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Newborn Eye Ointment

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WOW!  The Canadian Paediatric Society is no longer recommending routine eye ointment.  They say it's not effective.  Maternal screening and newborn observation are recommended instead.

The Canadian Society of Pediatrics has recommended against this treatment of babies’ eyes.

Ineffective, outdated and unethical [11/30/15 by Allison Vuchnich – the case against antibiotic eye drops for newborns

Is Erythromycin Eye Ointment Always Necessary for Newborns? from evidencebasedbirth.com - "Another option is to wait and see if a newborn develops ophthalmia neonatorum (ON)."

Clinical Trial of Eye Prophylaxis in the Newborn - "The results suggest that prenatal choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care who are screened for sexually transmitted diseases during pregnancy."

You Want to Stick that in my Baby Where!? Informed Consent in Newborn Procedures

Some midwives suggest prophylactic eye ointment for babies born in the hospital, even if they wouldn't make the same recommendation for a birth that takes place in the home or birth center.  The logic is that hospitals are full of more and worse germs.

I agree that the logic is appealing, but consider that the worst germs in the hospital are resistant to antibiotics.  When you use an antibiotic to kill off the non-resistant germs, then there is nothing to keep the resistant germs in check.  In particular, the normal skin flora that work to prevent infections in the first place aren't allowed to colonize the eyelash beds.

From a mom:

My midwife initially tried the same stuff on me this last time (there are other bacteria in the vagina...) Well, there are other bacteria in the vagina- good ones.  Is there any proof that this bacteria causes infection in a newborn's eyes?  I kept asking for proof, for medical references, and finally she broke down and admitted that the real reason Dr.s and midwives tell you it's for other reasons than STD's is because *they* can get in trouble for not administering it, not because there is truly a medical need.  So I suggested if it would soothe her conscience, she could let *us* administer the drops.  And we would miss.

You might try this with your own health care professional.  My last two did not have the eye drops, and there was an amazing difference in their ability to focus on my face compared to the others.  I for one found that the weeks of deep, soul-searching gazes exchanged with these children in their early days and weeks is too valuable to trade for some unnecessary goop in their eyes for no valid reason.

Quite a high number of woman who have gonorrhea have no symptoms of it (20%?). They are the main reservoir of this illness in the population. That's why it's not exceptional pregnant woman are tested on STD during their pregnancies. Testing during pregnancy is however not a proof at all there won't be pathogen germs in the vagina by the time of the delivery.

The use of ointments and AgNO3 is in this perspective obsolete that nowadays eye infections, caused by gonococci or other germs, easily can be treated and cured from the moment of onset. In the rare occasion the eye infection is caused by gonococci this approach will reveal which woman have gonorrhea but not the symptoms. Both mother and baby and likely the partner(s) too then can be treated and cured. This approach is safe and effective. It will too safe clients and health care a lot of unnecessary costs (imagine the pool of silver nitrate or the pile of ointment (or the $$$) used to treat something that wasn't there!!). The use of AgNO3 and ointment is no full guarantee an eye infection won't occur. Quite often AgNO3 causes some eye irritation itself.

Historical Perspective on Eye Infections

I couldn't find numbers, but all authors agree that it used to be a primary cause of blindness -- 1965 Universal Home Doctor
gonorrhea It has been calculated that this disease accounted for one third to one half of all the persons in blind asylums, so destructive of sight it is; but now that it is more vigorously dealt with and is notifiable by doctors and midwives its incidence has been kept down. [This was written in 1930.]
It was a very obvious infection and very difficult to treat.

Delee's Obstetrics for Nurses (1937 edition):

[gonorrhea] quickly sets up a violent inflammation of the conjunctiva. at first the lids grow red , then there is a thin, irritating discharge, with yellowish flakes. After a few hours this becomes purulent and th lids become so swollen that the eyes are closed. Unless active and constant treatment is instituted, the inflammation gains headway, the cornea may ulcerate, leaving ugly scars which shut out the light, or the lens may escape and the whole eye be destroyed. A large part of the blindness in the world is caused by this dreadful affliction, and it is primarily venereal in origin. pg 496-497
There is a HORRIBLE picture of a baby with the disease -- eyes --really the entire upper face -- swollen and distorted, red, oozing yellow pus. Believe me, it looks nothing like any conjunctivitis I have ever seen. I can't imagine anyone not noticing it, or ignoring it.

The treatment in those days consisted of frequent "irrigations" with warm saline and/or applications of ice packs made of sterile saline poured over sterile ice cubes. The nurse applies these "ice-cold pledgets (cotton balls) on the lids, changing them every minute, and throwing the waste into a paper bag at the side. The order may be to keep up the application of cold for twenty-four hours and not to interrupt it while the child is nursing." And days and weeks of constant care were required to fight the infection, prevent eye damage and attempt to prevent its spread to the family and caregivers.

It's really very sad to see the pictures in this book.

Contrast this treatment with a later book- Handbook of Pediatrics (1975: post-penicillin)-- "The prognosis with treatment is generally very good, and cure should result within two to four days."

I frequently send up a prayer of thanks for the discovery of antibiotics.

The whole notion of gonorrhea causing blindness in this day and age is ridiculous.  GC in a newborns eyes is supposed to cause an outrageously awful infection.  They go blind from abscesses and ulcerations - not a silent destructive subclinical infection.  Nobody would miss it.  It's like other pathological conjunctivitis's: if the eye is extremely purulent, swollen, and red they need antibiotics.  Even if the babe developed the beginning of a GC positive eye infection the treatment would still prevent blindness.  Nobody would be home with a lavender and saline compresses, mistaking it for a plugged duct.  I saw a film once of the treatment before antibiotics, when all they could do was irrigate the eyes with who knows what.  I was impressed.

 How about chlamydia and blindness?  Is that symptomatic as well?

Washington State Makes a Mockery of Informed Consent for Eye Ointment

I am required by law to administer erythromycin to the NB's eyes. I made an informed consent sheet my clients could sign if they refused the treatment. When I was given a routine QA review by my malpractice ins they said I could not offer the informed consent. They said the only way I could not legally administer the treatment was to be physically impeded by the parents from doing so and then my obligation was to inform CPS of the incident. Needless to say, I quit offering the informed consent but I have not called CPS on any parents. I believe this to be a no win situation for me. 

Though the erythromycin doesn't burn, it is an antibiotic which I suspect will enter the bloodstream through the eye, thus it is my assumption that the potential for candida diaper rash, thrush, digestive problems and antibiotic resistance are raised when eye prophylaxis is administered.

I don't know about those problems, but I have noticed that we tend to see more sticky eyes in babies who have had the erythromycin. My thought on that one is that there is likely some kind of local irritant reaction to the ointment, which causes swelling of the tear ducts and blockage. With improper drainage, a breeding site for bacteria develops and, voila, a sticky eye (almost always just one, we've noticed).

Would be good to see a clinical trial on this. I think mandatory eye prophylaxis is a stupid notion, frankly. For all the reasons cited, thus far.

Goopy Eye

If the eyes are just goopy or watery and not red, it's a plugged duct and usually resolves by the first birthday.

The mom can try the following:  cut fingernails really short, hold her finger in hot water and massage the inner corner of the eye.  Also, have her drip breastmilk in the eye at every feeding.

Clogged tear ducts are usually one-sided.  A bacterial infection will usually infect both eyes pretty quickly.  Sometimes a clogged duct will resolve on one side and then the other side becomes clogged.  Clogged ducts can last for weeks and weeks.

If they want to try alternative remedies, I'd recommend an infusion of plantain made fresh daily; personally, I consider goldenseal too strong for a baby.

Plantain may be used in place of antibiotics for drawing infection out of the eye. Be diligent and treat with warm, infusion-soaked sterile 2x2 or 4x4, TID to QID. Drizzle a little into the open eye as well. Be sure infusion is strained  of all bits of plantain. Fresh and dried plant works equally well, use more of the fresh when making the infusion (strong tea). Works well for pink eye, too. Takes 2-3 days of treatment.  If it still hasn't cleared up, consider a ped visit. 

Photos of Serious Eye Infections

It's very common for newborns to get minor eye infections or a simple clogged duct.  Like the newborn's skin, the newborn's eyes have to be colonized with the normal, healthy flora, and there may be little skirmishes with abnormal bacteria in the first few days after birth.

It's also very common for my clients to decline erythromycin eye ointment, based on clinical evidence, and they often get very worried if their baby develops a minor eye infection.

So I'm including some links here to photos of the kinds of gonococcal eye infections that can cause blindness.  If your baby's eyes look like this, take them to the doctor immediately!

Gonococcal conjunctivitis

Gonococcal eye infection 

General Google search for images of gonococcal conjunctivitis


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