EDITORIAL COMMENT: We accepted this paper for publication because we thought it would interest readers and probably help their patients. The authors did not obtain confirmatory evidence of infection with Candida in Case 2 which is a pity, especially as the condition did not respond rapidly to nystatin and gentian violet. The editorial committee does not endorse the comments regarding the usefulness of dietary measures in the control of candidiasis. We would be interested to publish a study of a larger series of lactating women with these symptoms, with bacteriological diagnosis, and treatment by a single antifungal agent if C. albicans is isolated. Since the patients took so long to respond to treatment, it could be that an orally active antifungal agent would achieve a superior therapeutic result.

Author's response: Itmay well be that an orally active antifungal agent would achieve a superior therapeutic result, but the only such agent available in Australia at present is ketoconazole which is excreted in breast milk and is not recommended for use in lactating mothers. It is also contraindicated in pregnancy because it is teratogenic, and use in children is not recommended according to the manufacturers, as stated in MIMS 1991.

Thus, we are limited to using nystatin as an oral agent in mothers or infants, or miconazole gel as a topical treatment for oral candidiasis in the infant; nystatin is not absorbed into the blood stream or excreted in breast milk, and the status of miconazole in relation to lactation is not understood, although it is considered safe even for newborn infants.

There is also some difficulty in avoiding use of gentian violet as a topical nipple treatment in nipple thrush because we have experienced some degree of sensitivity to nystatin, miconazole and clotrimazole creams or ointments, probably due to the vehicle rather than the therapeutic agent. This is why we have decided to slay with gentian violet, fully aware of the animal studies which suggest it to be carcinogenic in mice; we have not found any allergic reactions in over 300 users. Thus, a study in which only one antifungal agent was used might be difficult to set up since application of some antifungal substance to the nipple seems necessary to clear symptoms.

We think that we are dealing with a condition which usually develops over a period of several weeks, and which may need a similar time to resolve.

Summary: During lactation, persistently sore nipples or shooting breast pain in the absence of local or systemic signs may be symptoms of C. albicans infection of the nipples and/or breast ducts. The nipple may be erythematous or fissured, but the appearance does not resemble oral or vaginal candidiasis. Case 1 is a woman with sore nipples following a course of antibiotics. Case 2 is a woman with severe shooting breast pain which was worsened by antibiotic treatment. Treatment included topical and oral antifungal treatment for the mother in conjunction with an ‘anti-candida’ diet. The infant's mouth was also treated to prevent reinfection.