A 3-month-old male came to clinic because his thrush had returned.
He was a previously healthy, bottle fed infant who was growing normally.
His parents had tried two courses of oral nystatin prescribed by physicians in the clinic and a course of oral fluconazole prescribed by an emergency room physician.
He had stopped the fluconazole 3 days ago and today his parents noticed white patches again on his buccal mucosa.
They stated that they always “painted” his entire mouth with the nystatin and sterilized his bottles and nipples by washing in a dishwasher.
They had also bought new nipples recently.
He did not use a pacifier or any other objects in his mouth.
His parents were both healthy without any skin, oral or vaginal infections.
The past medical history showed a second child in the family, born full-term without prenatal or natal complications.
The review of systems was negative for any rashes including in his diaper area, infections, fever, or any problems eating.
The pertinent physical exam showed a happy infant with growth parameters in the 75-90%.
Oral examination showed some white patches on his buccal mucosa which did not scrape off and with minimal erythema around them.
He did not have any rashes and the rest of his examination was normal.
The diagnosis of recurrent oral candidiasis was made. The family was offered a choice of clotrimazole or gentian violet as treatment.
They chose gentian violet and were instructed to again “paint” his entire mouth, tongue and palate with the dye three times/day for a minimum of 2 weeks and at least 3 days after the patches appeared to disappear.
The physician did consider a possible immunodeficiency, but as the infant continued to have no problems with growth, infections or other problems elected to monitor the infant at that time.
The family was also going to boil the nipples and bottles on their stove and family was to call or return before his 4 month well child care appointment if the thrush continued or returned.
Oral candidiasis or thrush is most frequently caused by Candida albicans. Infants frequently acquire the organism perinatally or postnatally and it can be harbored in the oropharynx, skin and vagina.
In healthy newborns 2-5% of infants are affected. Symptoms can include being asymptomatic, white plaques and/or erythema on the buccal mucosa, tongue, or palate that do not scrape off, chelosis of the angle of the mouth, and concomitant diaper dermatitis.
Patients with underlying immunocompromising diseases such as AIDS, cancer and diabetes have thrush more commonly. Oral candidiasis is also more common in individuals using inhaled steroid medications. While oral candidiasis is usually a clinical diagnosis, microscopic examination by gram stain or potassium hydroxide can show yeast and pseudohyphae.
Patients who are more than 6 months old with frequent relapses or persistence of oral candidiasis should be considered for an evaluation of an underlying immunodeficiency.
Patients who are younger than 6 months with other symptoms of a possible underlying immunodeficiency should also be considered for evaluation.
Treatment for oral candidiasis for most healthy infants includes:
- Nystatin oral suspension (100,000-200,000 Units four times/day) painting of the entire mouth is usually the initial choice and often clears the infection. Older children and adolescents may require 200,000-400,000 Units four times/day.
- Gentian violet is a dye that has been used since 1925 for treatment of oral candidiasis. While it is overall less effective than other oral medications and can stain the mouth, clothing and other items, it can be effective. It is usually applied three times/day.
- Clotrimazole is also an option and is used frequently for patients who are immunocompromised. It is dispensed as a troche (lozenge) and therefore cannot be used with young infants. Some physicians will recommend off-label use of clotrimazole (1%) vaginal cream four times/day for young infants.
- Systemic antifungal treatment with other azole antifungals is often used in older infants, children and adolescents. These include fluconazole, ketoconazole or intraconazole. Again, these are used more often for patients with immunodeficiencies or other more serious yeast infections.
Fluconazole (Diflucan®) is available in tablets and oral suspension (10 mg/ml or 40 mg/ml). Dosage is usually 6 mg/kg/day on day 1 and 3 mg/kg/day on subsequent days but for at least 2 weeks for oral candidiasis.
In children 6 months to 13 years fluconazole has been shown to be effective for oral candidiasis. The drug has also been used in preterm infants for systemic candidiasis. Pharmacokinetic data is available for children 9 months and older, and also in preterm infants.
Questions for Further Discussion
1. What initial tests could be ordered for an initial immunodeficiency evaluation?
2. At what age would you prescribe oral fluconazole for uncomplicated oral candidiasis?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Vazquez JA, Sobel JD.
Infect Dis Clin North Am. 2002 Dec;16(4):793-82.
Krol DM, Keels MA.
Pediatr Rev. 2007 Jan;28(1):15-22.
Kalyousse S, Tolan RW, Greenberg ME. Candidiasis. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic312.htm (rev. 5/2/2007, cited 5/15/2008).
Diflucan. RxList The Internet Drug Index.
Available from the Internet at http://www.rxlist.com/cgi/generic/flucon.htm (rev. 2008, cited 5/15/08).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
July 14, 2008