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Candida - oral - Management
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How should I treat oral candidiasis in a child?
- Prescribe topical treatment for 7 days (and advise the person to continue treatment for 2 days after symptoms resolve).
- Offer miconazole oral gel first-line (off-label use in children younger than 4 months of age).
- Offer nystatin suspension (off-label use in neonates) if miconazole oral gel is unsuitable (for example if the child has liver dysfunction or is taking medication extensively metabolized by the liver).
- If the infection has not resolved after 7 days, and:
- There has been some response, extend the course of miconazole oral gel for a further week.
- Miconazole has had little or no effect despite adequate adherence, offer a 7-day course of oral nystatin suspension.
- If the child is using an inhaled corticosteroid, provide advice on the prevention of oral candidal infection (see Inhaled corticosteroids).
- If the child has extensive or severe candidiasis, consider seeking specialist advice.
Basis for recommendation
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].
When should I admit or refer a child with oral candidiasis?
- Admit the child if there is widespread infection (such as oesophageal candidiasis, characterized by difficulty or pain on swallowing, or retrosternal pain), or the child is systemically unwell.
- Refer or seek specialist advice if the child:
- Has extensive or severe oral candidiasis.
- Does not respond adequately to at least 2 weeks of treatment with miconazole and/or nystatin.
- Has recurrent episodes of oral candidal infection, or there is suspicion the child is immunocompromised.
Basis for recommendation
Admission
- Systemic candidiasis, or candidal infection spreading to the oesophagus, is a life-threatening infection requiring immediate intervention by specialists [Pappas et al, 2009].
Referral
- The British National Formulary recommends referral for investigation if candidal infection fails to respond to 1–2 weeks of treatment [BNF 57, 2009].
- Oral candidal infection that becomes chronic in an infant or child is unusual and requires further assessment by a specialist. Treatment options that may be suitable for initiation in secondary care include oral fluconazole [Samaranayake et al, 2009].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
1st-line antifungal: miconazole oral gel
Age under 1 month
Miconazole s/f oral gel: use 1ml four times a day
Miconazole 20mg/g oromucosal gel sugar free
Measure 1ml using the oral syringe provided. Then, using a clean finger, apply the gel in small amounts until the whole of the inside of the mouth has been covered. Do NOT apply the gel near the back of the throat (risk of choking). Apply the gel two to four times a day, after feeds.
Supply 15 grams.
Age from 1 month to 3 months
Miconazole s/f oral gel: use 2.5ml twice a day
Miconazole 20mg/g oromucosal gel sugar free
Measure 2.5 ml using the oral syringe provided. Then, using a clean finger, apply the gel in small amounts until the whole of the inside of the mouth has been covered. Do NOT apply the gel near the back of the throat (risk of choking). Apply the gel twice a day, after feeds.
Supply 80 grams.
Age from 4 months to 1 year 11 months
Miconazole s/f oral gel: use 2.5ml twice a day
Miconazole 20mg/g oromucosal gel sugar free
Measure 2.5 ml using the oral syringe provided. Then, using a clean finger, apply the gel in small amounts until the whole of the inside of the mouth has been covered. Do NOT apply the gel near the back of the throat (risk of choking). Apply the gel twice a day, after feeds.
Supply 80 grams.
Age from 2 years to 5 years 11 months
Miconazole s/f oral gel: use 5ml twice a day
Miconazole 20mg/g oromucosal gel sugar free
Place 5ml in the mouth and hold near the affected area(s) twice a day.
Supply 80 grams.
Age from 6 years to 11 years 11 months
Miconazole s/f oral gel: use 5ml four times a day
Miconazole 20mg/g oromucosal gel sugar free
Place 5ml in the mouth and hold near the affected area(s) four times a day.
Supply 80 grams.
Alternative or 2nd-line antifungal (nystatin suspension)
Age under 1 month
Nystatin 100,000units/ml s/f susp: use 1ml four times a day
Nystatin 100,000units/ml oral suspension sugar free
Using the oral dispenser provided, place 1ml in the mouth four times a day.
Supply 30 ml.
Age from 1 month to 11 years 11 months
Nystatin 100,000units/ml s/f susp: use 1ml four times a day
Nystatin 100,000units/ml oral suspension sugar free
Using the oral dispenser provided, place 1ml in the mouth four times a day.
Supply 30 ml.
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