To the editor:
Nipple thrush in lactating patients is characterized by nipple-areolar complex (NAC) pain, itch, and burning with breast pain.1,2,3 Expert opinion and single clinic chart reviews suggest that most cases of nipple thrush are actually contact or irritant dermatitis, nipple vasospasm, or subclinical mastitis often in the setting of improper breast pump use.1,2,4 The relationship between breast pump use, symptoms of nipple thrush, and thrush diagnosis has not been examined at the level of a health system.
We endeavored to determine which elements of a lactating patient’s clinical presentation, including breast pump use and symptoms, were associated with a diagnosis of nipple thrush. We used data from the largest-to-date retrospective cohort study at a tertiary health system where all NAC complaints of reproductive-age female-identifying patients between 2015 and 2019 were reviewed. Following approval by the institutional review board, data about symptoms, diagnosis, specialty providing care, diagnostic considerations, and treatments were collected.
Only lactating patients (204 encounters) with NAC complaints were included, where some (15 encounters, 7%) were diagnosed via email or phone by an advice nurse only. While nipple dermatitis was a rare diagnosis (14, 7%), NAC irritation was common (80, 39%) (Table 1). Lactating patients (40, 20%) with NAC itch or burn were more often diagnosed with a nipple thrush (23, 58%) than dermatitis (9, 23%). Thrush was usually (65/66, 98%) diagnosed without microscoping confirmation or fungal culture, which is standard to avoid culturing normal flora.5 While non-lactating patients with nipple dermatitis were counseled to discontinue fragrant lotions and soaps and change their bra, lactating patients never received this advice.
Table 1.
Frequency of breast pump use by NAC complaint among lactating patients. The term NAC irritation was defined as a patient presenting with at least one of the following patient-reported symptoms: itch, burn, rash, skin flaking, erythema/redness, irritation, or inflammation.
| NAC Complaint | Total N |
No data n (%) |
Only nursing n (%) |
Nursing and pumping n (%) |
Exclusive pumping n (%) |
|---|---|---|---|---|---|
| Nipple pain | 155 | 27 (17) | 25 (16) | 50 (32) | 53 (34) |
| Breast pain | 83 | 15 (18) | 3 (7) | 23 (28) | 42 (51) |
| Nipple pain + Breast pain | 70 | 13 (19) | 2 (3) | 21 (30) | 34 (49) |
| Itch | 23 | 2 (9) | 0 (0) | 13 (57) | 8 (35) |
| Burn | 17 | 4 (24) | 0 (0) | 8 (47) | 5 (29) |
| General NAC irritation | 80 | 14 (18) | 4 (5) | 35 (44) | 27 (34) |
| Nipple pain + Breast pain + NAC irritation | 33 | 5 (15) | 1 (3) | 13 (39) | 14 (42) |
Patients who were both nursing and pumping (OR, 11.8; 95% CI, 1.3 – 110.1; P = .03) or exclusively pumping (OR, 23.4; 95% CI, 2.5 – 218.7; P = .0006) were more likely than those who were just nursing to be diagnosed with nipple thrush. More than half of breastfeeding patients (17/33, 52%) who presented with nipple and breast pain alongside NAC irritation were given a diagnosis of nipple thrush, where most patients were frequently (8, 47%) or exclusively (8, 47%) pumping. Notably, few (4, 5%) patients with a NAC complaint who were only nursing had nipple irritation (Table 1).
The risk of NAC dermatitis is increased postpartum as patients are using new bras and detergents, applying novel and often pro-allergenic substances directly onto their NAC, and mechanically irritating the NAC skin with breast pumps. Dermatologists were rarely (5, 2%) involved in the management of lactating patients with NAC complaints. The preponderance of nipple thrush diagnoses, or potential misdiagnoses, made clinically in the setting of breast pump use in patients with NAC irritation and pain illustrates the need for multidisciplinary, dermatology-involved care for lactating patients.
Generalizability is limited by the single institution, retrospective nature of this study. Prospective studies with appropriate diagnostic considerations are warranted to evaluate the prevalence of nipple thrush in lactating patients that do or do not use a breast pump.
Funding sources:
Anna Sadovnikova was supported by the National Institutes of Health (F30 HD101295).
Footnotes
Conflicts of Interest: Anna Sadovnikova was the Chief Executive Officer, President, and shareholder of LiquidGoldConcept, Inc. until December 2021.
References
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