What is the treatment for pediatric oral candidiasis (thrush)?

From the Guidelines

Pediatric oral thrush should be treated with nystatin oral suspension as the first line of treatment, administered as 1-2 ml (100,000-200,000 units) in each side of the mouth four times daily for 7-14 days. This recommendation is based on the most recent and highest quality evidence available, which prioritizes the treatment of oral thrush in children to reduce morbidity, mortality, and improve quality of life 1.

Key Considerations

• For infants, apply the medication to the inside of the cheeks using a clean finger or cotton swab.
• Continue treatment for 48 hours after symptoms resolve to prevent recurrence.
• Alternative treatments include fluconazole oral suspension at 3-6 mg/kg on the first day, followed by 3 mg/kg daily for 7-14 days for resistant cases, as supported by studies such as 1.

Important Factors

• Breastfed infants require treatment of the mother's nipples with an antifungal cream like miconazole to prevent reinfection.
• Good hygiene practices are essential, including sterilizing pacifiers and bottle nipples after each use.
• Oral thrush in children is caused by an overgrowth of Candida albicans yeast, which naturally exists in the mouth but can proliferate when the immune system is compromised or after antibiotic use that disrupts normal oral flora.

Treatment Outcomes

• Most cases resolve completely with proper treatment, though recurrence is possible if underlying factors aren't addressed.
• It is crucial to follow the recommended treatment guidelines to ensure the best possible outcomes for children with oral thrush, as indicated by studies such as 1.

From the FDA Drug Label

An open-label, randomized, controlled trial has shown fluconazole to be effective in the treatment of oropharyngeal candidiasis in children 6 months to 13 years of age. The use of fluconazole in children with cryptococcal meningitis, Candida esophagitis, or systemic Candida infections is supported by the efficacy shown for these indications in adults and by the results from several small noncomparative pediatric clinical studies Pediatric Use ... The efficacy of fluconazole for the treatment of oropharyngeal candidiasis in children has been established in an open-label, comparative study vs. oral nystatin in immunocompromised children with oropharyngeal candidiasis Clinical and mycological response rates were higher in the children treated with fluconazole. Clinical cure at the end of treatment was reported for 86% of fluconazole-treated patients Mycologically, 76% of fluconazole treated patients had the infecting organism eradicated

Pediatric oral thrush treatment: Fluconazole is effective in the treatment of oropharyngeal candidiasis in children 6 months to 13 years of age.

• Key points:
  • Clinical cure rate: 86%
  • Mycological eradication rate: 76%
• Dosage: The labeled pediatric dose is 6 mg/kg/day on the first day followed by 3 mg/kg/day 2

From the Research

Treatment Options for Pediatric Oral Thrush

• Miconazole gel has been shown to be an effective treatment for oropharyngeal candidiasis (thrush) in immunocompetent infants, with a clinical cure rate of 84.7% by Day 5 of treatment 3.
• Nystatin suspension is also a commonly used treatment for oral thrush, but it has been shown to be less effective than miconazole gel, with a clinical cure rate of 21.2% by Day 5 of treatment 3.
• Other topical antifungal drugs, such as clotrimazole and amphotericin B, are also available, but their effectiveness and availability may vary 4.
• Systemic antifungal drugs, such as fluconazole, itraconazole, and posaconazole, may be used to treat oral thrush that does not respond to topical treatment, but their use may be limited by the risk of resistance and side effects 4, 5, 6.

Comparison of Treatment Options

• A study comparing miconazole gel with nystatin suspension found that miconazole gel was significantly superior to nystatin suspension in terms of efficacy, rapidity of achieving cure, and oropharyngeal yeast eradication 3.
• Another study found that fluconazole was an effective preventative intervention for oral candidiasis, but its use may be limited by the risk of resistance and cost 5.
• A review of antimycotic therapy for oral candidoses found that the triazole agents, such as fluconazole, were initially highly effective, but an alarming increase in organisms resistant to these agents has been reported recently 7.

Considerations for Treatment

• The choice of treatment for pediatric oral thrush should be based on the severity of the infection, the patient's immune status, and the potential for resistance and side effects 4, 5, 6.
• Topical antifungal drugs, such as miconazole gel and nystatin suspension, are generally well-tolerated and effective for mild to moderate infections, but may not be effective for more severe infections or those that do not respond to topical treatment 3, 4.
• Systemic antifungal drugs, such as fluconazole, may be necessary for more severe infections or those that do not respond to topical treatment, but their use should be carefully considered due to the risk of resistance and side effects 4, 5, 6.