Best treatment of conjunctivitis in babies

Conjunctivitis (also known as pink eye) is a common childhood eye condition characterised by redness of an eye due to inflammation of the conjunctiva, an outer membrane that covers the surface of the eye. It is very common for parents to seek treatment for conjunctivitis from the pharmacy, although in many cases, conjunctivitis is a self-limiting condition. In this post, we discuss the treatment of conjunctivitis in babies.

Conjunctivitis in babies: symptoms and causes

Conjunctivitis can affect one or both eyes. Conjunctivitis in babies can be caused by:

• Viruses (viral conjunctivitis)
• Bacteria (bacterial conjunctivitis).
• Allergens such as pollen  
• Irritants for example chlorine in the water

It is common for babies to get conjunctivitis during an episode of a cold. Although it can be difficult to distinguish between different types of conjunctivitis, taking a health history and description of the symptoms can help the diagnosis.

Ophthalmia neonatorum

Ophthalmia neonatorum is defined as conjunctivitis that happens in newborn babies in the first month of life. It is important to seek an urgent appointment with a doctor if your baby is less than 28 days old and shows symptoms of conjunctivitis. Ophthalmia neonatorum requires prompt treatment as there is a risk of corneal perforation and vision loss (blindness) due to infection (Kapoor et al, 2016).

Symptoms of conjunctivitis in babies:

• Red/pink eyes
• Watery eye(s)
• Swollen eyelid(s)
• Itchiness, burning sensation       
• Discomfort  

Bacterial conjunctivitis can be associated with a sticky, yellow discharge from the eye and/or the presence of a crust, usually in the morning. 

Both bacterial and viral conjunctivitis is contagious, it can spread from one person to another by direct contact, for example with hands, via hand-to-eye contact, or contact with different objects contaminated with bacteria or viruses. Conjunctivitis can also spread through the droplets containing viral or bacterial particles from coughing or sneezing.   

How to prevent the spreading of conjunctivitis?

The risk of conjunctivitis spreading can be reduced by:

• Regular hand wash when in contact with baby
• Not sharing towels or cloths
• Maintain a clean environment, for example, clean toys which are shared  

Does my baby need to stay away from the nursery/childminder?

Public Health Agency states that children do not have to stay away from school, nursery, or childminders when experiencing symptoms of conjunctivitis unless an outbreak occurs (PHA, 2017). This recommendation is often ignored by nurseries and parents are told to keep their children away from the nursery.  

Treatment of conjunctivitis in babies

In most cases, conjunctivitis is a self-limiting condition. It should go on its own without any treatment. It makes take a few days to two weeks for conjunctivitis to go away. Treatment with antibiotics may improve symptoms more quicker. 

Conjunctivitis in babies: managing the symptoms

Non-drug treatment of conjunctivitis involves the management of symptoms by keeping your baby’s eyes clean. Use cotton ball/wool to clean each eye individually. Use sterile saline or boiled and cooled water to clean the discharge (NICE, 2018).

Drug treatment of conjunctivitis in babies

Antibiotic treatment is not recommended for the treatment of viral conjunctivitis.

Chloramphenicol, an antibiotic which is used for the treatment of conjunctivitis, can be purchased from a pharmacy. Chloramphenicol is available as:

• Chloramphenicol 0.5% eye drops
• Chloramphenicol 1% eye ointment

Both chloramphenicol eye drops and eye ointment are pharmacy-only medications, meaning they can only be sold from a registered pharmacy. Both forms of Chloramphenicol are available as generic or branded products, for example, Optrex Infected Eye drops or Optrex Bacterial Conjunctivitis eye ointment.

Chloramphenicol eye drops and eye ointment are licensed for children aged two years and over. GP or another qualified prescriber can prescribe chloramphenicol to babies/toddlers under the age of 2.

Unfortunately, a verbal recommendation from a doctor to purchase chloramphenicol over the counter for babies under two years of age is not sufficient. Parents of children under two years of age need to get a prescription for chloramphenicol eye drops or ointment.

How often are Chloramphenicol eyed drops used?

Follow the directions of your prescriber for the administration of eye drops. The licensed dose for chloramphenicol eye drops (eMC, 2019):

• One drop to be instilled into the affected eye(s) every two hours for the first 48 hours, then every four hours.
• Chloramphenicol eye drops should be used for five days, even if symptoms improve.
• Eye drops do not need to be instilled at night when the baby is asleep.

Other relevant information about chloramphenicol eye drops:

• Eye drops need to be kept in the fridge.
• It is recommended to throw away eye drops after five days, although the shelf life once open is 28 days.

How often is Chloramphenicol eye ointment used?

The Chloramphenicol eye ointment (about 1 cm) is applied by pulling down the baby’s lower eyelid in the space between the lower eyelid and the eye. Follow this link to read more about eye ointment applications in children. The recommended licensed dose for chloramphenicol eye ointment is:

• To be applied to the affected eye(s) three to four times a day for five days.
• Chloramphenicol eye ointment should be used for five days, even if symptoms improve.

Other relevant information about chloramphenicol eye ointment:

• Chloramphenicol eye ointment does not have to be kept in the fridge
• It is recommended to throw away the ointment after five days, although the shelf life once open is 28 days.

Sometimes patients/parents may decide to use chloramphenicol eye drops during the day and chloramphenicol ointment at night before going to bed. This is ok.

Serious side effects of hypersensitivity to Chloramphenicol (eye drops or ointment) have been reported. Symptoms of such a reaction may include facial swelling, rash, and fever.

Are chloramphenicol eye drops out of stock?

At the beginning of 2023 chloramphenicol eye drops, generic and branded as Optrex Infected eye drops became short of supply. The price of chloramphenicol eye drops almost doubled. At this time, parents who wish to purchase chloramphenicol eye drops for the treatment of conjunctivitis may expect to pay up to £15 for a bottle of antibiotic eye drops. Read more about chloramphenicol shortage.

Is the treatment of conjunctivitis in babies with chloramphenicol effective?

This is an excellent question that needs addressing since general advice is that most cases of conjunctivitis resolve without any treatment. The most relevant study regarding the treatment of conjunctivitis in children comes from Rose et al who looked at 326 children aged 6 months to 12 years of age with infective conjunctivitis. At the end of the 7-day treatment, 85.0% of children who received chlorophenol eye drops were cured as compared to 78.5% of children who received placebo (not active) eye drops. It took on average 5 days to cure conjunctivitis with chloramphenicol eye drops and 5.4 days with placebo treatment. Antibiotic treatment improved the remission of bacteria (more bacteria were killed on day 7 of the treatment) (Sheikh & Hurwitz, 2005).

Overall when looking at data from different clinical trials, Cochrane (a group of scientists) concluded that the use of antibiotics in the treatment of conjunctivitis can be considered to speed up the resolution of symptoms (Sheikh & Hurwitz, 2012).

A poor response to antibiotic treatment might indicate viral or allergic conjunctivitis. (NICE, 2019)

What is the alternative to chloramphenicol drug treatment of conjunctivitis?

Fusidic acid 1% eye drops are recommended as a second-line treatment of conjunctivitis in babies (NICE, 2018). Fusidic acid 1% eye drops are prescription-only medication and can only be prescribed by a GP or another qualified prescriber.

Treatment of conjunctivitis in babies: are eye drops better than eye ointment?

There is no information suggesting chloramphenicol eye drops are better than eye ointment in the treatment of conjunctivitis and vice versa. Instilling eye drops to a baby may be challenging, and so does the application of the eye ointment. Chloramphenicol eye ointment is applied less frequently than eye drops. As suggested previously, it is possible to use eye drops during the day and apply the ointment at night. There is a storage advantage of chloramphenicol eye ointment, which does not have to be kept in the fridge.

References:

eMC (2019). Optrex Infected Eye Drops. Available at: https://www.medicines.org.uk/emc/product/612/smpc Accessed on 20/01/2023

Kapoor VS, Whyte R, Vedula SS. Interventions for preventing ophthalmia neonatorum. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD001862. DOI: 10.1002/14651858.CD001862.pub3. Available at: https://doi.org/10.1002/14651858.CD001862.pub3 Accessed on 20/01/2023

NICE (2018). Conjunctivitis – infective. Scenario: Management in primary care. Available at: https://cks.nice.org.uk/conjunctivitis-infective#!scenario:1 Accessed on 20/01/2023

NICE (2019). Eye infections. Available at: https://bnf.nice.org.uk/treatment-summary/eye-infections.html Accessed on 20/01/2023

Public Health Agency, PHA (2017). Guidance on infection control in schools and other childcare settings. Available at: https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf Accessed on 20/01/2023

Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: Cochrane systematic review and meta-analysis update. Br J Gen Pract. 2005;55(521):962–964. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570513/ Accessed on 20/01/2023

Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD001211. DOI: 10.1002/14651858.CD001211.pub3 Available at: https://doi.org/10.1002/14651858.CD001211.pub3 Accessed on 20/01/2023