What is the recommended treatment and duration for a 5-month-old infant with oral thrush?

Treatment of Oral Thrush in a 5-Month-Old Infant

For a 5-month-old infant with oral thrush, the recommended first-line treatment is nystatin oral suspension 1 mL (100,000 units/mL) four times daily for 7-14 days. 1, 2

First-Line Treatment Options

• Nystatin oral suspension (100,000 units/mL): Administer 1 mL four times daily for 7-14 days, placing half the dose in each side of the mouth and avoiding feeding for 5-10 minutes afterward 1, 2
• Treatment should continue for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2

Alternative Treatment Options

• Fluconazole oral suspension: 3-6 mg/kg once daily for 7 days if nystatin is ineffective or not tolerated 1, 3

  • Fluconazole has shown superior efficacy compared to nystatin in clinical trials, with 100% clinical cure rates versus 32% for nystatin in one study 3
  • The longer half-life (55-90 hours in neonates) allows for once-daily dosing 1

• Miconazole oral gel: 15 mg every 8 hours, which has demonstrated higher clinical cure rates (84.7% by day 5) compared to nystatin (21.2% by day 5) 1, 4

Special Considerations for Breastfeeding Infants

• If the infant is breastfed and the mother has symptoms of nipple candidiasis, simultaneous treatment of both mother and infant is recommended 1, 5
• For the mother, apply miconazole cream to the nipples/areola after each feeding 5
• Continue treatment for the full prescribed duration, even if symptoms resolve earlier, to prevent recurrence 5

Duration of Treatment

• Continue nystatin treatment for 7-14 days 1, 2
• Treatment should continue for at least 48 hours after clinical resolution of symptoms 2
• The endpoint of treatment should be mycological rather than just clinical cure 6

Monitoring and Follow-up

• Monitor for clinical improvement within 5-7 days of starting treatment 4
• If no improvement is seen after 7 days of nystatin therapy, consider switching to an alternative agent such as fluconazole 1, 3
• For persistent cases, evaluate for potential underlying conditions or consider extending the treatment duration 6

Precautions

• In premature infants, monitor for potential adverse effects of nystatin, such as intestinal damage and necrotizing enterocolitis 1
• Be aware that miconazole oral gel use may potentially lead to the development of triazole resistance 1

Prevention of Recurrence

• Ensure proper cleaning of pacifiers, bottle nipples, and toys that may go into the infant's mouth 7
• For breastfeeding mothers, keeping the nipples dry between feedings can help prevent reinfection 5