from expert advisory group

Nipple and breast thrush is often over diagnosed in response to nipple and breast pain in breastfeeding mothers. Occurrence is highly unlikely in this cohort.
In breastfeeding mothers presenting with breast pain and/ or dermatological changes, consider alternative diagnoses including difficulties with breastfeeding technique, nipple dermatitis, vasospasm, neuropathic pain, breast dysbiosis (subacute mastitis), nipple bleb, milk crust, hyperlactation and depression.
Assess breastfeeding technique and consider referral to lactation consultant/ public health nurse/ midwife.
Painkillers such as paracetamol and/ or ibuprofen may help with reducing pain.
Encourage patient to continue breastfeeding as thrush will not harm their baby.
To avoid cross-infection, ensure good personal hygiene (e.g. handwashing) and ensure all equipment e.g. pacifiers/ nipple shields/ teats/ bottles are cleaned and sterilised.
The use of all-purpose nipple ointment is not recommended as treatment option.
Fluconazole is not recommended as a first line treatment for nipple/breast thrush. It may be recommended on specialist advice for deep candida mastitis, which is very rare. See HPRA caution in women of childbearing potential.

Treatment

Nipple and Breast Thrush Empiric Treatment Table

Drug

Dose

Duration

Notes

1st choice options

Miconazole Cream for mother

Apply cream to nipple and areola

See Notes

Apply after every feed. If any visible cream remains at next feed, remove with oil e.g. olive oil.

Continue for at least 7 days after symptoms have cleared

Nystatin 100,000 units/mL oral suspension for baby

Neonate: birth to 1 month: 1 mL dropped into the mouth every 8 hours after feeds

Infant: 1 month to 2 years: 1-2 mL dropped into the mouth every 6 hours after feeds

Over 2 years: 1-6 mL every 6 hours after meals

See Notes

Duration usually 7 days (48 hours after lesions have cleared).

If signs and symptoms persist beyond 14 days, re-evaluate.

Miconazole 20 mg/mL oral gel for baby

Neonate: 1 mL to be applied two to four times daily after feeds*

1-24 months: 1.25 mL to be applied four times daily after feeds*

Over 2 years: 2.5 mL to be applied four times daily after feeds*

The dose should be divided into smaller pea-sized portions; gel should be smeared in baby’s mouth after feeds with a clean finger, ensuring there are no clumps of gel in the mouth

See Notes

*Unlicensed use in infants <4 months due to choking risk. Lower age limit increased to 5-6 months for infants who are pre-term or exhibiting slow neuromuscular development.

If prescribed, ensure counselling on administration provided:

The gel should not be applied to the back of the throat due to possible choking.
Gel should never be given by spoon or syringe.

Continue for at least 7 days after lesions have cleared.

Check for drug interactions before prescribing

Patient Information

Further information on thrush while breast feeding can be found on the HSE My Child website.
Further information on Antimicrobials and Breast-feeding can be found on the Mother to Baby website (USA) (Search or Use Browse by Medications category).

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Dosing in children quick reference dosage/weight guide
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed January 2026