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Eye Prophylaxis

Neonatal Eye Care
by Dr. Jay Gordon

Many of my patients refuse neonatal eye care. They do this after having read information on their own and discussing the issue at length with me during a prenatal visit in my office.

This is a controversial issue and the vast majority of doctors and experts recommend giving the treatment shortly after birth. Nonetheless, there is research to suggest that this routine may not be necessary.

Obviously, this represents a minority point of view both in the hospital and in the pediatric community in general.

I have added my own emphasis to these articles.

Pediatrics 1993 Dec;92(6):755-60
Randomized trial of silver nitrate, erythromycin, and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Eye Prophylaxis Study Group.
Bell TA, Grayston JT, Krohn MA, Kronmal RA

Department of Biostatistics, University of Washington, Seattle 98195.
OBJECTIVE. To compare the efficacy of commonly used forms of eye prophylaxis for newborns with no prophylaxis in the prevention of nongonococcal conjunctivitis. DESIGN. Randomized doubly masked clinical trial. SETTING. University of Washington Hospital and affiliated clinics, Seattle, between 1985 and 1990. SUBJECTS. The medical records of 8499 women were evaluated for possible participation; 2577 were eligible. Of the 758 enrolled, the infants of 630 were evaluable. INTERVENTION. Comparison of silver nitrate, erythromycin, and no eye prophylaxis given at birth for the prevention of conjunctivitis. MAIN OUTCOME MEASURES. Conjunctivitis during the first 60 days of life and nasolacrimal duct patency in the first 2 days of life. RESULTS. The frequency of impatent tear ducts at the 30- to 48-hour examination did not differ significantly by prophylaxis group. Among the 630 infants randomized and observed, 109 (17%) developed mild conjunctivitis. Sixty-nine (63%) of the cases appeared during the first 2 weeks of life. After 2 months of observation, infants allocated to silver nitrate eye prophylaxis at birth had a 39% lower rate of conjunctivitis (hazard ratio = 0.61, 95% confidence interval = 0.39 to 0.97), and those allocated to erythromycin had a 31% lower rate of conjunctivitis (hazard ratio = 0.69, 95% confidence interval = 0.44 to 1.07), than did those allocated to no prophylaxis. CONCLUSION. Silver nitrate eye prophylaxis caused no sustained deleterious effects and even provided some benefit to infants born to women without Neisseria gonorrhoeae. However, the effect was modest and against microorganisms of low virulence. The results suggest that parental choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy.

Pediatr Infect Dis J 1992 Dec;11(12):1026-30
Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin and no prophylaxis.
Chen JY
Department of Pediatrics, Chung Shan Medical and Dental College Hospital, Taichung, Taiwan, Republic of China.
From November, 1989, to October, 1991, 4544 neonates were born at our hospital. Neonatal ocular prophylaxis immediately after birth was used with 1% tetracycline ophthalmic ointment in 1156 neonates, 0.5% erythromycin ophthalmic ointment in 1163 neonates and 1% silver nitrate drops in 1082 neonates. No prophylaxis for neonatal conjunctivitis was given to 1143 neonates. A total of 302 infants (6.7%) developed conjunctivitis during the first 4 weeks of life. Between December, 1991, and January, 1992, 425 neonates were born at our hospital and all were given 0.5% erythromycin ophthalmic ointment twice in the first 24 hours after birth for ocular prophylaxis. Thirty-one (7.3%) infants developed conjunctivitis during the neonatal period. The incidence rates of neonatal chlamydial conjunctivitis in the tetracycline, erythromycin, silver nitrate, no prophylaxis and erythromycin twice groups were 1.3, 1.5, 1.7, 1.6 and 1.4%, respectively. We conclude that neonatal ocular prophylaxis with erythromycin (one or two doses) or tetracycline or silver nitrate does not significantly reduce the incidence of neonatal chlamydial conjunctivitis compared with that in those given no prophylaxis.

5: Am J Epidemiol 1993 Sep 1;138(5):326-32
The bacterial etiology of conjunctivitis in early infancy. Eye Prophylaxis Study Group.
Krohn MA, Hillier SL, Bell TA, Kronmal RA, Grayston JT

Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle.
The authors conducted this study to determine the etiologic agents of conjunctivitis in early infancy. From 1985 to 1990, 630 infants enrolled in a randomized, controlled, double-masked study of eye prophylaxis were observed for 60 days after delivery for signs of conjunctivitis. The following isolates were categorized as pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria cinerea, Klebsiella pneumoniae, and Chlamydia trachomatis. Using conditional logistic regression for analysis of 97 infant pairs, the authors identified isolates categorized as pathogens almost exclusively among cases (odds ratio (OR) = 18.0, 95% confidence interval (CI) 2.3-128). Among the microorganisms which have not usually been regarded as pathogens in the etiology of infant conjunctivitis, Streptococcus mitis was the only microorganism associated with an increased risk of conjunctivitis (OR = 5.3, 95% CI 1.8-15.0). The findings concerning the species of bacteria most often associated with conjunctivitis, as well as the finding that method of delivery is unimportant, suggest that bacteria were transmitted to the infants' eyes after birth and not from the birth canal.

14: Pediatr Infect Dis J 1989 Aug;8(8):491-5
Failure of erythromycin ointment for postnatal ocular prophylaxis of chlamydial conjunctivitis.
Black-Payne C, Bocchini JA Jr, Cedotal C

Department of Pediatrics, Louisiana State University School of Medicine, Shreveport 71130.
Chlamydia trachomatis is the most common pathogen associated with conjunctivitis during early infancy in the United States. During a 13-month interval at our medical center 4834 infants were born, 311 of whom (6.4%) had conjunctival specimens tested for chlamydial antigen before the age of 12 weeks. In 44 (14% of all tested infants, 0.9% of live births) chlamydial antigen was present. Because the rate of asymptomatic maternal chlamydial endocervical colonization is estimated to be 26% at our institution (previous prospective study), we calculated a minimal failure rate for erythromycin ocular prophylaxis of from 7 to 19.5%. A subsequent case-control study revealed that mothers of infants with chlamydial conjunctivitis were more likely to be primiparous (P = 0.03) and experience longer duration of rupture of membranes before delivery (P = 0.046). We conclude that a substantial percentage of infants exposed to Chlamydia develop chlamydial conjunctivitis despite receiving erythromycin ocular prophylaxis.


Neonatal Ocular Prophylaxis/Newborn Eye Ointment
Is it necessary and effective?

According to medical studies, no. Below you will find studies which prove that the eye ointment routinely applied to newborns does not significantly alter eye infections as opposed to no ointment of any kind. Also, there is evidence that the bacteria which cause these infections are not passed to the infant in the birth canal, but after birth. Also, it has been found that a significant number of infants develop an infection even though the HAVE received the ointment.
Read for yourself.

Bell TA, Grayston JT, Krohn MA, Kronmal RA. Randomized trial of silver nitrate, erythromycin, and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 1993 Dec;92(6):755-60.

Eye Prophylaxis Study Group. Department of Biostatistics, University of Washington, Seattle 98195. OBJECTIVE. To compare the efficacy of commonly used forms of eye prophylaxis for newborns with no prophylaxis in the prevention of nongonococcal conjunctivitis. The results suggest that parental
choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy.

Chen JY. Prophylaxis of ophthalmia neonatorum: comparison of silver
nitrate, tetracycline, erythromycin and no prophylaxis. Pediatr Infect Dis J 1992 Dec;11(12):1026-30.

The incidence rates of neonatal chlamydial conjunctivitis in the tetracycline, erythromycin, silver nitrate, no prophylaxis and erythromycin twice groups were 1.3, 1.5, 1.7, 1.6 and 1.4%, respectively. We conclude that neonatal ocular prophylaxis with erythromycin (one or two doses) or tetracycline or silver nitrate does not significantly reduce the incidence of neonatal chlamydial conjunctivitis compared with that in those given no prophylaxis.

Krohn MA, Hillier SL, Bell TA, Kronmal RA, Grayston JT. The bacterial etiology of conjunctivitis in early infancy. 5: Am J Epidemiol 1993 Sep 1;138(5):326-32.

The findings concerning the species of bacteria most often associated with conjunctivitis, as well as the finding that method of delivery is unimportant, suggest that bacteria were transmitted to the infants' eyes after birth and not from the birth canal.

Black-Payne C, Bocchini JA Jr, Cedotal C. Failure of erythromycin ointment for postnatal ocular prophylaxis of chlamydial conjunctivitis. 14: Pediatr Infect Dis J 1989 Aug;8(8):491-5.

The conclusion was that a substantial percentage of infants exposed to Chlamydia develop chlamydial conjunctivitis despite receiving erythromycin ocular prophylaxis.

I feel inclined to ask, if the infants are contracting the bacteria after birth and not in the birth canal, where is it coming from? In the hospital, bacteria is rampant, and even the chemical sterilizing agents used to clean hospitals have been shown to be ineffective in totally wiping out bacteria. It is hard for me to believe that it was introduced to the infants by the mothers after birth; the baby makes it through the birth canal, with the mother's bodily fluids smeared all over it, and still comes out without an infection, only to be introduced to it from normal handling by the mother? I don't think so. I can only conclude it was introduced by the handling of hospital personnel.

Another good reason for home birth, where your baby is already immune to the germs in the environment it is born into.


Copyright 2001 Judie C. Rall and The Gathering Place

 

More Information about Routine Eye Prophylaxis:

Newborn Eye Ointment
http://gentlebirth.org/Midwife/eyeointm.html

Newborn Procedures
http://www.unhinderedliving.com/newborn.html

Newborn Eye Prophylaxis Ointment
http://www.midwifemama.com/eyeprophylaxis.html

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