From the Guidelines
Oral thrush in pediatric patients is typically managed with topical antifungal medications, with nystatin suspension being the first-line treatment. The recommended dosage is 1-2 mL of nystatin suspension (100,000 units/mL) four times daily after meals for 7-14 days 1. The medication should be swished around the mouth before swallowing or, for infants, applied directly to affected areas using a clean finger or cotton swab.
Key Considerations
- Alternatively, fluconazole oral suspension (10-12 mg/kg on day 1, followed by 5-6 mg/kg daily) for 7-14 days can be used for resistant cases, as per the guidelines for the management of candidiasis 1.
- For breastfed infants, treating both the infant and mother's nipples is important to prevent reinfection; mothers can apply nystatin cream to nipples after feedings.
- Good oral hygiene is essential during treatment, including cleaning bottle nipples, pacifiers, and toys regularly.
- For infants, wiping the mouth with clean water after feedings helps prevent recurrence.
Treatment Duration and Evaluation
- If thrush persists beyond two weeks of treatment, further evaluation is needed as it may indicate an underlying immune issue or incorrect diagnosis.
- The treatment duration and evaluation should be based on the clinical practice guideline for the management of candidiasis, which recommends a treatment duration of 2 weeks after documented clearance of Candida species from the bloodstream and resolution of signs attributable to candidemia 1.
Underlying Causes
- Oral thrush occurs when Candida albicans, normally present in the mouth, overgrows due to factors like antibiotic use, weakened immunity, or poor oral hygiene, making antifungal therapy necessary to restore normal oral flora.
- It is essential to identify and address the underlying cause of the thrush to prevent recurrence and ensure effective treatment.
From the FDA Drug Label
Oropharyngeal candidiasis: The recommended dosage of fluconazole tablets for oropharyngeal candidiasis in children is 6 mg/kg on the first day, followed by 3 mg/kg once daily. Treatment should be administered for at least 2 weeks to decrease the likelihood of relapse
The management of oral candidiasis (thrush) in pediatric patients is to administer fluconazole tablets at a dosage of 6 mg/kg on the first day, followed by 3 mg/kg once daily. Treatment should be continued for at least 2 weeks to decrease the likelihood of relapse 2.
- Key points:
- Dosage: 6 mg/kg on the first day, followed by 3 mg/kg once daily
- Duration of treatment: at least 2 weeks
- Goal: to decrease the likelihood of relapse
- Important consideration: The efficacy of fluconazole for the treatment of oropharyngeal candidiasis in children has been supported by clinical studies, including an open-label, randomized, controlled trial that showed fluconazole to be effective in children 6 months to 13 years of age 2.
From the Research
Management of Oral Candidiasis in Pediatric Patients
The management of oral candidiasis (thrush) in pediatric patients involves the use of antifungal medications.
- Treatment options include:
- Topical antifungal agents such as nystatin and miconazole
- Systemic antifungal agents such as fluconazole
- The choice of treatment depends on the severity of the infection and the patient's immune status.
Efficacy of Antifungal Agents
Studies have compared the efficacy of different antifungal agents in treating oral candidiasis in pediatric patients.
- A study published in 1995 found that fluconazole suspension was more effective than nystatin in treating oropharyngeal candidiasis in immunocompromised children 3.
- A study published in 1997 found that miconazole gel was more effective than nystatin suspension in treating oropharyngeal candidiasis in immunocompetent infants 4.
- A study published in 2002 found that fluconazole was more effective than nystatin in treating oral candidiasis in infants 5.
- A study published in 1996 found that miconazole oral gel was more effective than two commercial nystatin oral gels in treating oral thrush in infants 6.
Current and New Antifungal Drugs
A review of therapeutic tools for oral candidiasis published in 2019 found that nystatin and miconazole are the most commonly used topical antifungal drugs, but may require a long time to eradicate the infection 7.
- Other topical alternatives, such as amphotericin B or clotrimazole, may not be available in many countries.
- Systemic antifungal agents, such as fluconazole, itraconazole, voriconazole, or posaconazole, may be used to treat oral candidiasis that does not respond to topical treatment.
- New antifungal agents, such as echinocandins (anidulafungin, caspofungin) and isavuconazole, may be effective in treating oral candidiasis.