What is the recommended treatment for oral thrush in a newborn?

Treatment of Oral Thrush in Newborns

Oral nystatin suspension at a dose of 1 mL (100,000 units) four times daily for at least 48 hours after symptoms resolve is the recommended first-line treatment for oral thrush in newborns. 1, 2

First-Line Treatment Options

Nystatin Oral Suspension

• Dosage: 1 mL (100,000 units) four times daily 1, 2
• Administration: Use dropper to place half of dose in each side of mouth and avoid feeding for 5-10 minutes 2
• Duration: Continue treatment for at least 48 hours after symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2
• Evidence quality: Moderate (B-II) 3
• Benefits: Reduces fungal infection without systemic absorption 3
• Limitations: No change in overall mortality, potential for gut irritation 3

Administration Technique

1. Use the provided dropper to place 0.5 mL in each side of the infant's mouth
2. Apply after feedings to maximize contact time with oral mucosa
3. Avoid feeding for 5-10 minutes after administration to prevent immediate washing away of medication 2

Alternative Treatments

Fluconazole

• Consider if nystatin fails or in severe cases
• Dosage: 3 mg/kg once daily for 7 days 4
• Evidence: Small studies show superior efficacy (100% vs 32% cure rate compared to nystatin) 4
• Caution: Reserved as second-line due to concerns about developing triazole resistance 3

Miconazole Oral Gel

• Dosage: 15 mg every 8 hours 1
• Evidence quality: Low (D-II) due to concerns regarding development of triazole resistance 3
• Note: Has shown higher clinical cure rates than nystatin gel formulations in some studies 5

Prevention of Reinfection

1. Sterilize pacifiers and bottle nipples regularly during treatment period 1
2. If mother is breastfeeding and has nipple candidiasis, treat simultaneously to prevent reinfection 1
3. In high-risk nursery settings with high rates of invasive candidiasis (>10%), prophylactic fluconazole may be considered for very low birth weight infants 3

Treatment Assessment and Follow-up

• Assess response to therapy after 2-3 days 1
• If no improvement is seen within 3-5 days, consider:
  1. Confirming diagnosis with culture
  2. Switching to alternative antifungal agent
  3. Evaluating for underlying conditions affecting immune function

Special Considerations

• For premature and low birth weight infants, 1 mL of nystatin four times daily has been shown to be effective 2
• Prophylactic oral nystatin (100,000 units every 8 hours) has been shown to reduce fungal colonization and infection in very low birth weight infants 6, 7

Common Pitfalls to Avoid

1. Inadequate duration of therapy (must continue at least 48 hours after symptoms resolve)
2. Poor administration technique (medication should contact all affected areas)
3. Failure to address potential sources of reinfection (pacifiers, bottle nipples, maternal breast infection)
4. Stopping treatment prematurely when symptoms improve but before complete eradication

Nystatin remains the cornerstone of treatment for oral thrush in newborns due to its established safety profile and efficacy when properly administered, despite some studies showing higher cure rates with alternatives like fluconazole or miconazole.