Neonatal Conjunctivitis

What is Neonatal Conjunctivitis (Ophthalmia Neonatorum)?

Neonatal conjunctivitis (ophthalmia neonatorum) occurs in newborns. It is an infection that turns one or both of their eyes red. It can be caused by bacteria, viruses, or chemicals.

Conjunctivitis is commonly known as "pink eye." The conjunctiva is the transparent layer of tissue surrounding the whites of the eye. When it gets inflamed or irritated it turns pink or red.

Neonatal conjunctivitis occurs within the first 28 days of life (the neonatal period). It is caused by a bacterial or viral pathogen acquired during birth. This means that the birth canal is infected.

Historically, gonorrhea was the usual cause, but chlamydial infection is now more common. Untreated neonatal conjunctivitis can be severe and can lead to blindness.

Globally, neonatal conjunctivitis occurs in 1 to 12 percent of all newborns. However, its prevalence varies widely according to:

• Socio-economic conditions
• Health education
• Maternal healthcare
• Type of prophylaxis (preventative treatment) used.

In developed countries, the rate of this condition is less than .5%, but it is much more common in low-income countries.

What Causes Neonatal Conjunctivitis?

The common causes of neonatal conjunctivitis are chemical, bacterial, and viral:

Chemical conjunctivitis is caused by eye drops used to prevent gonococcal infection. They are commonly made of silver nitrate. In the United States, this prophylaxis method has been replaced by tetracycline or erythromycin ointment. Chemical conjunctivitis usually appears 6 to 8 hours after the eye drops are administered. It usually disappears spontaneously after 24 to 96 hours.

Bacterial conjunctivitis is the most common cause of ophthalmia neonatorum. The bacteria gets transferred from the mother to the baby during birth. The most common type of bacterial conjunctivitis is chlamydial conjunctivitis, caused by Chlamydia trachomatis. In the United States, 2% to 40% of neonatal conjunctivitis cases are caused by chlamydia.

Gonococcal conjunctivitis is the next most common bacterial conjunctivitis. It is caused by Neisseria gonorrhoeae. N. gonorrhoeae causes the sexually transmitted infection gonorrhea. Gonorrhea causes less than 1% of cases of neonatal conjunctivitis.

Other bacteria that cause neonatal conjunctivitis include:

• Haemophilus species
• Streptococcus pneumoniae
• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus viridans
• Escherichia coli
• Pseudomonas aeruginosa

Viral or infectious conjunctivitis is caused by a virus. Herpes Simplex Virus (HSV) and adenovirus are the most common causes. Adenoviral conjunctivitis is extremely contagious, and caregivers should use extreme caution and keep their hands clean to prevent the virus from spreading to others.

Symptoms of Neonatal Conjunctivitis

Symptoms of neonatal conjunctivitis usually appear within one day to two weeks after birth.

Common symptoms include:

• Redness in the eye
• Mucopurulent or purulent discharge (liquid oozing from the eye)
• Chemosis, or swelling of the conjunctiva
• Symptoms present in both eyes

Neonatal conjunctivitis might also be asymptomatic, which is why practicing good prevention is essential.

Neonatal conjunctivitis should not be confused with keratitis, the inflammation of the cornea. If neonatal conjunctivitis is suspected, an ophthalmologist should examine the patient to rule out keratitis or other conditions.

How to Prevent Conjunctivitis in a Newborn

There are four strategies to prevent ophthalmia neonatorum:

• Screen pregnant women for genital infection. All pregnant women should be screened for gonorrhea, herpes, and chlamydia  at their first prenatal visit. If they are infected, they should be treated before the baby is born.
• Prevent the spread of sexually transmitted diseases from mother to child. If they are not tested during pregnancy, pregnant mothers should be tested at delivery or before taking the baby home. Mothers with sexually transmitted infections must take measures to prevent neonatal conjunctivitis.  Babies born to women with untreated chlamydia at delivery have a 30-50% chance of developing ophthalmia neonatorum. Approximately 25% to 50% of infants exposed to C. trachomatis and Neisseria gonorrhea develop neonatal conjunctivitis without prophylaxis. Before giving birth, women with genital herpes should consult with their doctor about ways to reduce the chances of spreading the infection to their newborn. Women with genital herpes may take acyclovir as a prophylaxis to prevent an outbreak that could spread to the child.
• Provide topical or systemic eye prophylaxis at birth. State law requires most hospitals to put drops or ointment in a newborn’s eyes as ocular prophylaxis (preventative treatment) administered to the eyes. Standard prophylaxis includes topical antibiotics, such as erythromycin or tetracycline ointment.
• Early diagnosis and treatment of eye infections in newborns. All infants should receive ocular prophylaxis at birth to prevent gonococcal ophthalmia. If conjunctivitis is suspected, the newborn should be treated immediately.

An individual with a cold or virus should avoid contact with a newborn infant under the age of three months because cold and flu viruses sometimes cause neonatal conjunctivitis.

How Do You Treat Conjunctivitis in Babies?

If conjunctivitis is suspected, a doctor or ophthalmologist will perform tests to determine the cause of conjunctivitis.

Standard tests include:

• taking swabs for culture,
• PCR test
• gram test

If a bacterial infection is suspected, a doctor may use a gram stain to distinguish the type of bacteria that caused the illness to provide appropriate care.

Early diagnosis of neonatal conjunctivitis is essential because the infection can progress quickly. Even if the exact cause is undetermined at the onset of symptoms, patients should begin treatment immediately to prevent complications.

Common treatments for conjunctivitis in babies include:

• Frequent irrigation with sterile isotonic saline, lubrication, or artificial tears
• Avoiding eye patching
• Topical erythromycin 
• Antibiotic drops or ointments, including azithromycin or chloramphenicol
• Antivirals such as acyclovir
• Intravenous (IV) antibiotics such as ceftriaxone 
• A warm compress to the eye
• Isolation of a patient to prevent contagion spread
• Treatment of mothers and their sexual partners in cases where sexually transmitted bacteria is the cause.

Prognosis, Dangers & Complications

The prognosis for neonatal conjunctivitis is generally good, especially if early diagnosis and treatment are undergone.

• Chemical infections. Full recovery is expected spontaneously after 24 to 96 hours.
• Chlamydial infections. Approximately 80% of neonates fully recover after one round of treatment. Further treatment may be required in other cases.
• Other bacterial infections. These infections usually respond to appropriate treatment. However, missed infections can cause sight impairment or even death.
• Viral Infections. Vision impairment is likely, and results may be fatal.

Dangers and Complications

The most common and dangerous complications relate to gonococcal conjunctivitis. These may include:

• Conjunctival scarring
• Keratitis
• Corneal pannus
• Permanent visual impairment
• Other rare side-effects of treatments

Most other cases of conjunctivitis are not dangerous. However, rare side effects may occur, including:

• Systemic infection (chlamydial pneumonia, disseminated herpes simplex, etc.)
• Corneal ulceration
• Pseudomonas is very rare but could cause keratitis and ultimately death

If left untreated, ophthalmia neonatorum can lead to severe complications, including ulceration and perforation of the cornea, and blindness. The chlamydial infection can also cause pneumonia in newborns.