What is the appropriate management of oral thrush (candidiasis) in a 14‑month‑old infant?

Management of Oral Thrush in a 14-Month-Old Infant

For a 14-month-old with oral thrush, administer nystatin oral suspension (100,000 IU/mL) 2 mL (200,000 units) four times daily for 7-14 days, retained in the mouth as long as possible before swallowing, and continue treatment for at least 48 hours after symptoms resolve. 1, 2, 3

First-Line Treatment

• Nystatin oral suspension is the recommended first-line therapy at a dose of 2 mL (200,000 units) four times daily for children in this age group 1, 3
• The medication should be retained in the mouth as long as possible before swallowing to maximize contact time with affected mucosa 3
• Use a dropper to place one-half of the dose in each side of the mouth 3
• Avoid feeding for 5-10 minutes after administration to allow adequate mucosal contact 3

Alternative Treatment Option

• Miconazole oral gel (15 mg every 8 hours) is an alternative with higher cure rates compared to nystatin gels, though it carries a theoretical concern for promoting triazole resistance that could affect future fluconazole efficacy 1, 2
• This resistance concern is particularly relevant if the child might later require systemic azole therapy for invasive infections 2

Critical Treatment Duration

• Treat for a minimum of 7-14 days and continue for at least 48 hours (or one week per some guidelines) after clinical resolution to ensure mycological cure and prevent recurrence 1, 2, 3
• The treatment endpoint should be mycological cure, not merely clinical improvement 1, 2
• Premature discontinuation when symptoms improve leads to high recurrence rates 1, 2

Essential Adjunctive Measures for Breastfeeding-Associated Thrush

• If the infant is breastfeeding, simultaneous treatment of the mother is essential: apply miconazole cream to nipples and areola after each feeding while treating the infant 1, 2
• This prevents the ping-pong effect of reinfection between mother and infant 1

Environmental Decontamination

• Sterilize all items that contact the infant's mouth including pacifiers, bottle nipples, and toys during and after treatment 1
• Wash all clothing, bedding, and towels in hot water to eliminate fungal spores 1, 4

When to Escalate to Systemic Therapy

• Systemic antifungal therapy is NOT indicated for healthy term infants with localized oral thrush 1, 2, 4
• Consider oral fluconazole (3-6 mg/kg daily for 7 days) only for:
  • Resistant cases not responding to topical therapy after 7 days 1, 2
  • Extensive or recurrent infections 1, 2
  • Immunocompromised infants 1, 2

Common Pitfalls to Avoid

• Never discontinue therapy when white patches disappear but before completing the full 7-14 day course, as this leads to recurrence 1, 2
• Do not use combination antifungal/corticosteroid preparations in infants, as these cause persistent and recurrent infections 1, 2
• Avoid prolonged systemic azole therapy in otherwise healthy infants due to resistance concerns 1

Clinical Monitoring

• Clinical improvement should be evident within 48-72 hours of initiating therapy 1
• If no improvement occurs after 7 days of appropriate therapy, consider alternative diagnosis (the white patches may not be candidiasis), resistant Candida species, or need for systemic therapy 1, 5
• Recent research suggests that not all white patches in infants' mouths are actually Candida albicans, so if treatment fails, reconsider the diagnosis 5

Additional Considerations

• Evaluate for predisposing factors such as recent antibiotic use (particularly third-generation cephalosporins or carbapenems), which increases fungal colonization risk 2, 4
• Check for and treat maternal vaginal candidiasis if present, as this is a common source of infant colonization 2, 4