BNF for Children (BNFC) 2018-2019

unresponsive infections or if a topical antifungal drug

cannot be used. Topical therapy may not be adequate in

immunocompromised children and an oral triazole

antifungal is preferred.

Acute erythematous candidiasis

Acute erythematous (atrophic) candidiasis is a relatively

uncommon condition associated with corticosteroid and

broad-spectrum antibacterial use and with HIV disease. It is

usually treated withfluconazole.

Angular cheilitis

Angular cheilitis (angular stomatitis) is characterised by

soreness, erythema andfissuring at the angles of the mouth.

It may represent a nutritional deficiency or it may be related

to orofacial granulomatosis or HIV infection. Both yeasts

(Candidaspp.) and bacteria (Staphylococcus aureusand beta-

haemolytic streptococci) are commonly involved as

interacting, infective factors. While the underlying cause is

being identified and treated, it is often helpful to apply

miconazole cream p. 725 or fusidic acid ointment p. 357 ;if

the angular cheilitis is unresponsive to treatment,

hydrocortisone with miconazole cream or ointment p. 744

can be used.

Immunocompromised patients

See advice on prevention of fungal infections under

Immunocompromised childrenin Antifungals, systemic use

p. 370.

Antiseptic mouthwashes can have a role in the prevention

of oral candidiasis in immunocompromised children.

Drugs used in oropharyngeal candidiasis

Nystatin is not absorbed from the gastro-intestinal tract and

is applied locally (as a suspension) to the mouth for treating

local fungal infections. Miconazole is used by local

application (as an oral gel) in the mouth but it is also

absorbed to the extent that potential interactions need to be

considered. Miconazole also has some activity against Gram-

positive bacteria including streptococci and staphylococci. In

neonates, nystatin oral suspension or miconazole oral gel is

used for the treatment of oropharyngeal candidiasis; to

prevent re-infection it is important to ensure that the

mother’s breast nipples and the teats of feeding bottles are

cleaned adequately.

Fluconazole given by mouth is reliably absorbed; it is used

for infections that do not respond to topical therapy or when

topical therapy cannot be used. Itraconazole p. 375 can be

used forfluconazole-resistant infections.

If candidal infection fails to respond after 1 to 2 weeks of

treatment with antifungal drugs the child should be sent for

investigation to eliminate the possibility of underlying

disease. Persistent infection may also be caused by re-

infection from the genito-urinary or gastro-intestinal tract.

ANTIFUNGALS›IMIDAZOLE ANTIFUNGALS

Miconazole 11-Oct-2017

lINDICATIONS AND DOSE

Oral candidiasis

▶BY MOUTH USING ORAL GEL

▶Neonate: 1 mL 2 – 4 times a day treatment should be

continued for at least 7 days after lesions have healed or

symptoms have cleared, to be smeared around the

inside of the mouth after feeds.

▶Child 1 month–1 year: 1. 25 mL 4 times a day treatment

should be continued for at least 7 days after lesions

have healed or symptoms have cleared, to be smeared

around the inside of the mouth after feeds

▶Child 2–17 years: 2. 5 mL 4 times a day treatment should

be continued for at least 7 days after lesions have

healed or symptoms have cleared, to be administered

after meals, retain near oral lesions before swallowing

(dental prostheses and orthodontic appliances should

be removed at night and brushed with gel)

Intestinal candidiasis

▶BY MOUTH USING ORAL GEL

▶Child 4 months–17 years: 5 mg/kg 4 times a day (max. per

dose 250 mg) treatment should be continued for at

least 7 days after lesions have healed or symptoms

have cleared

lUNLICENSED USENot licensed for use in children under

4 months of age or duringfirst 5 – 6 months of life of an

infant born pre-term.

lCONTRA-INDICATIONSInfants with impaired swallowing

reflex

lCAUTIONSAvoid in Acute porphyrias p. 603

lINTERACTIONS→Appendix 1 : antifungals, azoles

lSIDE-EFFECTS

▶Common or very commonDry mouth.nausea.oral

disorders.regurgitation.skin reaction

▶UncommonTaste altered

▶Frequency not knownAngioedema.choking.diarrhoea.

hepatitis.severe cutaneous adverse reactions (SCARs)

lPREGNANCYManufacturer advises avoid if possible—

toxicity at high doses inanimalstudies.

lBREAST FEEDINGManufacturer advises caution—no

information available.

lHEPATIC IMPAIRMENTAvoid.

lDIRECTIONS FOR ADMINISTRATIONOral gel should be held

in mouth, after food.

lPRESCRIBING AND DISPENSING INFORMATIONFlavours of

oral gel may include orange.

lPATIENT AND CARER ADVICEPatients or carers should be

given advice on how to administer miconazole oromucosal

gel.

lPROFESSION SPECIFIC INFORMATION

Dental practitioners’formulary

Miconazole Oromucosal Gel may be prescribed.

lEXCEPTIONS TO LEGAL CATEGORY 15 -g tube of oral gel can

be sold to the public.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines

containing the same drug.

Oromucosal gel

CAUTIONARY AND ADVISORY LABELS 9

▶Daktarin(McNeil Products Ltd, Janssen-Cilag Ltd)

Miconazole 20 mg per 1 gramDaktarin 20 mg/g oromucosal gel

sugar-free| 15 gramp£ 3. 78 DT = £ 3. 48 sugar-free|

80 gramP£ 4. 38 DT = £ 4. 38

ANTIFUNGALS›POLYENE ANTIFUNGALS

Nystatin 08-Feb-2017

lINDICATIONS AND DOSE

Oral candidiasis

▶BY MOUTH

▶Neonate:100 000units 4 times a day usually for 7 days,

and continued for 48 hours after lesions have resolved,

to be given after feeds.

▶Child:100 000units 4 times a day usually for 7 days,

and continued for 48 hours after lesions have resolved

lUNLICENSED USEgNot licensed for use in neonates.

l

lCAUTIONSContact with eyes and mucous membranes

should be avoided

710 Oropharyngeal fungal infections BNFC 2018 – 2019

Ear, nose and oropharynx

12