White plaques on buccal mucosa/tongue/palate that don't wipe off (or leave erythematous base when scraped). Common in healthy infants. Persistent / recurrent thrush after age 6 mo → rule out HIV / immunodeficiency / inhaled steroids.
🚩 Red-flag clues (must not miss)
- •Persistent thrush > 6 mo of age → HIV / SCID / immunodeficiency
- •Esophageal involvement (odynophagia, refusing feeds) = systemic Rx
- •Maternal vaginal candida → consider treating mom + nipples concurrently if breastfeeding
Exam
- White plaques, erythematous base when scraped
- Angular cheilitis, perlèche
- Maternal nipple candidiasis (burning, shiny, deep pain)
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Candidiasis | — | Nystatin oral suspension |
| Milk residue (mimic) | Wipes off easily, no base | Reassure |
| Geographic tongue | Map-like patches, asymptomatic | Reassure |
| Leukoplakia / OHL (HIV) | Lateral tongue, cannot scrape | HIV testing |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Nystatin oral suspension | 100,000 U/mL: 1 mL each cheek QID × 7–14 d (continue 2 d after clearance) | Swab and let drip to mucosa |
| Fluconazole | 6 mg/kg PO ×1 then 3 mg/kg/day × 7–14 d | If nystatin fails or esophageal |
| Clotrimazole troches (older child) | 10 mg dissolved 5×/day × 14 d | |
| Maternal nipple antifungal | Topical miconazole/clotrimazole + treat infant simultaneously |
Management / next steps
- Nystatin × 7–14 d, treat 2 d past clearance
- Sterilize bottle nipples / pacifiers daily
- If recurrent: investigate for immune deficiency, HIV; review steroid inhalers
Source: https://fprmed.com/fprmedcom/Pages/Pedi/Oral_Thrush.html
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