Why do we overuse antimicrobials for breastfeeding problems? Dr Pamela Douglas comments during World Antimicrobial Awareness Week 2022
It’s World Antimicrobial Awareness Week, and the World Health Organisation (WHO) is asking us to put a brake on the ‘slow motion catastrophe’ of drug resistance by avoiding unnecessary use of antimicrobial medications. Yet antifungals and antibiotics are widely overused in breastfeeding women, contributing to the crisis of antimicrobial resistance worldwide which already impacts many people’s lives.
Antifungal overuse in breastfeeding women
If a breastfeeding woman has nipple pain, she is quite likely to be prescribed antifungal medications: lotions or drops or ointment to apply to her nipples and her baby’s mouth, and also as capsules to swallow. If her nipple pain persists, she is likely to be prescribed repeat courses. One study even found that women were taking up to 29 oral doses of antifungal treatment (fluconazole 150 mg) over time for persistent nipple pain.1 When you think that if the same woman has vaginal thrush, she might be prescribed just one dose, you can see the scale of the problem.
Serious thrush overgrowth requiring treatment is rarely a complication when a breastfeeding woman has nipple pain, although there will mostly be some Candida involved.2 Yeast normally inhabits nipple skin and baby’s mouth. It’s often part of protective biofilms. To read about the case of Emily, who is breastfeeding a three month old baby and has nipple pain, click here. In the clinic, I’ve regularly seen how serious underlying causes of a woman’s nipple pain have been missed by her health professionals, even as she takes antifungals day after day for weeks or even months. Quite often the application makes her nipples even more susceptible to damage, because of irritative and overhydrating effects.3
In 2020 I took a close look at the research literature, and published a systematic review showing that existing studies don’t support the diagnosis of nipple thrush when a woman has nipple pain (including persistent pain and deep stabbing burning pain between breastfeeds).2 If your doctor or midwife think you might be one of the rare ones who really does have a serious and unusual overgrowth of Candida, repeat courses of treatment aren’t required. And there is no reason to treat your baby unless you and your health professional can see those white films of thrush in your little one’s mouth.
But women definitely need help with nipple pain. You can my blogs about what helps here and here. Unfortunately, and for historical reasons, breastfeeding support remains a research frontier. Often you’ll be told that your fit and hold, or latch and positioning, is fine when other when from the perspective of the latest research about the biomechanics of infant suck, it’s not.4 You might also be interested in our video and animation about how babies suck.
Antibiotic overuse in breastfeeding women
The Academy of Breastfeeding Medicine, of which I’ve been a member for many years, has recently published Clinical Protocol #36 ‘The mastitis spectrum’, which I argue continues to promote unnecessary diagnoses and unnecessary antibiotic use for breast inflammation in lactating women.
In the approach to management of the spectrum of breast inflammation, which I’ve put forward in my own research publications, applying the Neuroprotective Developmental Care evolutionary biology and complexity science lenses, antibiotic use remains essential when inflammation of a lactating woman’s breast is severe and worsening rather than resolving over time with frequent milk removal.5 6 Antibiotic use is also essential if there is an abscess, although there is also no evidence, actually, to suggest that antibiotic use prevents abscess and limited evidence to suggest it helps more than drainage. I analyse Clinical Protocol #36 and its scientific flaws here.
I show in my own work why there is no scientific rationale to the belief that applying the ill-defined diagnoses of subacute mastitis and phlegmon and also ill-defined attempts to distinguish between ‘inflammatory’ and ‘infective’ mastitis will improve outcomes for breastfeeding women. Instead, I suggest these diagnoses will continue high rates of unnecessary antibiotic use in breastfeeding women.5 6
My perspective is not popular because breastfeeding women are often managed with a medicalised lens, applied even by providers who aren’t medical but who offer complementary therapies. In our times of ecological and climate crisis, we face burgeoning trends to overdiagnosis and overtreatment in health systems internationally.7 8 Overdiagnosis and overtreatment is one of the drivers of the terrible antimicrobial resistances which are, according to the WHO, about to crash upon us like a health system tsunami.
Unnecessary new diagnoses may be driven by financial interest, and – from my perspective as a generalist doctor in primary care – also by highly medicalised specialty lenses. Unnecessary diagnoses put us at risk of unnecessary treatments. The United States, home to my daughter and her family, and also to the Academy of Breastfeeding Medicine, is something of an international leader in the trend to overdiagnosis and overtreatment. The USA also lacks a strong primary health care system. Where there is a strong primary health care system (and although our own in Australia is under immense strain it is still amongst the best in the world) doctors are more likely to address complex health conditions using behavioural changes, resorting to diagnoses and medications only if the evidence shows benefit or, if it hasn’t been properly researched, there is convincing pathophysiological rationale.
It seems that many who provide clinical breastfeeding support believe that the more diagnoses and pathologies we identify, the more medical, surgical and bodywork exercise interventions we prescribe, the better care we are offering to a breastfeeding woman and her baby. Yet paradoxically, research across health systems suggests that unnecessary pathologizing and medicalising not only drive up costs for patients and the health system, but increase risks to patients.
I have been very interested in the emerging field of mechanobiology and what it can teach those of us caring for breastfeeding women. Important underlying problems of breastfeeding (how a woman’s body interacts and fits into her baby’s body, mechanical pressure dynamics within the lactating breast tissue, and cellular mechanobiological effects on inflammation) are still often overlooked, even by bodywork therapists - at the same time as we offer her the 21st century silver bullets of poorly defined diagnoses, interventions, and antimicrobials.
Will this change in my lifetime? Backlash against new perspectives within breastfeeding advocacy circles, fuelled by social media, high profile personalities, and commercial interest, can devastate incomes and reputation. Who wants to risk swimming against the tide? Yet for the sake of avoiding catastrophic antimicrobial resistance, and for the sake of our breastfeeding women and their babies, I hope change happens soon. I’ll keep doing my bit as best I can.
Dr Pamela Douglas is an Associate Professor Adjunct with the School of Nursing and Midwifery, Griffith University, and Senior Lecturer at the General Practice Clinical Unit, The University of Queensland. She first qualified as an International Board Certified Lactation Consultant in 1994, and has practiced breastfeeding medicine since then, most recently in the Queensland Centre of Excellence in Lactation Support at The Possums Clinic Brisbane, 10 Park Terrace, Sherwood +61 7 3911 1262
1. Moorhead A, Amir LH, O'Brien PW, et al. A prospective study of fluconzaole treatment for breast and nipple thrush. Breastfeeding Review 2011;19(3):25-29.
2. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health 2021;17:DOI: 10.1177/17455065211031480.
3. Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health 2022;18:DOI: 10.1177/17455057221087865.
4. Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth 2022;22(94):https://doi.org/10.1186/s12884-021-04363-7.
5. Douglas PS. Re-thinking benign inflammation of the lactating breast: a mechanobiological model. Women's Health 2022;18:https://doi.org/10.1177/17455065221075907.
6. Douglas PS. Re-thinking benign inflammation of the lactating breast: classification, prevention, and management. Women's Health 2022;18:doi: 10.1177/17455057221091349.
7. Coon ER, Quinonez RA, Moyer VA, et al. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics 2014;134(5):1-11.
8. Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. The Lancet 2017;390:156–68.