eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Thrush

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Mudra Kumar, MD, MBBS, MRCP, Associate Professor, Department of Pediatrics, University of South Florida College of Medicine
Contributor Information and Disclosures

Updated: Jan 23, 2009

Introduction

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 discomfort sufficient to disrupt feeding in a newborn. 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

History

  • Parents of children with thrush 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 candidiasis2,3,4 ).

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.

More on Thrush

Overview: Thrush
Differential Diagnoses & Workup: Thrush
Treatment & Medication: Thrush
Follow-up: Thrush
References
[ CLOSE WINDOW ]

References

  1. Hoppe JE. Treatment of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants: review and reappraisal. Pediatr Infect Dis J. Sep 1997;16(9):885-94. [Medline].

  2. Kalfa VC, Roberts RL, Stiehm ER. The syndrome of chronic mucocutaneous candidiasis with selective antibody deficiency. Ann Allergy Asthma Immunol. Feb 2003;90(2):259-64. [Medline].

  3. Liu X, Hua H. Oral manifestation of chronic mucocutaneous candidiasis: seven case reports. J Oral Pathol Med. Oct 2007;36(9):528-32. [Medline].

  4. Rowen JL. Mucocutaneous candidiasis. Semin Perinatol. Oct 2003;27(5):406-13. [Medline].

  5. Raucher HS. Should we be treating oral thrush?. Pediatr Infect Dis J. Mar 1998;17(3):267. [Medline].

  6. [Best Evidence] Adams NP, Bestall JC, Lasserson TJ, et al. Fluticasone versus placebo for chronic asthma in adults and children. Cochrane Database Syst Rev. 2005;CD003135. [Medline].

  7. Baley JE. Neonatal candidiasis: the current challenge. Clin Perinatol. Jun 1991;18(2):263-80. [Medline].

  8. Brown RS, Berg W, Schlesinger W, Childers EL. The CDx brush biopsy and the diagnosis of oral candidiasis. Dent Today. Aug 2007;26(8):96, 98-9. [Medline].

  9. Butler KM, Baker CJ. Candida: an increasingly important pathogen in the nursery. Pediatr Clin North Am. Jun 1988;35(3):543-63. [Medline].

  10. Egusa H, Soysa NS, Ellepola AN, Yatani H, Samaranayake LP. Oral candidosis in HIV-infected patients. Curr HIV Res. Nov 2008;6(6):485-99. [Medline].

  11. Gonzalez Gravina H, Gonzalez de Moran E, Zambrano O, et al. Oral Candidiasis in children and adolescents with cancer. Identification of Candida spp. Med Oral Patol Oral Cir Bucal. Oct 2007;12(6):E419-23. [Medline].

  12. Kumamoto CA, Vinces MD. Alternative Candida albicans lifestyles: growth on surfaces. Annu Rev Microbiol. 2005;59:113-33. [Medline].

  13. Kwon-Chung KJ, Bennett JE, eds. Medical Mycology. Philadelphia, Pa: Lea & Febiger; 1992:2288-301.

  14. Liguori G, Lucariello A, Colella G, De Luca A, Marinelli P. Rapid identification of Candida species in oral rinse solutions by PCR. J Clin Pathol. Sep 2007;60(9):1035-9. [Medline].

  15. Nokta M. Oral manifestations associated with HIV infection. Curr HIV/AIDS Rep. Feb 2008;5(1):5-12. [Medline].

  16. Ozturk MA, Gunes T, Koklu E, et al. Oral nystatin prophylaxis to prevent invasive candidiasis in Neonatal Intensive Care Unit. Mycoses. Nov 2006;49(6):484-92. [Medline].

  17. Pankhurst C. Candidiasis (oropharyngeal). Clin Evid. Jun 2005;1701-16. [Medline].

  18. Perniola R, Congedo M, Rizzo A, et al. Innate and adaptive immunity in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. Mycoses. May 2008;51(3):228-35. [Medline].

  19. Roland NJ, Bhalla RK, Earis J. The local side effects of inhaled corticosteroids: current understanding and review of the literature. Chest. Jul 2004;126(1):213-9. [Medline]. [Full Text].

  20. Russell C, Lay KM. Natural history of Candida species and yeasts in the oral cavities of infants. Arch Oral Biol. Aug 1973;18(8):957-62. [Medline].

  21. Segal BH, Steinbach WJ. Combination antifungals: an update. Expert Rev Anti Infect Ther. Oct 2007;5(5):883-92. [Medline].

  22. Shepherd J. Thrush and breastfeeding. Pract Midwife. Dec 2002;5(11):24-7. [Medline].

  23. Su CW, Gaskie S, Jamieson B, Triezenberg D. Clinical inquiries. What is the best treatment for oral thrush in healthy infants?. J Fam Pract. Jul 2008;57(7):484-5. [Medline].

  24. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 7th ed. 2000.

  25. Terai H, Shimahara M. Tongue pain: burning mouth syndrome vs Candida- associated lesion. Oral Dis. Jul 2007;13(4):440-2. [Medline].

  26. Vazquez JA. Posaconazole for the management of mucosal candidiasis. Future Microbiol. Jun 2007;2:245-56. [Medline].

  27. Vazquez JA, Sobel JD. Mucosal candidiasis. Infect Dis Clin North Am. Dec 2002;16(4):793-820, v. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

thrush, Candida albicans, C albicans, candidal diaper rash, candidiasis, diaper dermatitis, fungal infection, hepatosplenomegaly, human immunodeficiency virus, HIV, immune dysfunction, lymphadenopathy, monilia, moniliasis, mucocutaneous candidiasis, oral candidiasis, oral thrush, oropharyngeal yeast infection, polyendocrine disorders, vaginal candidiasis, white tongue coating

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Mudra Kumar, MD, MBBS, MRCP, Associate Professor, Department of Pediatrics, University of South Florida College of Medicine
Mudra Kumar, MD, MBBS, MRCP is a member of the following medical societies: American Academy of Pediatrics and American Society of Hematology
Disclosure: Nothing to disclose.

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital
Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.