Oral Thrush

Dear Lisa,

My 3 week old daughter has a white coating on her tongue. My sister said it is thrush. I am breastfeeding her and she seems to be eating without any problem. She doesn’t have any rashes, she has a bowel movement everyday and there is no fever. What are the signs of thrush? Why do babies get thrush and how do I treat it?

“White coating on baby’s tongue"

Dear “White coating on baby’s tongue”,

Oral Thrush or Oral Candidiasis is a fungal infection caused by Candida albicans. Oral Candidiasis is commonly found in a baby’s mouth during the first 6 months of life. It presents as a white coating on the tongue or as white patches with an irregular border inside the mouth, in the back of the throat and on the inner lips. The white patches may look like curdled milk. (1)

Many times a coating of milk on a baby’s tongue may be mistaken for Oral Thrush. In order to decipher if the white coating on the baby’s tongue is due to milk or Thrush you can give your baby a few sips of water to drink. If the coating washes away, then the tongue coating was milk. If the coating remains your baby’s Doctor or Nurse Practitioner can evaluate your child to determine if the condition is Oral Thrush.

If a baby’s tongue is scraped with a tongue depressor and the white film comes off easily, then the coating was due to milk. If the coating is difficult to remove and the tongue starts to bleed or if a red raw area is exposed after the scraping, then the coating is due to Candida. (2)

Candida albicans is found on the skin, in the mouth, intestinal tract and vagina of healthy individuals. Five percent of all newborn infants contract Thrush when they are born, through the decent of an infected birth canal. Typically a Candida albican infection results 7 to 10 days later. (1,2)

Infants are susceptible to contracting oral thrush because they lack the circulating anticandidal factor present in the blood which keeps individuals free from Candida infections. This factor is absent or deficient in newborns during the first 6 months of life. (2) Other factors which make individuals more susceptible to Candida infections include use of antibiotics, administration of steroids, immunodeficiency, HIV, Diabetes and low birth weight infants. (1) Children with Asthma who take inhaled steroids are also at risk for developing Oral Thrush. Using holding chambers or spacer devices when taking inhaled steroids cuts down on the risk in this population. (3)

Treatment for Oral Thrush includes the application of a fungicide to the inside of the mouth four times per day. (2) The medication Nystatin is commonly used and can be prescribed by your Doctor or Nurse Practitioner. This liquid medication is given via a syringe or dropper which should be squirted on each side of the baby’s mouth. It is important to continue treatment for the duration that your Doctor prescribes even if the lesions seem to have cleared. (2) Many times the infection will reoccur if stopped too soon.

In addition to fungicide therapy, the baby’s bottles, nipples and pacifiers need to be cleaned. Simply washing these items in a dishwasher is not good enough. The dishwasher leaves plastic items wet and if the bottles, nipple and pacifiers are left wet and stored in a dark place, the organism may grow. Bottles, nipples and pacifiers should be dried well and left on a countertop exposed to the sunlight until the moisture is gone.

In addition, breastfeeding mothers may need to visit their Doctor or Obstetrician in order to see if they have a Candida infection too. They may need to treat their breasts with a topical antifungal creme because many times the Candida infection is also present on breastfeeding Mother’s breasts. If left untreated the infant can become re-infected when they breastfeed. I found that many Mothers experienced a lot of breast pain especially during breastfeeding when they had a Candida infection.

If your baby has recurrent Candida infections, difficulty feeding, fever or a concurrent diaper rash she should see her Doctor or Nurse Practitioner for an evaluation.

References:
(1)American Academy of Pediatrics. Candidiasis. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:162-164.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1702-1703.
(3)Hogan B, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003;32(1):20-25.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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