What is the recommended treatment for thrush in newborns?

Treatment of Thrush in Newborns

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

First-Line Treatment: Nystatin Oral Suspension

Dosing and Administration

• Dosage: 1 mL (100,000 units) four times daily 1
  • For premature and low birth weight infants, limited clinical studies indicate that 1 mL four times daily is effective 2
• Administration technique:
  • Use dropper to place half of dose in each side of mouth 2
  • Avoid feeding for 5-10 minutes after administration 2
• Duration: Continue treatment for at least 48 hours after perioral symptoms have disappeared 1, 2

Efficacy Considerations

While nystatin is the recommended first-line treatment, it's important to note that some studies have shown lower clinical cure rates compared to alternatives. In a small pilot study, nystatin showed only 32% clinical cure rate compared to 100% for fluconazole 3. However, guidelines still recommend nystatin as first-line due to its safety profile and to prevent development of antifungal resistance.

Second-Line Treatment: Fluconazole

If nystatin treatment fails, fluconazole may be considered as a second-line option:

• Dosage: 3 mg/kg once daily for 7 days 1
• Indications for use:
  • Failure of nystatin treatment
  • Severe cases of oral thrush
• Caution: Use is limited by concerns about developing triazole resistance 1

Prevention of Reinfection

To prevent recurrence of thrush:

• Sterilize pacifiers and bottle nipples regularly during treatment 1
• If mother is breastfeeding and has nipple candidiasis, treat both mother and infant simultaneously 1
• Continue treatment for the full recommended duration to prevent relapse 1, 2

Monitoring and Follow-up

• Assess response to therapy after 2-3 days 1
• Continue treatment for at least 48 hours after symptoms resolve 1, 2
• Verify eradication with cultures when possible, especially in severe or recurrent cases 1

Common Pitfalls to Avoid

• Inadequate duration of therapy: Stopping treatment too soon can lead to recurrence
• Poor administration technique: Ensure proper placement in mouth
• Failure to address sources of reinfection: Remember to sterilize pacifiers and bottle nipples
• Premature cessation of treatment: Complete the full course even if symptoms improve quickly

Special Considerations for High-Risk Newborns

In nurseries with high rates (>10%) of invasive candidiasis, prophylactic antifungal therapy may be considered:

• For neonates <1000g: Fluconazole prophylaxis, 3-6 mg/kg twice weekly for 6 weeks 1
• Alternative: Oral nystatin (100,000 units every 8 hours) for very low birth weight infants 1

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