Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Thrush
Characterized by adherent white plaques on inflamed oral mucosa. It is often associated with cutaneous candidiasis in the diaper or intertriginous areas.
I. Etiology: C. albicans
II. Incidence
A. Seen primarily in newborns and infants up to 6 months of age who have less immunity than older children to C. albicans
B. Newborns can be infected during passage through the vagina and infants can contract it from mother with breast infection.
III. Incubation period: Highly variable
IV. Subjective data
A. Fussy, irritable infant
B. Difficulty feeding or refusal to nurse
C. “White spots” on tongue and inside of mouth
D. Mother may have history of vaginal candidiasis.
E. Nursing mother may have concomitant infection of nipples and areola.
F. Infant may have history of concurrent or previous antibiotic or corticosteroid therapy.
V. Objective data
A. White, curdlike plaques on inflamed oral mucosa
B. Located on tongue, buccal mucosa, gingivae, and throat
C. Plaques cannot be easily removed. If they are wiped away, bleeding occurs.
D. Early lesions start as pinpoint in size and grow larger.
E. Cracks or fissures may appear in corners of mouth.
F. Lesions may extend to esophagus.
G. Inspect skin for concomitant candidiasis of diaper area and intertriginous areas.
VI. Assessment
A. Diagnosis is readily made by the clinical picture.
B. Differential diagnosis: Milk deposits may resemble thrush but are easily removed by wiping with a gauze pad.
VII. Plan
A. Mycostatin oral suspension
1. Infants: 1 mL in each side of mouth 4 times a day
2. Premature or low-birth-weight infants: 0.5 mL in each side of mouth 4 times a day
3. Continue for 48 hours after symptoms disappear.
B. Candidiasis in diaper area (see Candidiasis/Diaper Rash, p. 253)
VIII. Education
A. Give infant small amount of water before medication to rinse inside of mouth. Administer medication percutaneously.
B. Try to remove large plaques with cotton swab moistened with water.
C. Call immediately if infant refuses liquids.
D. Try infant feeder if infant refuses bottle or breast.
E. Diaper rash may occur concomitantly. Leave diaper area exposed as much as possible to help eliminate the warmth and moisture on which
C. albicans thrives (see Candidiasis/Diaper Rash, p. 253)
F. Sterilize nipples and pacifiers.
G. Wash toys well to prevent reinfection.
H. If breastfeeding, wash nipples well with warm water before and after feeding. Allow to air dry. May treat with mycostatin oral suspension
I. Observe careful handwashing technique.
J. Notify office if infant does not improve or seems worse.
K. If mother has any symptoms of vaginal candidiasis, she should be referred for treatment.
L. Newborns can be infected during passage through the vagina of a mother with C. albicans.
M. Infants can contract it from mothers with breast infection.
IX. Follow-up: Telephone contact in 3 to 4 days to assess progress. If no improvement noted by mother, return visit is indicated.
X. Complications
A. Persistent or recurrent thrush
B. Systemic candidiasis in debilitated infants or those on immunosuppressive therapy
XI. Consultation/referral
A. Persistent or recurrent thrush for evaluation of immunologic status
B. No improvement in 5 days
C. Mother with vaginal candidiasis