Thrush and breastfeeding with Dr Naomi Dow

Thrush in a breastfeeding dyad has commonly been diagnosed as a response to pain, but my guest today is a part of an important global conversation asking us to look at the evidence more closely. I’m delighted to be joined by Dr Naomi Dow, GP and IBCLC to talk about her work to better understand what is going on, and reduce the over-diagnosis of nipple and breast thrush.

In this episode we discuss the causes of nipple and breast pain, wounds and discolouration, including dermatitis, poor wound management, and physiological conditions. Naomi explains how the symptoms of thrush have often been confused with other things, or even caused by the very things which are supposed to help with nipple pain. We talk about how we can communicate the new messages and what needs to happen next.

Dr Naomi Dow is @‌dr_naomidow_ibclc on instagram

My latest book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

Resources mentioned - 

Dr Katrina Mitchell’s resource:

Physician Guide to Breastfeeding for Parents, Physicians, Lactation Consultants, Doulas

IABLE website https://lacted.org/
The Role of Host and Fungal Factors in the Commensal-to-Pathogen Transition of Candida albicans - a paper discussing the mechanisms by which Candida changes from commensal to pathogen
Mammary candidiasis: A medical condition without scientific evidence? - the Jiminez et al paper - one of the key pieces of evidence we have that demonstrates that Candida is not the cause of nipple/breast pain

NCBI - WWW Error Blocked Diagnostic - study looking at alternative explanations for breast/nipple pain

MiLC https://www.facebook.com/groups/480916214609440/

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

This transcript is AI generated.

[00:00:00] Emma Pickett: I'm Emma Pickett and I'm a Lactation Consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end.

And I'm big on making sure parents get support at the end too. Join me for conversations on how breastfeeding Breastfeeding is amazing and also sometimes really, really hard. We'll look honestly and openly at that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk.

I'm really honoured to be joined today by Dr Naomi Dow, who is a GP and an IBCLC from Aberdeenshire in Scotland. She is also a medical educator who teaches medical students. So she's the perfect person to do some educating for us today. We're going to be talking specifically about thrush and breastfeeding, although I could ask her about any aspect of infant feeding and breastfeeding.

She and I have worked together over, gosh, how many, when did we first start doing those fact sheets, Naomi? Must be a good four or five years ago. Pre COVID I think, wasn't it? Yeah, definitely 

[00:01:21] Naomi Dow: pre COVID, yep. 

[00:01:21] Emma Pickett: So we did some fact sheets on. Cow milk protein allergy and also breastfeeding older children, although I'm not going to remotely pretend that I did anything like my equal share because Naomi was absolutely the lead author and those of the rest of us were editors and her supporters, but today, as I said, we're going to really focus on thrush and breastfeeding because that's something that Naomi's been looking at in detail and doing some education around.

So I'm really grateful for you joining me today, Naomi. Thank you. 

[00:01:49] Naomi Dow: Thanks Emma. Thanks for having me. I'm happy to be here and looking forward to everything we're going to chat about. 

[00:01:55] Emma Pickett: Great. So before we get stuck into Thrush, which sounds a bit gross, now I say that phrase, before we talk about Thrush, um, can I just start a little bit by asking you about your journey on becoming an IBCLC?

How did you get there? 

[00:02:06] Naomi Dow: Yeah, absolutely. So I suppose I got into. The world of breastfeeding supports in probably quite a similar fashion to many other people, which was through my own parenting journey. Um, so I had my, my daughter. Just the year after I qualified as a GP, and when I was pregnant with her, I, I knew that I wanted to breastfeed, and I thought I knew a little bit about it, and, um, didn't particularly foresee any, um, issues, and thought it would all be sort of fairly straightforward, um, and then she was I was born at 37 weeks and suddenly I had an early term, small, sleepy, jaundiced, tongue tied little baby and I didn't have the foggiest what I was doing and yeah, it was, it was really, it was really very challenging.

I had a really tough time breastfeeding her. I did get there in the end. I had some not great support and then I had some really great support as well. And I suppose one of the sort of key aspects for me was that I went to my local breastfeeding support group when she was two weeks old. And, um, I met the most lovely, um, ABM breastfeeding counsellor called Claire there, who I think you know as well, Emma.

And Clare was brilliant and I, you know, we, we did get there and then that breastfeeding support group very rapidly became my little tribe, um, and they were such a, such an important part of my, of my maternity leave, of my motherhood journey and I really felt that it was, I felt like it was such a defining part of my motherhood, um, was that.

breastfeeding experience and, and that peer support experience. And so when Jessica was still a baby, I decided to do peer support training myself, which I did through the ABM Association of Breastfeeding Mothers. And I then went on to run that same local breastfeeding support group, um, for several years, got into some online breastfeeding support training as well.

Um, and really just, um. I found the experience so, I guess, satisfying and just, I really felt like it, um, it added something to, to kind of my, sort of, personal satisfaction and, uh, and, and loved it. And then when my son was born, so he was a lockdown baby, I felt at that point I'd had really quite a bit of experience as a peer supporter and felt, um, pretty well prepared, uh, for, for breastfeeding him.

And, uh, Then he was born, also tongue tied, and I had another sort of challenging journey with him for some slightly different reasons. And with him, I got some support from an IBCLC and, um, that made such a difference. It was, it was really, um, it was really an incredible difference. And While I was on maternity leave with him, um, I kind of thought, do you know what, why, why do I look at doing this?

And, um, so yes, I spent my maternity leave studying super hard for the exam. Uh, and um, yeah, so, um, kind of past the exam, just, uh, just after I'd gone back to work and, um, yeah. And so here I am now and yeah, so it was, I, I guess all through, through my, my own sort of motherhood experience and realizing the value of, of breastfeeding support at all levels.

[00:05:39] Emma Pickett: Gosh, yeah, so you got sucked into it. I really did. That thing in The Godfather where he says, I can't get out, I've been sucked in. Once you've been sucked into lactation world, it's hard to get out of it. It really is. And we're very lucky that you happened to be a GP because you could have been, you know, somebody who dug up roads and wouldn't necessarily be in the medical education world on top of being an IBCLC.

So you've got those amazing skills as a GP obviously behind your work as an IBCLC as well. What does a sort of typical work week look like for you at the moment? 

[00:06:10] Naomi Dow: So I have, I have numerous jobs, um, I, so I, I work just kind of as a, as a regular GP sort of doing normal NHS clinical work, um, just like any other GP does, um, I work I work, uh, at the University of Aberdeen, so I'm a senior clinical lecturer there and I lead a team of, uh, 22 GP tutors who are teaching medical students, um, and, uh, we're teaching them about sort of all aspects of general practice, um, so that role, I do do some direct teaching, but quite a lot of it is sort of, um, kind of management related.

And then my third page role is doing, um, a small amount of private IBCLC work. So, majority of the clients I see are home visits, that's why I like to do best. There's nothing just quite as satisfying as getting somebody tucked up in their own bed, uh, with their, with their newborn. Um, so those are my, my sort of paid roles.

Um, and then I'm heavily involved with MILK, which is the Medics Lactation Community. So this is, at the moment, it is a Facebook group, and we've got about, just coming up for 3, 000 members now of UK and Irish doctors, and a few medical students as well, and yeah, at the moment our, um, our role is providing peer support, um, to those doctors, so it's doctors providing peer support to other doctors.

But we've got some really exciting plans coming up for the future around education and advocacy, because we think we're in a great position to be able to further that area of work. So, yeah, so within MILK I'm a peer support lead. So we've got a large team of peer supporters who've all done peer supporter training, a lot through the ABM but some through other organisations as well.

And we are a really busy group, we have a lot of posts going on every day, and yeah, it's such a great way of spending time doing peer support as well as sort of, you know, and supporting others. And it's been so lovely to see our peer supporters are growing confidence and skills as they, as they spend time sort of answering all these often quite complex questions that our members put up and, uh, complex scenarios that they find themselves in.

[00:08:28] Emma Pickett: Yeah. Um, I, I know I don't need to tell you this cause this is the core of what you do, but there's, there's something so beautifully simple about When you support a doctor to reach their breastfeeding goals, the ripple effect of that is felt throughout their community, through the generations of parents they'll support, through the generations that follow those generations.

I mean, it's such a powerful thing to do because, you know, those of us who've met doctors who haven't met their breastfeeding goals and are, you know, maybe in a place of still feeling anger and resentment and all sorts of complex feelings. It's very difficult for them to be able to then support somebody to be with their breastfeeding journey, so it's such important work that you do not just add the advocacy stuff, but just the very simple task of of helping a doctor to be able to breastfeed for as long as they want to breastfeed is super important.

So thank you on behalf of the lactation community for, for the work that you're doing and I'm going to ask you for some links and info that we can put in the show notes so if anyone's listening to this and they'd like to learn more they can, they can find you. How many GP IBCLCs are there in the UK and is there any way of finding out how many there are?

[00:09:33] Naomi Dow: I don't think there's 

[00:09:33] Emma Pickett: an 

[00:09:34] Naomi Dow: easy way of finding out. I mean, obviously there's the Lactation Consultants Great Britain, um, sort of directory where you can look, but, uh, you know, that information doesn't sort of filter it down by sort of if people have got other roles or not. So, to the best of my knowledge, and I'm really happy to be corrected on this if I've, um, if I've missed anyone, but I don't believe there are any other UK.

I think there are around about 10 doctor IBCLCs, um, who come from sort of a variety of, um, sort of. backgrounds and specialties. But yeah, I think it's, it's definitely, um, not a common thing to do in the UK. In the U. S. and Canada, there's very much a sort of established, um, fairly newly established, but, uh, there is a sort of breastfeeding medicine specialty, um, but that's not recognized at all in the U.

K. as yet, but, um, watch this space, you never know what might happen in the future, but yeah, I mean, I think it's, it's certainly more common in the U. S., it's, it's pretty unusual in the U. K. 

[00:10:35] Emma Pickett: Yeah. I mean, I guess it's a side effect partly of the IBCLC record, you know, qualifications not necessarily fully recognized across the UK.

Whereas in the States, you know, you were going to find a lot more people in hospital settings and a lot more people in, you know, private insurance world, um, who are formal IBCLCs. Yeah, some way to go, but I'm excited to hear about your plans because it sounds like the watch this space is always a good phrase.

Let's get stuck into the thrush because we could talk about the general world of lactation for another hour, but let's get stuck into the thrush. So what is thrush? Let's start with the absolute basics for anybody who doesn't know. Even before we talk about breastfeeding, what is thrush and why does it cause humans problems?

[00:11:22] Naomi Dow: So thrush is an infection of candida. So candida is a type of fungus and I think there's a lot of there's a lot of Unnecessary fear about candida and thrush And so I think the first thing to say is that most of us carry candida in or on us And and that's that's not a bad thing. That's it's it's meant to be there.

It's part of our microbiome So there's been lots of chats in the news Social media over recent years about the guts microbiome. But we've got microbiomes elsewhere on us as well in our skin, in our vaginas, in our, um, in our breasts. Um, and candida is a, a sort of normal part of the microbiome in the vagina and in in our mouths as well.

So it's, it's meant to be there and, um, it's not something that we should be trying to eradicate. Thrush happens when that sort of normal, sort of low level lumbers of it, sort of rapidly increases and the, the Candida fungus becomes the sort of dominant microbe, um, within that environment. So as part of our microbiome, we've got multiple different sort of bacteria and fungi and, and Candida is usually just kind of a small part of that.

But when those candida numbers sort of rapidly increase, um, and they become the sort of dominant microbe, that's what we call thrush. So you might have heard of the medical term for it, which is candidiasis. Um, but yeah, colloquially we know it as thrush. So, um, I think it's It's important to say that the vast majority of the time Candida doesn't cause us any issues at all, but there are certain circumstances under which Candida can change from being a commensal to being a pathogen or being an infection.

And those circumstances happen when something in the host environment changes. So those low levels of Candida that we normally have in our vagina, if the host environment, so there's something within the vagina changes. That's when those candida levels can really, um, increase rapidly and become a thrush infection.

[00:13:34] Emma Pickett: Okay. Okay, thank you. Um, right. Okay. So let's talk about breast thrush and nipple thrush. I'm going to sort of give you a picture of a conversation that I've been having with a mum over the last few weeks. And I, and I've got her permission to share this, although I'm not going to share any distinguishing features.

So we can't necessarily work out where she is or who she is. So this is a mum I've met several times with my volunteer hat on, because I volunteer in Haringey, North London. And all the time I've known her, she's been having difficulties with positioning and attachment. So she's never been entirely pain free with her breastfeeding.

Baby is about five weeks old when we start hearing stories about thrush. So she went to see her GP. Her nipples were quite pink, pinker than normal. And she had a little ring of bright pink that sort of went beyond the nipple into the areola with a sort of fairly distinctive line. They felt sensitive to the touch and the baby does have some whites on the surface of their tongue.

She went to the GP and the GP was absolutely confident and adamant that this was nipple thrush. Um, gave the mum some myconazole cream, gave the baby some nystatin, um, to be given in a dropper. Um, and then I met the mum five, five days after treatment had started and there was no difference to her symptoms at all.

When you hear that story, which is not an unusual story in the world of breastfeeding support, what are, what are some of the things that strike you? 

[00:14:55] Naomi Dow: Yeah, I mean, I think anybody who has worked in breastfeeding support for, for any length of time will recognise this story. It's so common. And I guess there are, there are multiple things to unpick here, aren't there?

So, um, I guess when somebody has got, um, when somebody has got pain while breastfeeding. You know, all medical knowledge aside, the first thing that we should always be looking at is positioning and attachment because, you know, this is by far and away the most common cause of, of nipple pain. And I think, you know, looking at positioning and attachment is, is a real skill.

This is not something that can be done in a 10 minute appointment by somebody who's not trained to do so. And I think the, the thought of, of actually spending that time and sitting down with this mom and baby. And looking at how they are coming together, looking at how that attachment is actually taking place.

I think for, um, you know, for, for any breastfeeding peer supporter, yes, that's, that's what we do. That's what we're skilled at. But, yeah, that takes time and training to do. That's not something that can just be, be done by, by anybody. And certainly I think it's, um, If you've been given a message of, you know, nipple thrush causes pain and, um, and, you know, if the baby's got a white tongue, then it's definitely thrush and they both need treatment.

That's certainly the easier option is to kind of go down that route. And, you know, although we're talking about sort of, um, you know, this whole, um, sort of concept of, of nipple or breast thrush today, I think, We also need to touch upon the concept of oral thrush, which absolutely is, is, is true. It is something that happens, but it's hugely over diagnosed and I think this is something that causes people an awful lot of, um, stress and worry when they see that their baby has got a white tongue.

And, you know, you know, true oral thrush, as I say, it does happen, but it's, it's relatively unusual actually. But when we see that sort of white tongue, um, which is usually just milk on the tongue, and then we've got somebody with sore nipples, I can absolutely see why, why people sort of join those dots and, and come up with, come up with nipple thrush.

It's really frustrating that we're seeing so many people who are, um, going down this route of, of kind of thrush. Getting this treatment that is ineffective for them, and then they're left with the same problem. And when we've got somebody who's got poorly managed nipple pain, obviously they're at risk of stopping breastfeeding before they're ready.

And that's something that, I guess, as breastfeeding supporters, we're all trying so hard to try and avoid that scenario. That's, you know, we're wanting to help people meet their goals. So yeah, it's, it's, uh, it's, it's a lot to unpick and, um, and I'm sure we'll talk about some aspects of it a bit later, but I, I suppose, you know, I, I guess the other thing to say is that I have a lot of sympathy for GPs who are not trained in infant feeding who kind of go down this route and I, and I'm not sure that, um, I'm not sure that there's any value in sort of pointing the finger at them when there's lots of information kind of out there about, you know, this is nipple thrush and you, you have to treat mum and baby at the same time and.

You know, it's, it's difficult when there's lots of conflicting and confusing information out there. So, yeah, I think it's a complex picture. 

[00:18:19] Emma Pickett: Yeah, I mean, nobody can do anything in 10 minutes when it comes to breastfeeding. Positioning an attachment in 10 minutes, you know, the most experienced breastfeeding counsellor, lactation consultant in the world, won't be able to analyse what's happening in that short time.

And, and parents often do want answers. And, you know, historically we've also given GPs a hard time when they say, there's nothing I can do for you. Um, you know, and not, I'm not saying this particular mum pushed for this resolution, but you can see how doctors will often say, well, it might be, you know, this medication doesn't necessarily have a lot of side effects.

You might as well try. I mean, that's giving somebody hope and, and some sort of control over their world. The thing about the white on the tongue, I would say that this mum also went to see her health visitor. And the health visitor said, nah, that's not thrush. Thrush is not, um, it's not just a white tongue, which I was very happy to hear her say.

Um, you know, oral thrush doesn't stay in a very neat, thin little strip along the back of her tongue. Oral thrush, you know, likes to go in funny places and you get kind of cottage cheesy chunks and cottony bits and little patches on the inside of the lip. Um, so yeah, if you've just got a little bit of white on the baby's tongue, very, very, very likely to just be milk or some skin cells hanging around, um, depending on what's happened to baby's palate or tongue as well.

Just to update you on that story, she was then pushed, she then pushed for a swab and was given a little plastic spoon, which nothing came off, nothing came off and we'll talk about swabs in a minute, but um, she then pushed for a, a charcoal swab and that came back negative. And, um, she eventually. became more comfortable with more work on positioning attachment with the group that I've been working in.

Um, but definitely took that, you know, that medication for, you know, several weeks before that, that resolved entirely. Yeah, not easy. So when I first started in breastfeeding support, which is now coming up for sort of 17, 18 years ago, it was, it was super common to talk about nipple thrush and also even thrush, you know, deeper in the breast.

We talked about, um, you know, the symptoms of feeling deep pain that would, we were told that it would get worse as the feed progressed, as the breast emptied, the pain would get more. It would feel like cut glass, daggers, needles pointing into the breast, all these very specific terms were used. And we were told that mums should ask for fluconazole, um, should start with a loading dose on the first day.

It was very, very strict and you start with your loading dose and if you didn't get the loading dose, that's why it's not working properly. Um, and then if that didn't work, you got your second course. We were really guided in this very firm way that this is how you treated breast thrust. And breast thrush and nipple thrush, we didn't even dispute that that might not be a thing.

Let's start with a simple question. Do we have any evidence that, that thrush grows deep in the breast and grows in milk ducts and causes problems deeper in the breast? 

[00:21:11] Naomi Dow: So, um, it's a lovely simple question, but I apologize. I'm not going to give you a simple answer. That's okay. So, um, When we think about thrush, um, so when we spoke earlier about when thrush changes from a sort of commensal to a, to a pathogen.

[00:21:27] Emma Pickett: Can I ask a dumb question? Commensal just means around and being normal commensal is just 

[00:21:32] Naomi Dow: part of the normal microbiome, so just kind of part of you. Um, so we are all covered in bacteria and fungi, that's kind of, that's normal. Humans are not supposed to be sterile. And so, um, When we think about thrush developing somewhere, the places that thrush likes to hang out are kind of your warm, moist areas.

So that's why the mouth and vagina are kind of the two sort of hot spots for, for thrush. That's where we most commonly see it happening. It can grow on the skin in certain circumstances. Um, but it doesn't grow on the extremities. It doesn't grow on the tips of the fingers, the tips of, uh, the toes. It doesn't grow on the tip of your nose.

And the nipple is also viewed as, as an extremity. It can, under very rare circumstances, infect, um, sort of deep internal organs. However, this only happens in people who've got a really, really, uh, compromised immune system. So that would include people undergoing chemotherapy. Bone marrow transplantation, or a sort of, um, a congenital, sort of profoundly compromised immune system.

So people who don't have a normally functioning immune system, they can get internal infections with thrush, and that includes thrush actually in the bloodstream, so you might know that as sort of septicemia. And people with these deep infections of thrush are critically unwell. These are people in intensive care units who are fighting for their lives.

So this is a very, very different situation than a sort of superficial skin infection, um, or an infection in the, in the mouth or vagina. So, when we think about, um, thrush in the sort of lactating breast or, or nipple, we know beyond doubt that candida can be isolated from, from the nipple. So, if you, if you swab lots and lots of nipples, you will get, uh, some candida growing on, on some of those swabs, but, um, as we spoke about before, um, it's very, very common for people to have, um, candida growing in their mouth, and that includes babies.

And so, in breastfeeding, it's not unusual to find candida on a nipple swab because there is, um, transfer of that commensal, of that, of that sort of normally growing candida in the baby's mouth onto the, the, um, onto the, the nipple. But that doesn't mean that it's an infection. This is, this is low level candida, small numbers of candida that become part of the, the nipple skin commensal.

Now, when we think about the breast and, and actually, um, what's in the ducts, what's in the, what's in the milk, there are conflicting results depending on which study or studies that you look at, and I think quite a bit of this, um, sort of conflicting information comes from how the, the milk samples in the studies are actually collected.

So, if you, um, if you sort of just kind of wipe the nipple and then, and then take a milk sample, hand expressing the milk out of the breast, you'll get a candidate growth in quite a few of the milk samples. But again, that's coming from, from the nipple and we know that if we have a milk sample that doesn't have any candidate in it.

And we deliberately add candida to it in a, in a laboratory setting. Candida grows really, really well in the milk. Milk is a great kind of growth medium for that, uh, for that to grow in the lab setting. But if you collect a milk sample having really, really thoroughly washed the nipple, Uh, multiple times with disinfectant, and you then take a milk sample from it.

The number of, of milk samples that actually have candida growing in it is really small. There is a small number growing in it, but again, this is low levels of candida. This isn't levels that suggest that the milk ducts are actually infected with candida. Rather, it's, it's just a, a small amount of, of candida within the milk.

Um, we know that breast milk is not sterile, it's absolutely teeming with bacteria, um, and again, they're supposed to be there, that's, that's part of the breast milk microbiome, nobody produces sterile breast milk, and in some people, they will have a small amount of canceta in their milk, that doesn't mean that the, that the milk ducts are infected.

[00:26:09] Emma Pickett: Okay. So just sort of. If someone is a healthy person without a compromised immune system, we don't really have a reason to believe that their milk ducts will be infested with high levels of candida. That doesn't seem entirely logical based on what we know of how infection develops and what happens to bodies.

So if someone is experiencing that deep breast pain then, you and I can both brainstorm this, the answer to this question. What could be going on for somebody if they're experiencing deep breast pain? Breast pain. Towards the end of a feed or after a feed, tell us some of the things that could be going on instead.

[00:26:43] Naomi Dow: So, um, at the risk of sounding like a broken record, I would again come back to positioning and attachment. So, when we think about, um, the sort of nerve supply of the nipple and breast, I think this is a really important point to understand why problems with the nipple can cause breast pain. So, the breast and nipple have got a really rich nerve supply and, um, and that's needed because When our baby is latched onto our, our nipple, um, that sends signals back through the breast up to our brain, um, to allow the milk ejection reflex, so the letdown, um, of the milk to happen.

If we didn't have that nerve supply there, and indeed for people who don't have that nerve supply there, they can have real problems with that milk ejection reflex. But the downside of that is that if you have got problems with the nipple, whether that is through. Um, positioning attachment, or it's through nipple trauma, nipple wounds, dermatitis, whatever it might be, that can cause this really sort of deep, um, pain sort of much, much further back in the breast.

Um, so, you know, whenever there is, there's pain at play, whether it's nipple or breast or both, I will always look at positioning and attachment as sort of a first, first port of call. But if positioning and attachment has been, has been optimized and there is still pain. There are, um, multiple other things I would be sort of considering as a, as a cause for pain.

So, Um, probably one of the most common things that I see is, is dermatitis of the nipple. So kind of inflammation of the skin of the nipple. And dermatitis of the nipple can be, um, I think it can be overcomplicated by people sometimes. So dermatitis of the nipple is really very similar to dermatitis of other parts of our body.

So, um, you get different types. You get sort of, um, atopic dermatitis, which people might know better as eczema. And just like you can get eczema on your arms or legs, you can get it on your nipples as well. And often people who've already got eczema somewhere else in their body will find that they get it on their nipples as well.

Um, and that can be exacerbated during breastfeeding. You know, the symptoms of that can be, can be worsened during breastfeeding, but it's, it's a really, really treatable condition. Other types of dermatitis that we can get on the nipple are sort of allergic or contact dermatitis. And again, I see quite a bit of that during breastfeeding because very often people will be applying things like lanolin to their nipples.

And some people get on fine with lanolin. You know, I don't want to say that it's, that it's, it's never, it's never suitable. You know, if you get on fine with it, if you find it helps, then, then fine, don't let me stop you. But there are, there are a number of people who are. Um, who, who are sensitive to the lanolin and, and it will cause irritation to their nipple.

And again, when that nipple is irritated, when that skin barrier is broken, that can cause really quite severe pain both in the nipple and further back in the breast. Um, so dermatitis is certainly something that I would be considering. 

[00:29:52] Emma Pickett: Yeah. Can I just pause you for a second there? What you were saying about that deep breast pain, I think that's just super important just to reinforce that message.

If something is happening just on the nipple, you can still get that, even back pain. I mean, the intercostal nerves send signals all over the place. I mean, it's a, it's obviously a very sophisticated nerve system, but sometimes a bit daft in that, you know, the referred pain flies all over the place and, and you can have absolutely nothing going on deeper in your breast, but you're, Your brain receives that pain as having come from deeper in your breast.

And, and that can absolutely happen between feeds. That doesn't necessarily, you know, positioning attachment pain doesn't just have to be at the beginning of a feed when your baby is first latching on. It can be at any point. So I think that's, that's super important. And I, and thank you for highlighting dermatitis.

And I did, I did wonder, the mother that we're talking about, She'd started using lanolin around the time that this pink area appeared. And I did have a couple of conversations with her about maybe experimenting with something else and to see if that was the cause. People are often doing things with their nipples that they've never done before and, and, you know, whether it's putting them against a bleached breast pad or, you know, whatever it might be, it's, you know, it's, it's an unusual experience for that nipple, those first few weeks of breastfeeding.

And I also want just to shout out about silver cups. I think we're seeing a lot and lot of silver cup use and another mum, separately from this one, who actually also gave me permission to tell her story on social media. told me how, you know, she was thinking she must have some kind of infection and her nipples were really red and they were red the whole time and she was going to have to go to the GP and she'd been wearing the silver cup constantly, non stop.

And I said, well, I wonder whether maybe your nipple's just asking for a bit of a bit of oxygen. So I suggested that she, she maybe took it off and she literally messaged later in the day and said, Oh, it's gone. The red's gone. I just needed a few hours without the silver cups and it's 

[00:31:48] Naomi Dow: gone. Excellent. I think the silver cups are really divisive, aren't they?

Because some people genuinely do find them helpful. And again, you know, I'm not going to deny anybody's experience. If they find them helpful, then that, then that's great. But yeah, I think like you, I, I, I definitely see a lot of downsides of, of using silver cups and particularly if there's a wound on the nipple, because the, the nipple is just sitting in, in milk often in the, in the silver cup.

It's just bathing in this really high water content milk. And that skin just breaks down further and you've got delayed wound healing and um, yeah, I would definitely issue a note of caution with silver cups for sure. 

[00:32:26] Emma Pickett: I saw someone today describe it as trench foot. Yes, trench nipple. Yeah, I mean that's literally what was happening in the First World War.

If you're keeping a, keeping damaged tissue wet, it just starts to absorb water and you get this kind of soggy, wet, white looking nipple. Absolutely. And, you know, as you say, it's not about saying. Don't ever use them, they're evil. It's just about, you know, everything in moderation. And even the silver cup people, I'm pretty sure in their silver cup meeting are saying, you know, we need to make sure people don't use it 24 hours a day.

And this mum I mentioned was literally sleeping with them on, um, which is why her skin was going, ah,

a little advert just to say that you can buy my four books online, you've got it in you. A positive guide to breastfeeding is 99 P as an ebook. And that's aimed at expectant and new parents. The Breast Book, published by Pinter and Martin, is a guide for 9 14 year olds and it's a puberty book that puts the emphasis on breasts, which I think is very much needed.

And my last two books are about supporting breastfeeding beyond 6 months and supporting the transition from breastfeeding. For a 10 percent discount on the last two, Go to Jessica Kingsley Press, that's uk. jkp. com, and use the code mmpe10. Makes milk, pick it, Emma, 10. Thanks. We used to talk about thrush being red nipples and, and if you've got a very, if you've got pale skin tone and you've got a very cherry pink nipple, that's thrush.

And as you say, there are so many other things that can look like that as well. And, and a bacterial infection, how common is a bacterial infection on the nipple? 

[00:34:11] Naomi Dow: Yeah, so pretty rare, um, the nipple is, is, is really, um, well protected against infection. Um, it's very, uh, vulnerable to things like dermatitis, particularly if we're doing things like lanolin and bathing it in milk and all those sorts of things.

But it's really quite well protected against, um, infection. The nipple and breast have got a fantastic blood supply normally, but during lactation that blood supply increases further. And that blood supply is really, um, protective against infection. It's also got a, um, a very extensive lymphatic system, which is part of the immune system.

So that, um, sort of drains excess fluids away from, from the breast and also has got sort of immune functions in terms of, um, sort of fighting against sort of microbes that shouldn't be there. Um, so it's, it's really well protected against infection and Yeah, we'll come on to talk about swabs later, I guess, but I very often see people saying oh, you know I've got this, this horrible nipple wound and it's not healing, so I think it must be infected.

And actually, if you treat nipple wounds the way they need to be treated, with the correct treatment, actually they heal really well. Some more complex wounds do take, um, do take a bit of time to heal, but for your sort of, your standard, um, sort of little split in the nipple that's often just caused by the sort of suboptimal.

Positioning and attachment, actually if you treat it in the right way, so with a moist rather than a wet wound environment, um, it actually heals really, really well, um, and Um, infection is, is not something that I see often at all. Um, it's Okay. 

[00:35:58] Emma Pickett: Can I pick your doctor brain? And I know the answer to this is there isn't one answer to this, but if you are talking about nipple healing and let's say someone does have a crack and positioning attachment has been corrected, what are some of your favourite go tos?

[00:36:11] Naomi Dow: So it depends what the wound looks like. Um, so, um, for, for most, for most wounds, um, I will, uh, uh, suggest sort of, um, Moist wound, um, healing environment, so things like hydrogel dressings and, and that sort of thing. And I suggest keeping these on 24 7, um, so just taking off for feeding and for going in the shower.

Um, but otherwise keeping it, keeping it covered. Um, I, I don't, I don't suggest putting breast milk on, on wounds. Um, and I know that is something that was suggested in the past, and I think some people do still advise that. But if we think about what's actually in breast milk. Aside from all the amazing, unique properties of breast milk, it is mostly water.

It's got a very high water content, and, you know, if we think about, um, if we sit in the bath for too long, um, and our, our fingers and toes go, go wrinkly, um, that's exactly what happens to, to the nipple if you're, if you're bathing it in breast milk. So a moist wound environment is, is kind of the, the, the go to for, for most cases.

For some wounds that are really, really weepy, that are sort of, um, leaking a lot of fluid, so these tend to be sort of deeper wounds, then different dressings are required, so sort of, um, they're known as kind of like filler dressings, um, so things like polymeme, um, but they are, they are the trickier wounds to heal, and they can take quite a bit longer, and they, they do normally need a bit more sort of specialist input to get them healed.

[00:37:45] Emma Pickett: And we're healing without a scab. We don't want that dry scab to form on the top and then just flies off with every feed. We're sort of healing from the inside outwards, which is something that people aren't necessarily used to. Coming back to that, that conversation about the very cherry pink nipple. So that could have been a nipple that maybe had dermatitis or abrasion damage or something else was going on, you know, some sort of allergic reaction.

But there were also photographs around, never enough because we don't ever talk about people with dark skin tones enough, but there are some photographs in the literature which show sort of hyperpigmentation and talk about, you know, if a black woman has thrush, she may lose pigment on her areola and she'll have these white patches.

I'm thinking of one photograph in particular, which Catherine Watson Jenner has in one of her books. If a black woman has got white patches on the areola, what's, what could be going on there, what could be causing that loss of pigment? 

[00:38:37] Naomi Dow: I think it's a great question. So, hypopigmentation is just the medical term for kind of, um, lighter pigmentation or loss of pigmentation and this is most obvious to see in, in people with darker skin.

But it, it can happen in all skin tones and there are lots of different causes for hypopigmentation but probably the most common one that I see in this particular scenario is something called post inflammatory hypopigmentation. So if somebody has had a lot of inflammation, Um, on their skin, usually caused by some sort of a dermatitis, um, although it can be trauma related as well, then, um, it's not unusual to see a loss of pigment in that, in that area of skin, and this is usually a temporary thing, um, you know, it will, it will come back, um, and there are various theories as to why this happens.

Um, but it's probably something to do with, um, damage to the melanocytes, which is the cells that produce melanin. Interestingly, you can get hyperpigmentation as a post inflammatory change as well, so kind of extra pigmentation, so darker skin, which, um, conversely is more obvious in lighter skinned individuals.

Um, and again, um, see this a lot, um, particularly in children who've got sort of poorly controlled eczema. You know, quite often you'll see, sort of, on the insides of their elbows, they'll get, you know, a sort of darker patch of skin and that's just because they've had lots and lots of inflammation from, from poorly controlled eczema.

So, I mean, I think it's difficult to say, you know, what one individual's cause is, but that's kind of one of the more common causes I would see. 

[00:40:20] Emma Pickett: Okay. Yeah. And again, we're coming back to possibly dermatitis is what may have caused those nipple symptoms in the first place. Okay. Right. So to pin you down then, Naomi, are you saying, are you saying that, that thrush on the nipple is so unlikely that we should not be considering as part of normal?

Diagnosis for nipple pain, or are you saying it, it, it very rarely does occur, so it should be in the far back reaches of our minds? Where are you on the sort of the spectrum? Okay, so I try really hard 

[00:40:50] Naomi Dow: not to say never or always, because I think, um, there, you know, there are, there's always lots of, you know, muddiness in the middle, isn't there?

And, you know, and I think it can be. I think you can land yourself in hot water if you say never or always a lot because there's always going to be exceptions to the rule, isn't there? From my perspective, there is insufficient evidence in the literature for me to consider thrush as a diagnosis for breast pain or nipple pain.

And I have not personally prescribed antifungals for breasts or nipples. Yeah, for, I don't know, six years maybe? Ever since I first sort of started questioning, questioning this, this, um, this diagnosis as a whole. And I've, yeah, I've, I've not, I've not needed to use antifungals. Um, so, um, would I, would I never ever consider it?

I, I, I might, um, under rare circumstances, but I would be considering much more likely causes first. 

[00:41:55] Emma Pickett: How's that for you? Did you have a sort of a, no, that was perfect, that was perfect. Did you have a kind of epiphany? I mean, what happened to you that sort of, cause you know, in those days, six years ago, we all went to the standard leaflets.

We all, you know, everyone was doing the, you know, dactarin gel and dactarin cream. What led you to think, hang on, we need to think about this. Was there some sort of big day? 

[00:42:18] Naomi Dow: Um, no, it was, it was a gradual process really, and I've definitely got people to thank for, for this. So, when I was doing my peer supporter training, I was taught about nipple and breast thrush.

That was part of the, part of the course, and it didn't sit right with me. It just, it didn't, it didn't make sense to me because it didn't tally. With what I'd been taught as a medical student and as a doctor about candida. It didn't, it didn't, you know, um, make logical sense to me because of what I knew about how candida grows and how it changes from a commensal to a pathogen and all those sorts of things.

So, so that didn't make sense to me, but, um, I, I kind of went along with it because I, when I became a mom, and I started breastfeeding. It very rapidly dawned on me how little I knew about breastfeeding. So I, I kind of, um, I accepted it and sort of parked it in the back of my brain of, yeah, this doesn't tally with what I know about, but there's lots of things that I didn't know about breastfeeding.

So, sure, let's go with it. 

[00:43:24] Emma Pickett: So you suppressed your doctor's science brain because you thought, I am humble in this world and, and this lactation world must know what they're talking about, and it turns out we didn't really. Well, no, 

[00:43:35] Naomi Dow: I, honestly, Emma, I think motherhood has been the most humbling experience of my life.

There has been, um, I, I honestly just did not know what I did not know, um, and you know, so it's been a, it's been a real sort of journey for me and I love the way that it's sort of impacted, you know, my professional and personal lives have just kind of, um, have kind of met in the middle really. But yeah, I, I suppose it, it never made sense to me, but there was all these, um, sort of guidelines online about, you know, how to treat breast and nipple thrush it and.

So, I guess I kind of went along with it for, for a while and then as I was sort of studying for my IBCLC exam, I was looking into it further and I was thinking, no, this really just does not make sense. And I remember speaking, um, to my sort of study buddies in my, um, in my LCGB group. Uh, there was sort of a group of us all kind of studying for the exam together, and I remember speaking to him about it and saying, but you know, this doesn't make sense, and you know, what about this, and what about that, and you know, there was really quite a lot of resistance from, from people within the group, which I totally get, you know, I'm not, um, that's not a, not, it's not a criticism of them at all.

And then I, I kind of happened upon a couple of resources which, um, I, I really want to give a shout out to. So one is, um, IABL, which is the Institute for Advancement of Breastfeeding and Lactation Education, which is a group of IBCLCs, breastfeeding medicine doctors, um, breastfeeding supporters from all across the world.

They're fairly sort of, um, US focused or, or North America focused, um. But there was lots of discussions in there which really helped kind of, um, confirm my doubts. Um, and then, uh, the, the other resource is, um, the Physician Guide to Breastfeeding, um, which is written by Katrina Mitchells. It's a, a website, um, that's free to access for everyone.

And it's the most amazing resource with, um, so much useful information. And I suppose Katrina was the one that really sort of, um, yeah, she didn't beat about the bush and she really, she was really just very emphatic about, nope, this is definitely not Thrush. And so that really, that was really validating for me, um, and, and I suppose gave me the confidence to be a bit more vocal about my doubts.

[00:46:02] Emma Pickett: Yeah. Well, thank you for being vocal because I think you've, you know, you're not to say you're the only voice because you are a team of people who are talking about this, but particularly in the UK, you've been really instrumental in asking people to think about what we've historically accepted. And, and as you say, the best people don't know what they don't know, if that makes sense, and admit they don't know what they don't know.

And I think, you know, it's been great to see actually how the, you know, the breastfeeding support world has gone. Okay, fair enough. You know, we're happy to look at this. And, you know, the, the Breastfeeding Network fact sheets were the sort of bible for thrush treatment in the UK and all the, all the charities, you know, if you weren't Breastfeeding Network, you still used the Breastfeeding Network sheets and, and we've seen that we saw them sort of evolve a little bit as, as, you know, they became worried about the overdiagnosis of thrush and obviously overdiagnosis means babies being exposed to medications and some of these medications are not.

So, yeah. are not benign. Um, you know, talk us through some of the medications that were historically used um, for thrush treatment and what the issues are with those. 

[00:47:05] Naomi Dow: Yeah, so essentially the, the medications come in kind of two different forms, either oral or, or, or, um, or, or topical, so sort of creams and things.

The sort of two most common, um, sort of creams that are, are used would be, um, miconazole and um, clotrimazole is the other one. Um, now the breastfeeding network always said that clotrimazole shouldn't be the, the cream of choice. It should be, it should be, uh, miconazole. But certainly I have seen plenty of clotrimazole, so some people might know it as Canon.

Um, that's the sort of, um, brand name for it. Um. Yeah, I've certainly seen plenty of people, uh, putting, um, putting Clotrimazole on their nipples. So, so yeah, those would be the two most common, um, sort of, uh, topical treatments. And then the oral treatment, as you, you've mentioned already, the most common one would be Fluconazole.

And, yeah, I think it's, it's really tricky with these, with these medications. As you say, we want to avoid exposing people to unnecessary drugs where possible. But I think a much bigger, um, a much bigger sort of, uh, I guess risk of using these medications is that if we are treating the wrong thing, then people aren't getting the right treatment for their, for their underlying issue, meaning that their symptoms sort of persevere.

So that, that mum that you described, that you helped at your, your group, you know, I would be worried for her that, you know, if she's got ongoing or if she had ongoing. Um, nipple pain, you know, that wasn't being addressed for the, the sort of correct reasons that she would, um, she would be at risk of, of stopping breastfeeding before she was ready.

Um, you know, and I think that's, I think that's one of the biggest risks. I suppose other things to think about, um, are that for some people, putting antifungal creams on their nipples, um, can actually make the problem worse. You know, if they've got a, a sort of, um, allergic or contact dermatitis going on, then for some people that, that antifungal can actually make things worse.

Conversely, confusingly, for some people with dermatitis, antifungals can actually help a bit because their antifungals have got sort of a mild anti inflammatory effect. So depending on what the underlying issue is and how that individual responds to the cream, it can sometimes help, which I think causes a lot of confusion for people.

And then I suppose the other sort of risk of antifungals, which I guess people might not think of so much on an individual level but I think is really important on a population level, is the risk of antifungal resistance. So I think most people would be aware of antibiotic resistance. It's something that's spoken about quite a lot.

And this has come about because antibiotics have been around for many decades now. We've used them a lot, um, a lot of the time quite appropriately, but sometimes we've used them inappropriately and, um, the bacteria are getting clever. They are, they are getting increasingly resistant and, um, antibiotic resistance is something that I deal with as a GP every day, you know, and this is something that I need to bear in mind and, you know, I, when I'm treating patients with, with bacterial infections, I can't always treat them with the first line antibiotic anymore.

But in addition to bacteria becoming resistant, so are fungi. So fungi are getting clever as well. And although this doesn't tend to be much of an issue for individual people with sort of mild fungal infections, who've got normally functioning immune systems, For people with profoundly compromised immune systems, so the people in the intensive care unit, who are fighting for their lives with a systemic thrush infection, um, they are, there are increasingly common cases of, of, um, of antifungal resistance, um, amongst these patients.

And we need to accept some responsibility for that when we are inappropriately using antifungal medications. We are contributing to antifungal resistance and from a public health perspective, that's important. That's something that we need to be mindful of and that we need to be, you know, we need to be thinking very carefully about, is an antifungal actually the right thing to do here?

[00:51:23] Emma Pickett: Yeah, that's, that's really important. Thank you. Okay. So leaflets have now been removed from the Brass Fiddy Network website. We're not telling people to get their charcoal swabs anymore. As you say, not a lot of point doing a swab when it's around all over the place and it's going to come back positive.

That doesn't tell us an enormous amount. And we're doing a lot of work sort of unpicking previous thinking, um, but there's a little bit of a void I think at the moment where the leaflets have gone and particularly people who've been in practice for a while are a bit, haven't yet had the full education.

So I know you spoke at the LCGB conference, um, last year. And, you know, they've done lots of education around, um, thrush, but we, we need, I think we need something to fill that gap. We haven't quite filled that gap. What do you think needs to happen next in this conversation? 

[00:52:08] Naomi Dow: Yeah, absolutely. So the Breastfeeding Network are working extremely hard.

They are an incredible organization with the most amazing team of volunteers and staff. They have removed the thrush guidance and they are. Not replacing it per se, but they are, um, I guess fleshing out their, um, their information leaflet on what to do if breastfeeding hurts. And they are also going to be publishing a fungal infections, uh, information leaflet, which I think is coming quite soon.

So I've been working, uh, with the Breastfeeding Network on these, sort of providing some, some guidance and some evidence to include in these leaflets. So I hope they'll be really helpful for people. to refer to. I think, in addition to the, um, fantastic work the Breastfeeding Network are doing, I do think we need to be getting this information into other areas as well.

So, I would say that the majority of GPs wouldn't look at the Breastfeeding Network for, for guidance, um, on, on prescribing, which is a shame because there's fantastic information there, but you know, um, not everybody is, is, is clued up about it. I think probably, uh, the most important target next is the NICE guidance, so National Institute for, for Health and Clinical Excellence, um, which is the UK wide guidance that, that we use in, in primary care for sort of diagnosis and management of sort of common medical conditions and.

They have updated some of their information, so, um, I got in contact with them back, uh, in the summer, um, and they have slightly updated their information on mastitis pages. Um, I've, um, asked if they can have a look at their, uh, sort of breastfeeding problems page. And they've said they will do, um, it's not been updated as yet, but I'm really hopeful that that will be updated soon, because I think that will be a real help, because it's a resource that is very familiar to, um, to a lot of healthcare professionals, and I think They will feel, um, more confident and, and, and happier going to their sort of familiar resources rather than one that's sort of brand new.

Um, so I'm, I'm hopeful that that'll be the, the next step in, in this, in this process. 

[00:54:31] Emma Pickett: Yeah. And I think just from talking from the sort of non medical background, I think we need to have more confident conversations about dermatitis, I think, in breastfeeding support training and peer support training. I think, I think we've talked about thrush, we've talked about mastitis, but the sort of dermatitis skin conditions bit needs to be filled out a bit more.

Um, yeah, I mean, I just thinking back to the stuff we used to say at the beginning, I mean gently and violet, am I saying that correctly? I mean that just the pitches of people painting their babies' mouths with this. caustic, nasty purple stuff. I mean, we, we were just absolutely accepting that we were fighting this nasty thing called thrush.

And we, we didn't even question it. And I'm so grateful for you to, for holding your hand up and saying, um, excuse me, can we just think about this please? Because you know, you've made such a difference in the UK and beyond. It's really, really helpful. If anyone's listening to this and they're thinking, you know, hang on lady.

I had thrush five years ago. I know I had nipple thrush. I took my acidophilus capsules. I rinsed my nipples in cider apple vinegar. I, you know, did my dactarin cream. I gave my baby the gel. It went away. That was thrush. Who were these two blimmin women on this flippin podcast telling me I didn't have thrush?

I mean, what sort of messages would you want to give someone who's feeling that way? Or a breastfeeding supporter saying, I supported someone who definitely had thrush and when they took fluconazole, it went away. I mean, what sort of messages would you want to leave them with? 

[00:55:59] Naomi Dow: So, I think the first thing to say is that I absolutely do not want to deny anybody's experience.

And I think particularly for somebody who's had an awful experience with pain or other symptoms, I think, you know, I think we need to be really careful not to invalidate their experience. I know you've spoken before about it on one of your podcasts I listened to a while back about, you know, somebody who sort of put up with, with dreadful, dreadful nipple pain for months.

And then we need to be really careful about how we sort of approach that and say, you know, actually, you didn't need to do that. You know, that's, that's not helpful, is it? Um, to kind of, you know, kind of undermine their experience. Um, There has been sort of greater acceptance of, of, of this, this notion that the breast and nipple thrush is, is not an explanation for pain than I thought there would be.

Um, but there are always going to be people who are absolutely sort of convinced of that. And, you know, I'm not here to tell people what to think. Um, I'm here to share information and, and people can, can do, you know, what they feel comfortable, um, with, uh, about that. But I think, um, The whole sort of thrush thing is, is tricky because I absolutely can understand why people might think it's, it, it, it's, it's thrush, you know, if their, their nipple looks red, if their baby's got white bits in their mouth, their swab might come back, showing candida, um, which as we already spoke about doesn't mean that there's an infection, it just might be quite happily living there and not causing anybody any problems.

They might have gotten better because they've gotten an anti inflammatory effect from the antifungal. You know, so I think all of these experiences are really valid and, um, I think it's so important that we, that we don't undermine those experiences. I suppose from a, from a breastfeeding supporter point of view, um, we've got a responsibility to keep ourselves up to date with sort of, um, the most accurate and relevant guidelines.

And I think the mastitis guidelines is a really good example of this. So. I think probably most of us have changed our, our management of mastitis over recent years. And, you know, that sort of came about from the, um, updated ABM, a different ABM, the Academy of Breastfeeding Medicine Mastitis Protocol, which was released in 2022, which very much emphasized rather than it being a sort of blockage or an infection within the breast, that it's an inflammatory process and therefore we need to focus on anti inflammatory measures.

And I think that has been tricky for, for some people to, to update themselves with, but I, I think this is one of the responsibilities of working with lactating families is that there is new information coming out all the time and we need to keep ourselves, we need to keep ourselves up to date and I think that can be hard for a number of reasons.

So one is that there is a lot of information out there. Two is that there is conflicting information out there. And three, I think if we are to change our practice, change what we're actually doing, what that means is that we need to have that humility. To say, actually, I don't think I got it right a few years ago, and that I, I think I know better now.

And I think that can be really difficult to do, because we're all in this line of work, because we want to really help the families that we're supporting. And so to acknowledge that we might have got things wrong, that's really difficult. That, that's really hard. So I think it's, it's about giving ourselves a bit of grace to say, do you know what, I did the best that I had, that I could do with the knowledge that I had at the time, but now I've got this knowledge and so I'm going to make these changes to what I do.

That's not to say that, um, that the, that you weren't doing a brilliant job before. You were. You were doing a brilliant job before with the information you had at the time, but now you've got some new information and it's time to incorporate that into, into day to day practice. 

[01:00:06] Emma Pickett: Yeah. You described that very well.

That's, that's the journey we need to go on, isn't it? And, and that word grace, giving yourself, like we tell the parents all the time, you know, forgive yourself for the things you didn't know. We have to do that for ourselves as well. That example you gave about the Academy of Breastfeeding Medicine protocol and the mastitis protocol.

We had this really kind of concrete document that came from lots of clever medical people and it sort of filtered down through all the different breast feeding organizations in the UK and without a doubt, the way we approach mastitis has completely transformed in the last, you know, for four years or so.

But with thrush, it's a little bit more difficult because how do you. prove a negative, if that makes sense. How do you kind of have, right, here's this amazing RCT all about how thrush didn't exist. I mean, it's going to be difficult, isn't it, to have the equivalent of that because you are asking people to prove a negative, which isn't possible.

[01:00:56] Naomi Dow: Absolutely. I, you know, I'm under no illusions. I think this is going to be a long, slow process. Um, and I've been really surprised at how quickly the mastitis protocol has been adopted by most people. You know, it has, um, It has changed pretty rapidly and, um, you know, historically if we look at, um, how long it takes for, uh, sort of new information to actually change day to day practice, it's usually many, many years, um, so actually the mastitis has, has happened much quicker.

I suppose the flipped side to that is that, um, I, and I'm sure many other IBCLCs have seen such fantastic results from adopting the new mastitis protocol. Um, you know, I've, I've actually not prescribed antibiotics for mastitis for several years now. And I think the, the proof is in the pudding really. And, you know, if you're seeing great results from something, actually that gives you more confidence to keep going with it.

And as I say, I've not advised or, or prescribed antifungals for, for so long now that actually it's, it's really given me the confidence that yes, the, the, the sort of scientific data is out there, but actually the sort of practical data from my, my sort of day to day practice is actually backing that up as well.

And I think that's, that's very reassuring, um, to know that we're kind of on the right path. 

[01:02:23] Emma Pickett: Yeah, no, that's, that's helpful to know. And I think, I mean, ultimately all we can ask people to do is just, just take another look. I think, you know, question the assumptions, take a bit longer to investigate. check that you really have looked at positioning attachment, you know, make sure you are thinking about dermatitis.

Could they be reacting to something else and just, just taking a step back and not jumping into something and assuming historically what you always said was necessarily the right way to go. Um, and if we just take, you know, another few minutes to think about it, we might come up with a solution, which is obviously going to resolve symptoms in a way that bunging cream on something which doesn't help is not going to.

Yeah, thank you so much for your time today Naomi. I'm really interested to see where you go next with this and I'm looking forward to seeing what comes out on the on the breastfeeding network website. In terms of the nice guidance then, is there a review coming up that people will be able to feed into or is this just about chipping away at the documents on the website?

[01:03:19] Naomi Dow: Um, yeah, I'm not sure, um, I have been in contact with them several times, I'm nothing if not persistent, um, and, uh, we'll see what happens, but, yeah, I mean, ultimately it's, um, I don't work for NICE, so it's, you know, I don't have any sort of sway there, I've, I've shared, um, I've shared the sort of relevant resources with them, and I'm hoping that they'll, they'll have a look at it.

As I say, they did make some updates to the mastitis, uh, page, so I'm hopeful that, um, the, the breastfeeding problems page will follow as well. 

[01:03:51] Emma Pickett: Okay, brilliant. Is there anything we haven't mentioned that you think we should have definitely covered, or anything we haven't talked about? 

[01:03:58] Naomi Dow: Um, I suppose it's just for, um, anybody listening who feels that their positioning an attachment is good and that they don't have dermatitis, I suppose they might be sort of asking, well, you know, what else could it be?

Um, and um, yeah, it might be worth sort of just covering some other potential causes of Yeah, please do. Yeah. Of breast pain. Um. So other things I might consider if somebody has got, um, good positioning and attachment and they don't have any evidence of dermatitis on their nipple, something that, um, that we see quite a lot within the sort of breastfeeding support world is vasospasm.

Um, so this is when the, the blood supply to the, to the nipple is temporarily reduced. Um, and, uh, this can happen as part of, um, if positioning and attachment is not brilliant. Um, but it can also happen just of its own accord. Um, so, um, even if positioning and attachment is optimal, some people will still get vasospasm of their nipples.

Um, and we all get some vasospasm now and then. Uh, that's, that's normal as a kind of response to, to cold. But if, um, if that's happening persistently, that can cause really quite severe pain for, for people. And again, because it's affecting the nipple, um, it can cause pain deeper in the breast as well. And vasospasm, there's, you know, a number of different things that we can do to, to treat vasospasm, but it is really treatable, um, and definitely not something that people need to, need to put up with.

A couple of other causes of, of sort of nipple and breast pain that I see, so, um, one is, is, is dysbiosis. So we spoke earlier a little bit about, um, the breast milk microbiome, so the sort of, um, bacteria and fungi that are normally in milk. If that sort of, um, balance of bacteria gets changed, um, then you can get this thing called dysbiosis where the, the sort of, um, the healthy balance of bacteria has gone and there's now sort of, um, other bacteria that are more dominant within the breast, um, and dysbiosis happens most commonly, um, in, in people who pump, particularly exclusive pumpers, um, when they no longer have that sort of interaction with the baby's mouth.

Um, and you don't get that interaction of the baby's mouth microbiome and the breast microbiome, then you can get dysbiosis. Also see it in people who've got too much milk, so hyper lactation or oversupply. Um, and sometimes in people who've received antibiotics, um, so that those, those can all cause dysbiosis and.

In dysbiosis, the, the, the sort of, um, milk ducts can become narrowed, um, through a sort of biofilm that builds up through, um, through, um, particular bacteria. And when the milk is going through sort of increasingly narrow lumens. Um, that can cause this really sort of deep, horrible, stabbing pain within the breast.

Um, so that's something to think about as well. And then finally, the other thing that I would consider is, is, is nerve pain. Um, so neuropathic pain of the nipple and breast. So, anybody who's had sciatica before will be familiar with, or shingles, will be familiar with nerve pain, where you get this, um, real sort of, um, burning, electric shock, stabbing like pain within the breast.

And neuropathic pain of the breast is not well understood. Um, but it's, it certainly does happen and, um, again, it's, it's, it's, it's, it's a treatable condition. It's not something that people just need to put up with. So I guess my message for, for anybody who's got ongoing pain, despite having optimized their positioning and attachment, Is really to see, um, somebody who's experienced in dealing with nipple and breast pain, um, and, and, and get to the bottom of it, um, because, um, it's, it's all treatable.

It's, it's not something that needs to, that you need to just sort of put up with or, or power through. 

[01:07:57] Emma Pickett: Coming back full circle, we need more Dr. IBCLCs. We need people who've got both those hats on to, to be able to look at that whole picture. And, uh, yeah, thank you so much for your time today, Naomi. I really appreciate it and good luck with your, with your next steps on this.

[01:08:11] Naomi Dow: Thank you so much for having me. Thanks, Emma.

[01:08:17] Emma Pickett: Thank you for joining me today. You can find me on Instagram at Emma Pickett Ibclc and on Twitter at Makes milk. It would be lovely if you subscribed because that helps other people to know I exist and leaving a review would be great. As well, get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast.

This podcast is produced by the lovely Emily Crosby Media.