Treatment of Thrush in Children with Diflucan (Fluconazole) Suspension
For oropharyngeal candidiasis (thrush) in children, administer fluconazole suspension at 6 mg/kg on the first day, followed by 3 mg/kg once daily for at least 2 weeks. 1, 2
Dosing Algorithm by Age and Clinical Context
Standard Pediatric Dosing (≥6 months of age)
- Loading dose: 6 mg/kg on day 1 1, 2
- Maintenance dose: 3 mg/kg once daily 1, 2
- Minimum treatment duration: 2 weeks to decrease likelihood of relapse 1, 2
Neonatal Dosing (<1 month of age)
- First 2 weeks of life: 6 mg/kg every 72 hours (not daily) 1, 3
- Weeks 2-4 of life: 6 mg/kg every 48 hours 3
- After 4 weeks: 6 mg/kg once daily 3
- This modified schedule accounts for prolonged half-life (55-90 hours) and altered pharmacokinetics in neonates 1, 3
Immunocompromised Children
- Dosing range: 2-3 mg/kg once daily for 14 days 4
- Higher cure rates (91%) compared to nystatin (51%) in this population 4
Evidence Supporting This Recommendation
The 2009 IDSA guidelines provide the most authoritative dosing recommendations for pediatric oropharyngeal candidiasis, specifying 6 mg/kg loading dose followed by 3 mg/kg daily maintenance 1. This is reinforced by FDA labeling 2 and supported by clinical trial data showing 100% cure rates in otherwise healthy infants at 3 mg/kg daily 5.
The superiority of fluconazole over nystatin is well-established, with clinical cure rates of 91% versus 51% in immunocompromised children 4 and 100% versus 32% in healthy infants 5. The once-daily dosing significantly improves compliance compared to nystatin's four-times-daily regimen 6.
Administration Considerations
- Route: Oral suspension, can be taken with or without food 2
- Duration: Minimum 2 weeks; continue for at least 2 weeks after symptom resolution 1, 2
- Monitoring: No routine laboratory monitoring required for short-course therapy in otherwise healthy children 2
Critical Pitfalls to Avoid
- Do not use adult dosing in neonates: The prolonged half-life requires extended dosing intervals (every 72 hours initially) to prevent toxicity 1, 3
- Do not stop treatment when symptoms resolve: Continue for full 2 weeks minimum to prevent relapse, which occurs in 18-28% of cases 4
- Do not use in children <6 months without careful consideration: Efficacy has not been established in infants <6 months, though safety data exists for neonates 2
- Adjust dose in renal impairment: For creatinine clearance ≤50 mL/min, reduce dose by 50% after loading dose 2
When to Consider Alternative Dosing
For esophageal candidiasis (not simple thrush), increase to 6 mg/kg daily after the loading dose, with maximum doses up to 12 mg/kg/day based on response 1, 2. This more severe presentation requires higher sustained levels and longer treatment (minimum 3 weeks) 1, 2.
For fluconazole-refractory cases in immunocompromised children, consider amphotericin B oral suspension or intravenous echinocandins rather than increasing fluconazole dose 1.