Treatment of Oral Thrush in Pediatric Patients
Nystatin oral suspension is the first-line treatment for oral thrush in otherwise healthy infants and children, dosed at 200,000 units (2 mL) four times daily for infants, or 400,000-600,000 units (4-6 mL) four times daily for older children and adults, continued for at least 48 hours after symptoms resolve. 1
First-Line Treatment: Nystatin
Dosing by age:
- Infants: 200,000 units (2 mL) four times daily, using a dropper to place half the dose in each side of the mouth, avoiding feeding for 5-10 minutes 1
- Premature and low birth weight infants: 100,000 units (1 mL) four times daily is effective based on limited clinical studies 1
- Children and adults: 400,000-600,000 units (4-6 mL) four times daily, with half the dose in each side of the mouth 1
Treatment duration:
- Continue for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans 1
- The American Academy of Pediatrics recommends 7-14 days of treatment 2
- The preparation should be retained in the mouth as long as possible before swallowing 1
Second-Line Treatment: Fluconazole
When nystatin fails or for more severe cases, fluconazole is superior and should be used:
Dosing for oral candidiasis:
- Infants and children: 6 mg/kg on day 1, followed by 3 mg/kg once daily 3
- Alternative dosing: 3-6 mg/kg daily for 7 days 2, 4
- Treatment should be administered for at least 2 weeks to decrease likelihood of relapse 3
Evidence supporting fluconazole superiority:
- In otherwise healthy infants, fluconazole achieved 100% clinical cure versus 32% with nystatin 4
- In immunocompromised children, fluconazole demonstrated 91% clinical cure versus 51% with nystatin, with organism eradication of 76% versus 11% 5
Special considerations for neonates:
- Premature newborns (gestational age 26-29 weeks) in the first two weeks of life should receive the same mg/kg dose but administered every 72 hours due to prolonged half-life 3
- After the first two weeks, dose once daily 3
Alternative Treatment: Miconazole Oral Gel
Miconazole oral gel 15 mg every 8 hours is another option:
- Clinical cure rates of 85.1% compared to nystatin gels (42.8-48.5%) 6
- Significantly superior to nystatin with 84.7% cure by day 5 versus 21.2% with nystatin 7
- Major caveat: Concerns exist regarding generation of triazole resistance, which may preclude subsequent use of fluconazole 8, 2
- Therefore, fluconazole is preferred over miconazole as second-line therapy 2
Critical Treatment Principles
Common pitfalls to avoid:
- Premature discontinuation: Continue treatment for full duration even when symptoms improve rapidly 2, 9
- Inadequate retention time: Ensure medication is retained in mouth as long as possible before swallowing 1
- Failing to treat maternal candidiasis: For breastfeeding-associated thrush, simultaneously treat mother and infant, with mother applying miconazol cream to nipples/areola after each feeding 2
When to consider systemic therapy:
- Systemic antifungal therapy is reserved for premature infants with disseminated disease, immunocompromised children, or those at risk for invasive candidiasis 2
- For invasive neonatal candidiasis: amphotericin B deoxycholate 1 mg/kg daily or fluconazole 12 mg/kg daily for at least 3 weeks 2
- All neonates with suspected invasive candidiasis require lumbar puncture and dilated retinal examination 2
Prophylaxis in High-Risk Settings
For extremely low birth weight infants (<1000g) in NICUs with high invasive candidiasis rates (>10%):
- Fluconazole 3-6 mg/kg twice weekly for 6 weeks 8, 2
- Oral nystatin 100,000 units three times daily for 6 weeks is an alternative when fluconazole is unavailable or resistance is a concern 2
- Nystatin prophylaxis reduces invasive candidiasis but has no impact on mortality, with potential concerns for necrotizing enterocolitis 8
Monitoring and Follow-up
Treatment endpoint should be mycological rather than just clinical cure 2