Recommendations for the assessment and treatment of oral candidiasis in children are in line with expert opinion from a textbook [Hay and Moore, 2004] and narrative reviews [Akpan and Morgan, 2002; Gonsalves et al, 2007; Samaranayake et al, 2009].

First line treatment

• Miconazole
• Oral candidal infection is common in young children and infants (affecting up to to 40% of infants) because their immune system is immature. There is good evidence from two comparative randomized controlled trials (RCTs) that topical miconazole is considerably more effective than nystatin suspension for the treatment of oral candidal infection in infants (although there is a lack of placebo-controlled trials for either drug) [Hoppe and Hahn, 1996; Hoppe, 1997b].
• Oral candidal infection is less common in older children, and consequently there is a lack of direct evidence from RCTs in this group. However, its use is supported by pharmacological principles, historical use, and extrapolation of clinical data from trials in younger children and infants.
• Nystatin
• Nystatin suspension is not suitable as first-line treatment because two comparative RCTs found that it is not as effective as topical miconazole in the treatment of infants with oral candidal infection [Hoppe and Hahn, 1996; Hoppe, 1997b].
• Fluconazole
• There is evidence from one RCT that oral fluconazole is more effective than nystatin suspension [Goins et al, 2002], but fluconazole is not recommended for use in children without seeking expert advice.
• Fluconazole is extensively absorbed and has the potential for adverse effects, and its use is associated with increasing levels of candidal resistance (especially in C. glabrata or C. krusei) [Samaranayake et al, 2009].
• The use of fluconazole in children is generally felt to be unnecessary for what is considered to be a minor illness [Su et al, 2008].

Second line treatment

• About 85% of infants experience clinical cure with miconazole after 1 week, increasing to 99% after 2 weeks [Hoppe, 1997b]. Therefore, it is worth considering an additional week of treatment if the initial course is not fully effective.
• If miconazole has proved ineffective, it could be due to the presence of a resistant candidal organism (such as C. glabrata or C. krusei). Nystatin has a broader spectrum of antimycotic activity than miconazole, and may be an effective alternative [Samaranayake et al, 2009].