Treatment of Baby Oral Thrush
For baby oral thrush, oral nystatin suspension 100,000 units 3 times daily is the recommended first-line treatment, while fluconazole (3-6 mg/kg daily) is an effective alternative when nystatin fails or cannot be used. 1, 2
First-Line Treatment Options
- Nystatin oral suspension: 100,000 units 3 times daily for infants. The medication should be placed with the dropper (one-half of dose in each side of mouth) and feeding should be avoided for 5-10 minutes after administration 1
- Treatment should continue for at least 48 hours after symptoms have disappeared and cultures demonstrate eradication of Candida albicans 1
- For premature and low birth weight infants, limited clinical studies indicate that 1 mL (100,000 units) four times daily is effective 1
Alternative Treatment Options
- Fluconazole: 3-6 mg/kg daily orally is recommended when nystatin is ineffective or unavailable 2, 3
- Fluconazole has demonstrated superior efficacy compared to nystatin in clinical studies, with one small study showing 100% clinical cure with fluconazole versus only 32% with nystatin 3
- The half-life of fluconazole in neonates is 55-90 hours (compared to 30 hours in adults), so once-daily dosing is appropriate even with this extended half-life 2
Comparative Efficacy
- In an open-label comparative study of immunocompromised children with oropharyngeal candidiasis, fluconazole (2-3 mg/kg/day) showed significantly higher clinical cure rates (86%) compared to oral nystatin (46%) 4
- Mycological eradication was also superior with fluconazole (76%) compared to nystatin (11%) 4
- Another study comparing miconazole gel with nystatin suspension found miconazole to be significantly more effective, with 84.7% clinical cure by day 5 versus 21.2% with nystatin 5
Treatment Duration and Follow-up
- Treatment should continue for at least 48 hours after oral symptoms have disappeared 1
- For candidemia without obvious metastatic complications, treatment is recommended for 2 weeks after documented clearance of Candida species and resolution of attributable signs 2
- Clinical relapse rates 2 weeks after treatment are similar between fluconazole (14%) and nystatin (16%) 4
Special Considerations
- If the infant is breastfeeding and the mother has symptoms of candidal mastitis, consider treating both mother and infant simultaneously to prevent reinfection 6, 7
- For persistent or refractory cases, evaluate for underlying conditions that might compromise immune function 8
- In nurseries with high rates of invasive candidiasis (>10%), prophylactic fluconazole (3-6 mg/kg twice weekly for 6 weeks) is recommended for neonates with birth weights <1000g 2
Treatment Algorithm
- Start with nystatin oral suspension 100,000 units 3 times daily 1
- If no improvement after 3-5 days or if case is severe, consider switching to fluconazole 3-6 mg/kg daily 3
- Continue treatment for at least 48 hours after symptoms resolve 1
- For recurrent cases, evaluate both mother and infant if breastfeeding, and consider concurrent treatment 6, 7
Remember that proper administration of nystatin is crucial - place half the dose on each side of the mouth and avoid feeding for 5-10 minutes afterward to maximize contact time with the affected tissues 1.