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Referral and warning signs
When to refer
Refer if: No improvement after 7 days of topical treatment. Severe thrush interfering significantly with feeding. Suspected oesophageal involvement (painful swallowing). Recurrent thrush (consider underlying immunodeficiency like HIV).
Red flags
- Signs of dehydration due to poor intake.
- Evidence of systemic illness.
- Difficulty swallowing or painful swallowing.
- Associated respiratory symptoms (suggesting aspiration or systemic spread).
Signs and symptoms
- White patches or plaques on tongue, inner cheeks, gums, palate (can sometimes be wiped off, leaving red base).
- Redness or soreness inside the mouth.
- Oral ulcers.
- Refusal to feed or discomfort during feeding.
- Associated diaper candidiasis may be present.
Risk factors
- Young age (infancy).
- Recent antibiotic use.
- Use of inhaled corticosteroids (without spacer/rinsing).
- Immunodeficiency (HIV infection, malnutrition).
- Poor oral hygiene.
- Diabetes Mellitus.
- Maternal vaginal candidiasis during birth.
Diagnosis
Clinical assessment
Diagnosis is usually clinical based on the characteristic appearance of white patches or ulcers in the mouth.
Investigations
- Clinical examination is primary.
- KOH smear of scraping (shows yeast/pseudohyphae) - rarely needed.
- Consider HIV testing if recurrent, severe, or occurring in older child without obvious risk factors.
Diagnostic criteria
Clinical appearance of characteristic oral lesions.
Management
Non-pharmacological management
- Maintain good oral hygiene.
- Clean feeding utensils thoroughly.
- If breastfeeding, check mother's nipples for signs of thrush and treat concurrently if present.
- Rinse mouth after inhaled steroid use.
Pharmacological treatment
- Topical Antifungals:
- - Nystatin Oral Suspension 100,000 units/ml: 1 ml applied into mouth QID for 7 days (after feeds). (UCG PED010 refers).
- - Gentian Violet 0.5% Aqueous Solution: Paint mouth BID-QID for 7 days using clean finger/cloth. (UCG preferred option in PED007/PED013 sections).
- - Miconazole Oral Gel (Use with caution <6m due to choking risk): Apply small amount QID.
- Systemic Antifungals (for severe/refractory cases or immunocompromised):
- - Fluconazole Oral Suspension/Tablets: Dose based on weight/age (e.g., 3-6 mg/kg OD). Specialist guidance recommended.
Monitoring
Monitor for resolution of lesions and improvement in feeding. Check adherence to treatment. Follow up in 2-5 days if needed.
Complications
- Feeding difficulties, poor weight gain.
- Discomfort, irritability.
- Spread to oesophagus (oesophageal candidiasis - dysphagia, pain).
- Systemic candidiasis (rare, in severely immunocompromised).
Prevention
- Good oral hygiene.
- Sterilizing feeding equipment.
- Treating maternal vaginal candidiasis.
- Using spacers and rinsing mouth after inhaled steroids.
- Prophylaxis in high-risk immunocompromised patients (specialist).
Patient education
- Explanation of thrush as a fungal infection.
- How to apply topical medication correctly (Nystatin, GV, Miconazole).
- Importance of completing the full course (7 days).
- Hygiene measures for feeding equipment.
- Treating mother's nipples if needed.
- When to return if not improving.
Uganda-specific notes
Very common in infants and HIV-infected children. Gentian Violet is widely available and commonly recommended in IMCI protocols. Nystatin suspension also used. Check HIV status for recurrent/severe cases.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Sections 17.2.5, 17.3.6, 17.3.10.2, 17.3.10.3 (Mentioned within Feeding/Malnutrition assessment & treatment tables/notes)