What is the appropriate treatment for oral thrush in a 1‑year‑old infant?

Treatment of Oral Thrush in a 1-Year-Old Infant

For a 1-year-old with oral thrush, start with nystatin oral suspension 200,000 units (2 mL) four times daily for 7-14 days, continuing for at least 48 hours after symptoms resolve. 1, 2

First-Line Treatment: Nystatin

• Nystatin oral suspension is the recommended first-line therapy at a dose of 200,000 units (2 mL) four times daily for 7-14 days 1, 2
• Use a dropper to place half the dose in each side of the mouth and avoid feeding for 5-10 minutes to maximize contact time 2
• The preparation should be retained in the mouth as long as possible before swallowing 2
• Continue treatment for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida 2

When Nystatin Fails: Second-Line Treatment

If there is no improvement after 7 days of nystatin therapy, switch to fluconazole oral suspension 1:

• Fluconazole 6 mg/kg on day 1, then 3 mg/kg once daily for 7 days 1, 3
• Fluconazole has demonstrated superior efficacy compared to nystatin, with clinical cure rates of 91-100% versus 32-51% in comparative trials 4, 5
• The once-daily dosing improves adherence compared to nystatin's four-times-daily regimen 1

Alternative Option: Miconazole

• Miconazole oral gel 15 mg every 8 hours is another effective alternative with clinical cure rates of 85.1% compared to nystatin's 42.8-48.5% 1
• However, miconazole use may promote development of triazole resistance, making fluconazole the preferred second-line agent 1

Critical Adjunctive Measures

For breastfeeding-associated thrush, simultaneous treatment of mother and infant is essential 1:

• Mother should apply miconazole cream to nipples/areola after each feeding 1
• This prevents the ping-pong reinfection cycle between mother and infant

When to Consider Systemic Therapy

Healthy, full-term 1-year-olds with localized oral thrush do NOT require systemic antifungal therapy 6. However, systemic therapy becomes necessary if 7, 6:

• The child is immunocompromised
• There is evidence of disseminated or invasive candidiasis
• The child has underlying conditions predisposing to systemic infection

Common Pitfalls to Avoid

• Do not stop treatment when symptoms improve—continue for the full 7-14 day course and at least 48 hours after clinical resolution to prevent recurrence 1, 2
• Do not use fluconazole as first-line in otherwise healthy infants—reserve it for nystatin failures to minimize unnecessary systemic exposure 1
• Do not forget to treat the mother if breastfeeding—maternal nipple candidiasis is a common source of reinfection 1
• Ensure proper administration technique—placing medication in both sides of the mouth and avoiding immediate feeding maximizes efficacy 2

Treatment Endpoint

• The endpoint should be mycological cure, not just clinical improvement 1
• Clinical improvement should be evident within 48-72 hours, but treatment must continue for the full course 1
• If no improvement occurs after 7 days of appropriate therapy, consider alternative diagnosis, resistant Candida species, or need to switch agents 1