Treatment of Oral Thrush in Infants
Nystatin oral suspension (100,000 units/mL) 1 mL four times daily for 7-14 days is the recommended first-line treatment for oral thrush in infants. 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 on each side of the mouth and avoiding feeding for 5-10 minutes afterward 2
- For premature and low birth weight infants, 1 mL four times daily has been shown to be effective 2
- Treatment should continue for at least 48 hours after oral symptoms have resolved to prevent recurrence 2
Administration Techniques
- For infants who cannot swish and spit, apply the suspension directly to affected areas using a clean finger or cotton swab 3
- Complete the full course of treatment even if symptoms resolve earlier to prevent recurrence 3
- Pacifiers and bottles should be sterilized regularly during treatment to prevent reinfection 3
Alternative Treatment Options
- Fluconazole oral suspension: 3-6 mg/kg once daily for 7 days is an effective alternative with superior clinical cure rates (100% vs. 32% for nystatin in one study) 1, 4
- Miconazole oral gel: 15 mg every 8 hours has shown higher clinical cure rates (85.1%) compared to nystatin gels (42.8-48.5%) 1, 5
- In a randomized multicenter study, miconazole gel demonstrated significantly higher clinical cure rates by day 5 (84.7%) compared to nystatin suspension (21.2%) 6
Special Considerations for Breastfeeding Infants
- For breastfeeding-associated oral candidiasis, simultaneous treatment of both mother and infant is recommended 1
- Mothers should apply miconazole cream to the nipples/areola after each feeding 7
- Keep affected areas dry between feedings to prevent reinfection 7
Treatment Duration and Follow-up
- Continue treatment for at least 7-14 days, even if symptoms resolve earlier 7
- The endpoint of treatment should be mycological rather than just clinical cure 1
- For persistent cases, evaluate for potential underlying conditions or consider extending the treatment duration 1
Precautions and Monitoring
- Monitor premature infants 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 resistance to triazoles 1
- Inadequate duration of therapy is a common reason for treatment failure; ensure completion of the full course 3
While both fluconazole and miconazole have shown superior efficacy compared to nystatin in clinical studies 4, 6, 5, nystatin remains the first-line recommendation due to its established safety profile, minimal systemic absorption, and widespread availability 1, 3.