What is the treatment for oral candidiasis (thrush) in a one-month-old infant?

From the Guidelines

For treating oral thrush in a one-month-old infant, nystatin oral suspension is typically the first-line treatment, as recommended by the most recent and highest quality study 1. The usual dose is 1 ml (100,000 units) applied to each side of the mouth four times daily after feedings for 7-14 days.

• Apply the medication with a clean finger or cotton swab, coating the inside of the cheeks, gums, and tongue.
• Continue treatment for 48 hours after symptoms resolve to prevent recurrence.
• If breastfeeding, the mother should also be treated with an antifungal cream on her nipples to prevent reinfection.
• Clean bottle nipples, pacifiers, and breast pump parts thoroughly after each use by boiling or using appropriate sterilization methods. Oral thrush in infants is caused by the Candida fungus, which thrives in warm, moist environments.
• It's common in infants due to their developing immune systems.
• If symptoms don't improve within a week, or if the baby has difficulty feeding, contact your pediatrician as alternative treatments may be needed. According to the evidence, nystatin is a reasonable choice for the treatment of oral thrush in neonates, with a grading of B-II 1.
• Miconazole is an alternative nonabsorbable agent, but its use is not recommended due to the potential for the development of triazole resistance 1.
• The most recent study 1 provides guidance on the management of candidiasis, including the use of nystatin for the treatment of oral thrush in neonates.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Infants: 2 mL (200,000 units) four times daily (in infants and young children, use dropper to place one-half of dose in each side of mouth and avoid feeding for 5 to 10 minutes).

• For a one-month-old infant with oral thrush, the recommended treatment is Nystatin (PO) at a dose of 2 mL (200,000 units) four times daily.
• The dose should be administered using a dropper, with one-half of the dose in each side of the mouth, and the infant should not be fed for 5 to 10 minutes after administration.
• Treatment should be continued for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2.

From the Research

Treatment Options for Oral Thrush in One-Month-Old Infants

• The treatment of oral thrush in infants can be challenging, and various antifungal medications have been studied for their efficacy and safety in this population 3, 4, 5, 6, 7.
• Fluconazole has been shown to be effective in treating oral thrush in infants, with a clinical cure rate of 100% in one study 3.
• Nystatin is another commonly used antifungal medication for oral thrush, but its efficacy has been variable, with some studies showing lower clinical cure rates compared to fluconazole 3, 4, 5.
• A systematic review and meta-analysis found that nystatin pastille was superior to placebo in treating denture stomatitis, but nystatin suspension was not superior to fluconazole in treating oral candidiasis in infants, children, or HIV/AIDS patients 5.
• Another study found that capric acid, nystatin, and fluconazole had antifungal activity against Candida isolates from neonatal oral thrush, but their combination was not more effective than using them alone 6.
• A Bayesian network meta-analysis found that fluconazole was one of the most effective antifungal drugs in reducing the mycological cure rate in oral candidiasis, with an odds ratio of 2.40 (95% CrI: 1.10-3.80) 7.

Comparison of Antifungal Medications

• Fluconazole has been compared to nystatin in several studies, with fluconazole generally showing higher clinical cure rates 3, 4, 7.
• Nystatin has been shown to have a lower clinical cure rate compared to fluconazole, but it may still be effective in some cases 3, 4, 5.
• Capric acid has been studied as a potential antifungal agent, but its efficacy and safety in treating oral thrush in infants are not well established 6.

Safety and Efficacy Considerations

• The safety and efficacy of antifungal medications in infants must be carefully considered, as they may have different pharmacokinetics and pharmacodynamics compared to adults 3, 4, 5, 6, 7.
• Fluconazole and nystatin are generally considered safe and effective in treating oral thrush in infants, but their use should be monitored closely for potential adverse effects 3, 4, 5, 6, 7.