What is the management of oral thrush (candidiasis) in a 21-day-old breastfeeding infant?

From the Guidelines

The management of oral thrush in a 21-day-old breastfeeding infant primarily involves topical antifungal medication and proper hygiene measures, with nystatin oral suspension being the first-line treatment, as recommended by the Infectious Diseases Society of America 1. The treatment should be administered as 1 ml (100,000 units) in each side of the mouth four times daily after feeds for 7-14 days.

• The medication should be applied directly to the affected areas using a clean finger or cotton swab.
• It's essential to continue treatment for at least 48 hours after symptoms resolve to prevent recurrence.
• Miconazole oral gel (20 mg/g) is an alternative option, applied four times daily. Since the mother's breasts may harbor Candida, treating both mother and baby simultaneously is crucial, as stated in the practice guidelines for the treatment of candidiasis 1.
• The mother should apply an antifungal cream like miconazole to her nipples after each feeding. Good hygiene practices include:
• Washing hands before handling the baby
• Sterilizing pacifiers and bottle nipples daily
• Replacing them after treatment Breastfeeding should continue during treatment, as oral thrush occurs due to Candida albicans overgrowth, which is common in newborns due to their underdeveloped immune systems, as noted in the clinical practice guideline for the management of candidiasis 1. If symptoms persist beyond two weeks of treatment, or if the infant develops feeding difficulties or appears ill, prompt medical reassessment is necessary, considering the potential for invasive candidiasis, especially in high-risk nurseries 1.

From the FDA Drug Label

Efficacy of fluconazole has not been established in infants less than 6 months of age. A small number of patients (29) ranging in age from 1 day to 6 months have been treated safely with fluconazole.

The management of oral thrush in a 21-day-old breastfeeding infant is not established with fluconazole, as efficacy has not been established in infants less than 6 months of age. Although a small number of patients in this age range have been treated safely, caution should be exercised when considering treatment options. Fluconazole use in this age group is not recommended due to lack of established efficacy. 2

From the Research

Management of Oral Thrush in a 21-Day-Old Breastfeeding Infant

The management of oral thrush (candidiasis) in a 21-day-old breastfeeding infant involves several considerations, including the treatment of the infant and the breastfeeding mother.

• Treatment options for the infant include:
  • Nystatin oral suspension, although it has been associated with frequent recurrences and difficulty in administration 3
  • Fluconazole suspension, which has been shown to be superior to nystatin suspension for the treatment of oral thrush in otherwise healthy infants 3
• Treatment of the breastfeeding mother is also crucial to prevent reinfection and ensure successful breastfeeding.
  • The mother's breasts can be a continuous source of Candida albicans, resulting in persistent thrush in the infant 4
  • Treatment options for the mother include clotrimazole in a gel form 4, oral fluconazole 5, 6, and topical yeast medications such as tristatin ointment 6
• It is essential to treat both the infected mother and infant to prevent reinfection and ensure successful breastfeeding 5, 4
• A survey of experts in the field of lactation found that the majority of respondents relied primarily on history and physical examination of the baby, but not the mother, to make the diagnosis, and that laboratory tests were ordered only rarely 5
• The most common initial treatment was oral nystatin for the infant and cream for the mother's breasts, followed by oral nystatin for the infant and oral fluconazole for the mother 5