AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

First described by the French pediatrician Francois Valleix in 1838, thrush is an infection of the buccal cavity by Candida albicans. The disease is typically limited to infants and neonates, patients on antibiotics or steroids, and patients with polyendocrine disorders or underlying immune dysfunction. Thrush may be the first sign of human immunodeficiency virus (HIV) infection; its appearance in advanced HIV indicates poor prognosis. Children on inhaled steroids also have increased incidence of oral candidiasis.

Pathophysiology

C albicans causes thrush when normal host immunity or normal host flora is disrupted. Overgrowth of yeast on the oral mucosa leads to desquamation of epithelial cells and accumulation of bacteria, keratin, and necrotic tissue. This debris combines to form a pseudomembrane, which may closely adhere to the mucosa. This membrane is usually not large but may rarely involve extensive areas of edema, ulceration, and necrosis of the underlying mucosa.

Affected neonates are typically colonized by C albicans during passage through the birth canal. Hence, the risk for thrush is increased when the mother has an active vaginal yeast infection. Other sources of transmission to neonates include colonized breasts (for breastfed infants), hands, and/or improperly cleaned bottle nipples. Kissing has also been implicated.

C albicans frequently and asymptomatically inhabits the GI tract of many children and adults, and the GI tract has been implicated as a reservoir for yeast contamination of the perineum. Thus, candidal diaper rash frequently occurs in conjunction with thrush.

Frequency

United States

As many as 37% of newborns may develop thrush during the first months of life.

International

Thrush is universal and is more common in poorly nourished populations.

Mortality/Morbidity

Thrush is usually a mild and self-limited illness, although it may cause sufficient discomfort in a newborn to disrupt feeding. Consider the possibility of an underlying immunodeficiency when thrush occurs after early infancy or without a reasonable explanation.

Sex

Thrush occurs equally in males and females.

Age

Thrush is rare during the first week of life. Incidence peaks around the fourth week of life; thrush is uncommon in infants older than 6-9 months. Thrush can occur, however, at any age in predisposed patients.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Parents usually notice a white coating in the child's mouth.
• Infants may have trouble feeding in severe cases.
• Medical history may include the following:
• • Recent antibiotic or steroid use may suggest a predisposing cause.
  • Diarrhea, rashes, failure to thrive, hepatosplenomegaly, or repeated infections suggest an underlying immunodeficiency.
• Maternal history may include the following:
• • Vaginal candidiasis is a source of perinatal exposure to infection.
  • HIV status may provide a clue to a predisposing factor.

Physical

• Lesions often start as tiny focal areas that enlarge to white patches on oral mucosae.
• When scraped with a tongue blade, lesions are difficult to remove and leave behind an inflamed base that may be painful and may bleed.
• Candidal infection in the diaper area may accompany thrush. Examine an infant with diaper dermatitis for oral lesions.¹
• Differentiate thrush from a coated tongue.
• Thorough physical examination is critical, especially for patients with recurrent thrush and for older children. Pay attention to the child's growth, rash distribution, lymphadenopathy, hepatosplenomegaly, and other potential sites of infection (eg, mucocutaneous candidiasis^{2, 3, 4}).

Causes

• Consider an underlying immune deficiency, especially in recurrent cases and in older infants.
• Systemic antibiotic use may disrupt the normal flora, promoting candidal overgrowth.
• Use of systemic and inhaled steroids is associated with increased incidence of oral thrush.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Milk curd
Foreign bodies

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• A relatively simple way to confirm the suspected diagnosis is to scrape the plaques with a tongue blade to reveal an inflamed and/or bleeding base.
• Plaques can be cultured, although cultures are rarely indicated. A simple Gram stain demonstrates large, gram-positive yeast.

Other Tests

• Diagnosis can be confirmed by simple histologic findings.

Histologic Findings

Pseudohyphae and gram-positive yeast can be seen on Gram stain or with potassium hydroxide stain.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Although some anecdotal reports indicate no treatment is necessary for otherwise healthy neonates, no published studies support this assertion.⁵

Consultations

In cases in which underlying immune dysfunction is suspected, consultation with an immunologist and infectious diseases specialist may be warranted for further evaluation.

Diet

No special diet is indicated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antifungal therapy generally hastens resolution of infection. The treatment of choice for thrush is oral nystatin suspension, although numerous antifungal agents are effective. Resistance to nystatin is rare, although the drug's contact killing makes it somewhat more difficult to use because it must be applied to all of the affected mucosal surfaces to be effective (unlike systemic therapies).

In older children and adults, antifungal medications should be swished around in the oral cavity and swallowed. Failure to do so may provide ineffective treatment for lesions in the posterior pharynx and esophagus. In younger patients, instruct parents to apply 1-2 mL of the solution to the inside of each cheek during each administration. Medication can also be directly applied to the lesions with a nonabsorbent swab or applicator. The best time to administer medication is between meals because this allows longer contact time.

Gentian violet solution should not be swallowed. Lozenges (troches) may be used if suspension preparations are unavailable.

These antifungal preparations have minimal adverse effects and few contraindications because they involve little or no systemic absorption. Aside from itraconazole, against which candidal resistance is increasing, other readily available antifungals are effective. If inability to adequately apply nystatin (or the oral cavity's normal flushing mechanisms) results in treatment failure, oral fluconazole or gentian violet are second-line agents.

Drug Category: Antifungal agents

The mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Complications

• Very rarely, extensive tracheal and esophageal involvement may lead to dysphagia and respiratory distress in otherwise healthy hosts.
• Bronchopulmonary candidiasis has been reported.
• Systemic dissemination may occur in immunosuppressed patients.
• Candidal esophagitis is a common complication of thrush in immunocompromised patients. In one study, it was the most common opportunistic infection in adults with acquired immunodeficiency syndrome (AIDS) (13.3 episodes per 100 person-years).

Prognosis

• Thrush is considered a self-limited disease, but resolution is hastened by medical therapy.

Patient Education

• Discuss thrush etiology and incidence as part of general reassurance to the parents of the healthy newborn or infant.
• If indicated, offer information about the necessity of further evaluation for underlying immune dysfunction.
• For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center. Also, see eMedicine's patient education article Candidiasis (Yeast Infection).

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Serious consideration and determination of the possibility of immune dysfunction is critical for patients beyond infancy, especially those with no apparent underlying cause for thrush (eg, antibiotics, corticosteroids).
• Immunodeficiency should also be considered in the infant with severe thrush associated with failure to thrive, severe eczema, and other infections.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Feb 1, 2008