What is the treatment for oral thrush in infants?

Treatment of Oral Thrush in Infants

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 first-line treatment for oral thrush in infants. 1, 2

First-Line Treatment: Nystatin Oral Suspension

Dosing and Administration

• Standard dosage: 2 mL (200,000 units) four times daily 2
• For premature and low birth weight infants: 1 mL (100,000 units) four times daily 1, 2
• Administration technique:
  • Use dropper to place 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 disappear 2

Efficacy and Considerations

• Nystatin works locally in the oral cavity without systemic absorption 1
• Treatment response should be assessed after 2-3 days 1
• Common causes of treatment failure include:
  • Inadequate duration of therapy
  • Poor administration technique
  • Failure to address potential sources of reinfection
  • Premature discontinuation of treatment 1

Second-Line Treatment: Fluconazole

Consider fluconazole in cases where:

• Nystatin treatment has failed
• Severe infection is present

Dosing Options

• 3 mg/kg once daily for 7 days 1, 3
• Alternative: 15 mg every 8 hours (less recommended due to resistance concerns) 1

Efficacy Comparison

Fluconazole has demonstrated superior efficacy in some studies:

• In a small pilot study, fluconazole achieved 100% clinical cure rate compared to 32% with nystatin suspension 3
• However, fluconazole use is limited by concerns about developing triazole resistance 1

Prevention of Reinfection

During Treatment

• Sterilize pacifiers and bottle nipples regularly 1
• If breastfeeding, treat mother's nipples simultaneously if candidiasis is present 1, 4

Prophylaxis in High-Risk Settings

• In nurseries with high rates (>10%) of invasive candidiasis:
  • Intravenous or oral fluconazole prophylaxis (3-6 mg/kg twice weekly for 6 weeks) is recommended for neonates with birth weights <1000g 5
  • Oral nystatin (100,000 units every 8 hours) can be used as an alternative for very low birth weight infants 5, 6

Treatment Duration and Follow-up

• Continue treatment for at least 48 hours after perioral symptoms have disappeared 1, 2
• Verify eradication with cultures when possible 2
• Monitor for recurrence, especially in immunocompromised infants 7

Common Pitfalls to Avoid

• Stopping treatment too early (before complete resolution)
• Inadequate application technique (not placing medication in contact with affected areas)
• Failing to identify and treat maternal breast infection in breastfeeding dyads
• Not addressing environmental sources of reinfection (pacifiers, bottle nipples)
• Overlooking the need for different dosing in premature or low birth weight infants