Nappy rash and oral thrush in babies, causes and treatment

Nappy rash is red, sore skin under the nappy, caused mostly by wetness and rubbing. It gets better in a few days with frequent changes, air time and a thick barrier cream. Oral thrush is a yeast infection that leaves white patches in the mouth that do not wipe off. Both are common, both are treatable, and neither means you are doing anything wrong.

What causes nappy rash?

Most nappy rash comes from skin sitting in urine and stool for too long. Wet skin softens, the nappy rubs it, and enzymes in stool irritate it.

Other triggers include nappies that are too tight, scented wipes or wipes with alcohol, soap, and a reaction to detergent.¹ Diarrhoea makes rash much more likely. So does Kolkata's sticky monsoon weather, when skin never quite dries. Nappy rash is so common that most babies get it at least once.²

How do I treat nappy rash fast?

Keep the skin clean and dry, change nappies often, give nappy-free time, and put a thick layer of barrier cream on at each change. Most mild rash improves in 2 to 3 days.

Steps that work:^1,2 - Change the nappy as soon as it is wet or dirty, even at night if the rash is bad - Clean with cotton wool and plain warm water, or wipes free of alcohol and fragrance - Pat dry or wipe gently, or let the skin air dry - Leave the nappy off for a while on a towel or old cloth whenever you can - Fasten the nappy loosely, and avoid plastic pants over it

Do not use soap, baby lotion, bubble bath or antiseptic creams on the rash.¹

Which nappy cream is best for my baby?

A plain zinc oxide cream or paste works well for most nappy rash. Petroleum jelly is a reasonable alternative for very mild redness.

A barrier cream sits on the skin like a raincoat, keeping urine and stool off. Put on a thin layer at each change to prevent rash,¹ and a thick layer to treat one. You do not need to scrub all the old cream off at each change. Wipe off the dirty layer and add more.

Avoid creams with perfume, many herbal extracts, or steroids unless your doctor prescribed them.

Cloth or disposable nappies: which is better for rash?

Either is fine. In a Brazilian study of almost 1400 families, whose children were mostly toddlers (median age about 16 months), mild rash was equally common with cloth (47.5%) and disposable nappies (47.0%), and cloth did not raise the rate of rash.³

What matters is how often you change and how dry the skin stays. Disposables pull wetness away from the skin. Cloth nappies need changing as soon as they are wet, and need careful washing and rinsing so no soap stays in the cloth. Many Kolkata families use cloth at home and disposables when travelling or at night, which is perfectly sensible.

How often should I change my baby's nappy?

As soon as it is wet or dirty. Young babies may need 10 to 12 changes a day, and older babies about 6 to 8.⁴

Change dirty nappies at once, even if your baby is asleep and it feels unkind to wake them. Stool on skin is the main cause of breakdown. For a girl, wipe from front to back. For a boy, clean around the penis and testicles but do not pull back the foreskin.⁴

Should I use talcum powder on my baby?

No. Powder does not prevent rash better than cream, and breathing it in can badly harm a baby's lungs.

In a small trial in babies aged 6 to 12 months, those given talc had nappy rash sooner than babies given zinc oxide cream, and their risk of rash was about 5 times higher.⁵ Doctors advise against talc on nappy rash.¹ Babies can inhale powder from a shaken tin, and this can cause serious breathing problems.⁶ Many of our grandmothers used powder with love. We now know a cream is safer and works better.

When is nappy rash a fungal infection?

Think of yeast (candida) when a rash lasts more than 2 or 3 days despite good care, or when it is bright red with small red spots spreading beyond the main patch.

Fungal rash often goes into the skin folds, which simple irritant rash usually spares. Candida is common in newborn nappy rash. In one study of 100 newborns with nappy rash, half had candida growing from the skin.⁷ It is more likely after antibiotics, or if your baby also has oral thrush.

How is fungal nappy rash treated?

A doctor will usually prescribe an antifungal cream such as clotrimazole or nystatin, used until a few days after the rash clears.

A doctor may prescribe an antifungal cream when thrush is suspected.¹ Put the antifungal on first, let it soak in, then add barrier cream on top. Keep up all the dry-skin steps. If the rash still does not settle, or has pus, crusts or blisters, the doctor may look for a bacterial infection.¹

Should I use baby wipes or plain water?

Both are fine. Cotton wool and warm water, or wipes made for babies, can be used from birth.²

Choose wipes without alcohol, fragrance, essential oils and soap.² When the rash is raw, plain water and cotton wool usually stings less. Pat dry gently. In a joint family, make sure everyone who changes the baby uses the same gentle routine.

What is oral thrush in a baby?

Oral thrush is a yeast infection in the mouth. It shows as white patches on the tongue, inner cheeks, gums or lips that look like cottage cheese.

It is most common in young babies and becomes much less common by 6 to 9 months.⁸ Mode of birth does not seem to matter; babies born by caesarean are no more likely to get it.⁸ Your baby may be fussy at the breast or not want to feed.⁹

White patches in my baby's mouth: milk or thrush?

Thrush in babies cannot be rubbed off easily.⁹ In Dr Dutta's experience, milk coating wipes off with a clean wet cloth and is usually only on the tongue.

Check after your baby has not fed for an hour. A white tongue alone with clean cheeks and gums is usually milk. Patches on the inside of the cheeks or gums point to thrush.

How is oral thrush treated?

A doctor will usually prescribe antifungal drops or gel for the mouth. With the right medicine, most babies clear within a week.¹⁰

In a trial of over 200 babies, miconazole gel cured 85% of thrush by day 5, compared with 21% for nystatin suspension.¹⁰ Gels can be a choking risk in very young babies. Pharmacy gel is sold for babies over 4 months, and babies younger than 4 months with thrush should see a doctor.⁹ Your doctor will choose the right medicine for your baby's age.

Boil or sterilise bottles, teats and dummies after each use while treating.⁹

Does the mother need treatment for thrush?

Only if she has symptoms. If your baby has thrush but your nipples are comfortable, you do not need antifungal medicine.

Burning nipple pain is often blamed on thrush. A review found little evidence that yeast causes most of this pain, and antifungal treatment for the mother is rarely needed.¹¹ A poor latch is a much more common cause. If your nipples hurt, ask a doctor or lactation counsellor to watch a feed before anyone prescribes antifungals. Keep breastfeeding through thrush.

Can I prevent nappy rash and thrush?

You can cut down nappy rash a lot with frequent changes, nappy-free time and a thin barrier cream at each change.^1,2 Thrush cannot always be prevented.

Clean bottles and dummies well.⁹ Avoid antibiotics unless a doctor says they are needed. Do not put honey, sugar or ghee on your baby's tongue or dummy.

When should I see a doctor about nappy rash or thrush?

See a doctor if: - The rash does not go away, gets worse, or spreads to other areas¹ - There are blisters, pus, open sores, crusts or bleeding - Your baby has a fever, or seems very unwell or very uncomfortable¹ - White patches in the mouth in a baby under 4 months⁹ - Your baby is not feeding well¹² - Your baby has fewer wet nappies than usual - Thrush keeps coming back, or appears in an older child with no clear reason

Go to hospital at once if your newborn has a temperature above 37.5 degrees C or is breathing faster than 60 times a minute.¹² A very sleepy baby also needs urgent care.