What is the recommended dose of magic mouthwash containing a 1:1:1:1 ratio of nystatin, Maalox (aluminum hydroxide/magnesium hydroxide), Benadryl (diphenhydramine), and lidocaine for a 2-year-old?

Dosing of Magic Mouthwash for a Two-Year-Old

For a two-year-old child, the recommended dose of magic mouthwash containing a 1:1:1:1 ratio of nystatin, Maalox, Benadryl, and lidocaine is 5 mL applied to the oral mucosa every 4-6 hours as needed, with careful supervision to ensure the child does not swallow the mixture.

Components and Safety Considerations

• Magic mouthwash typically contains a combination of ingredients with different therapeutic purposes:

  • Nystatin: Antifungal agent for treating oral candidiasis 1
  • Maalox (aluminum hydroxide/magnesium hydroxide): Coating agent to protect mucosa 1
  • Diphenhydramine (Benadryl): Antihistamine with local anesthetic properties 1
  • Lidocaine: Local anesthetic for pain relief 1

• The lidocaine component requires particular caution in pediatric patients:

  • Maximum recommended dose of lidocaine for children is 4.4 mg/kg without epinephrine 1
  • For a typical two-year-old weighing approximately 12-15 kg, this means a maximum of 53-66 mg of lidocaine per day 1
  • With 2% viscous lidocaine (20 mg/mL), each 5 mL dose contains 100 mg 1, 2

Administration Guidelines

• Apply the mouthwash with a cotton swab or gauze pad rather than having the child swish and spit 1
• Ensure the child does not swallow the mixture to prevent systemic absorption of lidocaine 1
• Monitor for signs of lidocaine toxicity including drowsiness, confusion, seizures, or cardiovascular effects 1
• Administer no more than 4 times daily with at least 4 hours between doses 1, 3

Alternative Approaches

• For children under 3 years, consider separating the components and using them individually as needed:

  • Nystatin oral suspension 100,000 units four times daily for fungal infections 1
  • Maalox alone as a coating agent 4
  • Reduced concentration of lidocaine (0.5-1%) if pain control is needed 1

• Salt and soda rinses may be equally effective and less costly for basic mucositis treatment in older children who can rinse and spit 4

Monitoring and Precautions

• Examine the child's mouth daily to assess response to treatment 1
• Discontinue use if any adverse reactions occur 5
• Store the preparation properly and discard after 21 days if compounded 2
• Consider alternative treatments if no improvement is seen within 3-5 days 1

Caution

• The risk of lidocaine toxicity is significantly higher in young children due to their lower body weight and potential for accidental swallowing 1
• Treatment of oral mucositis in young children should always be supervised by a healthcare provider 1