How do children acquire oral thrush?

How Children Acquire Oral Thrush

Children primarily acquire oral thrush through colonization by Candida albicans, which can occur during birth from mothers with vaginal candidiasis or through environmental exposure after birth, particularly following antibiotic use that disrupts normal oral flora. 1

Transmission Routes

Vertical Transmission

• Maternal to infant transmission: Infants can acquire Candida during vaginal delivery if the mother has vaginal candidiasis 1
• Treatment of maternal vaginal candidiasis prior to delivery can prevent subsequent neonatal colonization 2

Horizontal Transmission

• Person-to-person spread through:
  • Contaminated objects (pacifiers, bottle nipples, toys) 1
  • Direct contact with caregivers 1
• Environmental sources in healthcare settings:
  • Horizontal transmission in neonatal intensive care units (NICUs) requires rigorous infection control measures 2

Risk Factors

Medication-Related

• Recent antibiotic use: Particularly broad-spectrum antibiotics (third-generation cephalosporins and carbapenems) that disrupt normal oral bacterial flora 2, 1
• Corticosteroid use (inhaled or systemic) 3

Age-Related

• Neonates and infants are at higher risk due to:
  • Immature immune systems
  • Early eruption of primary teeth in some populations (particularly indigenous children) which may result in earlier Candida colonization 2

Feeding Practices

• Prolonged bottle-feeding, especially with sugary drinks 2
• Improper cleaning of feeding equipment 1
• Breastfeeding beyond 12 months with at-will nighttime feeding (without proper oral hygiene) 2

Medical Conditions

• Immunodeficiency disorders 3
• Diabetes mellitus 4
• Hyposalivation 4
• Poor oral hygiene 4, 5

Prevention Strategies

For Newborns

• Treatment of maternal vaginal candidiasis before delivery 2
• Proper sterilization of pacifiers and bottle nipples 1
• Rational use of broad-spectrum antibiotics 2, 1

For Breastfeeding Mothers and Infants

• Treat mother's nipples simultaneously if candidiasis is present during breastfeeding 1
• Wipe infant's gums and erupting teeth after breastfeeding, especially if breastfeeding to sleep 2

In Healthcare Settings

• Rigorous infection control measures in NICUs 2
• For extremely low birth weight infants (<1000g) in nurseries with high rates of invasive candidiasis:
  • Consider fluconazole prophylaxis (3-6 mg/kg twice weekly for 6 weeks) 1

Treatment Considerations

First-Line Treatment

• Oral nystatin suspension (100,000 units four times daily) for at least 48 hours after symptoms resolve 1

Treatment Monitoring

• Continue treatment for at least 48 hours after symptoms disappear 1
• Verify eradication with cultures when possible 1
• Monitor for recurrence, especially in immunocompromised children 1

Common Pitfalls in Management

• Inadequate treatment duration: Treatment should continue for at least 48 hours after symptoms resolve 1
• Failure to address reinfection sources: Not treating maternal nipple candidiasis or not sterilizing pacifiers/bottles 1
• Misdiagnosis: Not all white patches in infants' mouths are thrush - one study found C. albicans was not discovered in babies with clinical thrush, suggesting other etiologies for white patches 6
• Stopping treatment prematurely: This can lead to recurrence 1

By understanding these transmission routes and risk factors, healthcare providers can better prevent, diagnose, and manage oral thrush in children, reducing morbidity and improving quality of life.