What is the treatment for candidal thrush in babies?

Treatment of Candidal Thrush in Babies

For candidal thrush in babies, nystatin oral suspension (200,000 units four times daily) is the recommended first-line treatment, with fluconazole (3-6 mg/kg daily) as an effective alternative when nystatin fails or is not tolerated. 1, 2

First-Line Treatment

Nystatin Oral Suspension

• Dosage: 2 mL (200,000 units) four times daily 1
• For premature and low birth weight infants: 1 mL four times daily 1
• Administration technique:
  • Place one-half of dose in each side of mouth
  • Avoid feeding for 5-10 minutes after administration
  • Continue treatment for at least 48 hours after symptoms have disappeared and cultures demonstrate eradication of Candida albicans 1

Second-Line Treatment (When Nystatin Fails)

Fluconazole Oral Suspension

• Dosage: 3-6 mg/kg daily for 7 days 2, 3
• Clinical efficacy: In a comparative study, fluconazole showed 100% clinical cure rate compared to 32% with nystatin 2
• Particularly useful for persistent or recurrent cases

Treatment Considerations

Duration of Treatment

• Continue treatment for at least 48 hours after symptoms resolve 1
• Typical course: 7-14 days depending on response

Addressing the Breastfeeding Dyad

• If mother is breastfeeding and has symptoms of candidal mastitis, treat both mother and infant simultaneously to prevent reinfection 4, 5
• For breastfeeding mothers with symptoms:
  • Topical antifungal cream for nipples
  • Consider oral fluconazole for persistent cases 5

Monitoring Response

• Evaluate clinical response within 48-72 hours
• If no improvement, reassess diagnosis and consider second-line therapy
• Look for resolution of white plaques on oral mucosa and improvement in feeding behavior

Special Considerations

Premature or Low Birth Weight Infants

• Use lower doses of nystatin (1 mL four times daily) 1
• Monitor closely for response and side effects
• In nurseries with high rates of invasive candidiasis, fluconazole prophylaxis may be considered for neonates <1000g 3

When to Suspect Systemic Infection

• Persistent thrush despite appropriate therapy
• Signs of dissemination (lethargy, poor feeding, temperature instability)
• If systemic infection is suspected:
  • Perform lumbar puncture and dilated retinal examination 3
  • Consider imaging of genitourinary tract, liver, and spleen if blood cultures are persistently positive 3

Common Pitfalls to Avoid

• Inadequate dosing or duration of therapy
• Failure to treat both mother and infant in breastfeeding pairs
• Missing signs of systemic infection in high-risk infants
• Not addressing predisposing factors (e.g., antibiotic use, immunosuppression)
• Discontinuing treatment too early (before complete resolution)

Fluconazole has demonstrated superior efficacy compared to nystatin in clinical studies, with one study showing 100% cure rate versus 32% for nystatin 2. However, nystatin remains the first-line therapy due to its safety profile and long history of use in infants, with fluconazole reserved for cases that fail to respond to initial therapy.