Oral Candidiasis: Diagnosis And Management in Children

Oral candidiasis, also known as thrush, is a fungal infection caused by the yeast Candida, most commonly Candida albicans.

• Common in infant with poor oral hygiene
• It occurs when the normal balance of microorganisms in the oral cavity is disrupted, allowing Candida to proliferate. The epithelial cells desquamate as a result of yeast overgrowth on the oral mucosa. Bacteria, keratin, and necrotic tissue clump together to form a pseudomembrane.
• Neonates with thrush have usually been colonized when they passed through the birth canal
• In older children it is associated with the use of antibiotics
• If left untreated, oral candidiasis will resolve in 3–8 weeks
• Risk Factor: Bottle feeding, weak immune system (Recurrent Thrush), Pica, inhaled corticosteroid

History and examination

Symptoms	Signs
-Difficulty in feeding -Drooling of saliva -Curdish-like lesions are present on the buccal mucosa, tongue, palate, and gingiva	-White, creamy, curd-like patches on the oral mucosa (inner cheeks, tongue, palate) -Angular cheilitis (cracking at the corners of the mouth) -Lesions are difficult to scrape off and this differentiates it from milk. After scraping, there is an erythematous base and some bleeding.

Note: When thrush is present, it is importan to check for diaper rash.

Severity of Oral Thrush

Mild thrush	Involves <50% of the oral mucosa and absence of deep, erosive lesions
Moderate/Severe thrush	Involves ≥50% of the oral mucosa or deep, erosive lesions

Differential diagnosis (D/D) & Complication

D/D:

• Coxsackievirus infection (Hand, Foot, and Mouth disease)
• Apthous Ulcer
• Herpetic gingivostomatitis (clustered vesicles that rupture and form ulcers)
• Leukoplakia (white patches that cannot be scraped off)

Complications

• Esophageal candidiasis
• Systemic candidiasis
• Malnutrition
• Dehydration

Investigation

Clinical diagnosis based on history and physical examination

Management

Antifungal treatment: Topical nystatin or clotrimazole (for mild cases)

Oral Flucanozole: For mild thrush in immunocompromised children ≥12 months and moderate/severe thrush in all children ≥12 months; Oral thrush that is not responding to treatment: Systemic antifungal like fluconazole for 14 days treatment may be considered.

For infants, parents can apply 1–2 mL of the Nystatin suspension inside each cheek between meals or directly to the lesions with a swab. Older children can swish nystatin suspension around in their mouth and swallow it.

In nursing mothers, the breast may act as a reservoir for the yeast, applying a topical antifungal to the breast between feeds may help eradicate candidiasis.

Advices

• Bottle feeding irritate the lining of mouth, making it prone to yeast infection. So, thoroughly clean the nipples and pacifiers in hot water or a dishwasher after each use.
• If baby develop sever pain during bottle feed, try feeding using cup, spoon, or syringe.

Referral

Refer to a pediatric dentist or pediatrician if there are concerns about underlying medical conditions or recurrent, severe infections

Follow up

– Follow up within 1-2 weeks to monitor healing and response to treatment

References:

1. Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4th ed. St. Louis, MO: Elsevier; 2016.

2. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50.