What is the treatment for thrush in a 6-month-old?

Treatment of Thrush in a 6-Month-Old Infant

For a 6-month-old with oral thrush, nystatin oral suspension 2 mL (200,000 units) four times daily is the recommended first-line treatment, with half the dose placed in each side of the mouth and avoiding feeding for 5-10 minutes afterward. 1

First-Line Treatment Options

Nystatin Oral Suspension

• Dosage: 2 mL (200,000 units) four times daily 1
• Administration: Place half the dose in each side of the mouth
• Duration: Continue for at least 48 hours after symptoms resolve and cultures demonstrate eradication of Candida albicans 1
• Practical tip: Avoid feeding for 5-10 minutes after administration to maximize contact time

Treatment Considerations

1. Contact time is crucial: Nystatin works topically and requires adequate contact time with the affected areas
2. Administration challenges: Despite being first-line, nystatin can be difficult to administer to infants and has lower clinical cure rates compared to alternatives 2, 3
3. Monitor for recurrence: Thrush may recur and require repeated or alternative treatment

Second-Line Options (if nystatin fails)

Fluconazole

• Dosage: 3 mg/kg once daily for 7 days 2
• Efficacy: In a small study, fluconazole showed 100% clinical cure rate compared to 32% with nystatin 2
• Caution: Reserved for cases where nystatin fails due to:
  • Systemic absorption
  • Limited safety data in infants under 6 months
  • Risk of developing resistance

Miconazole Gel

• Consider as an alternative if available, as studies show superior efficacy compared to nystatin suspension 3
• Clinical cure rates of 84.7% by day 5 compared to 21.2% with nystatin 3

Comprehensive Management

Addressing Potential Sources of Reinfection

• If the infant is breastfed and mother has symptoms (nipple pain, redness), consider treating the mother as well to prevent reinfection 4
• Sterilize pacifiers, bottle nipples, and toys that go in the infant's mouth

When to Consider Alternative Diagnoses

• If thrush persists despite appropriate treatment, consider:
  • Incorrect diagnosis (milk residue can mimic thrush)
  • Underlying immunodeficiency (rare in otherwise healthy infants)
  • Resistant Candida species

Follow-up

• Assess response within 3-5 days of starting treatment
• If no improvement, consider second-line therapy
• Continue treatment for at least 48 hours after symptoms resolve 1

Common Pitfalls to Avoid

1. Inadequate duration of therapy: Stopping treatment as soon as visible thrush resolves often leads to recurrence
2. Poor administration technique: Nystatin requires proper application and contact time
3. Overlooking maternal infection: In breastfed infants, treating only the infant without addressing maternal candidiasis can lead to reinfection
4. Jumping to systemic therapy: While fluconazole is highly effective 2, it should be reserved for cases where topical therapy fails due to potential risks of systemic antifungals in infants

Remember that thrush in otherwise healthy infants typically responds well to appropriate treatment and rarely indicates serious underlying conditions.