What is the recommended dose of Nystatin (antifungal medication) for a 2-year-old patient with a fungal infection?

Nystatin Dosing for a 2-Year-Old Child

For a 2-year-old child with oral candidiasis, administer nystatin oral suspension 4-6 mL (400,000-600,000 units) four times daily, with half the dose placed in each side of the mouth, continuing treatment for at least 48 hours after symptoms resolve and cultures confirm Candida eradication. 1

Standard Treatment Protocol

Dosing Specifics

• The FDA-approved dose for children is 4-6 mL (400,000-600,000 units) four times daily 1
• Administer one-half of the dose in each side of the mouth 1
• The preparation should be retained in the mouth as long as possible before swallowing 1

Treatment Duration

• Continue treatment for at least 48 hours after symptoms disappear and cultures demonstrate eradication of Candida albicans 1
• The Infectious Diseases Society of America recommends a total treatment duration of 7-14 days for uncomplicated disease 2, 3

When Nystatin is the Appropriate Choice

• Nystatin is recommended as first-line therapy for mild oropharyngeal candidiasis alongside clotrimazole troches by the American College of Physicians and Infectious Diseases Society of America 2
• Consider nystatin when fluconazole is not available or when systemic azole therapy is contraindicated 2, 4
• Nystatin is appropriate for patients with contraindications to systemic azoles 4

When to Consider Alternative Therapy

For moderate to severe disease, oral fluconazole 100-200 mg (3 mg/kg) daily for 7-14 days is superior and represents the preferred treatment 2

Evidence of Fluconazole Superiority

• In a randomized trial of infants, fluconazole achieved 100% clinical cure (15/15) compared to only 32% (6/19) with nystatin (P < 0.0001) 5
• If nystatin treatment fails after 7-14 days, switch to fluconazole 3-6 mg/kg once daily 3

Important Clinical Considerations

Administration Technique

• For young children, use a dropper to place one-half of the dose in each side of the mouth 1
• Avoid feeding for 5-10 minutes after administration to maximize contact time 1

Monitoring and Follow-up

• Hypersensitivity reactions to nystatin are rare but possible; monitor for cutaneous reactions 2, 4
• Nystatin may be ineffective in patients with gastrointestinal dysfunction or feeding intolerance 2

Preventing Reinfection

• If the child is breastfeeding, the World Health Organization recommends simultaneous treatment of the mother's nipples with miconazole cream after each feeding to prevent reinfection 3

Common Pitfalls to Avoid

• Do not discontinue treatment prematurely—continue for at least 48 hours after symptom resolution 1
• Poor taste and gastrointestinal adverse reactions are the most common side effects of nystatin 6
• Nystatin has lower cure rates compared to fluconazole, particularly in moderate to severe cases 3, 5
• The medication requires four-times-daily dosing, which may affect compliance compared to once-daily fluconazole 5