What is neonatal conjunctivitis?

Neonatal conjunctivitis is also known as ophthalmia neonatorum (Latin term). It is characterised by redness and inflammation (erythema), swelling of the eyelids (oedema) and inflammation of the eyelids (palpebral conjunctiva) as well as purulent ocular discharge (mucus discharge from the eyes). This is one of the most prevalent infections in the first month of life of a newborn.

There are two forms of ophthalmia neonatorum: septic and aseptic. When administering silver nitrate drops for ocular prophylaxis, aseptic type (chemical conjunctivitis) usually develops. Viral and bacterial infections are the main causes of septic newborn conjunctivitis. Neisseria gonorrhoeae and Chlamydia trachomatis are two sexually transmitted infections that cause septic neonatal conjunctivitis linked to systemic issues and even vision loss if left untreated.¹ 

Predisposing factors of neonatal conjunctivitis

Many predisposing factors, including decreased tear production, lack of immunoglobulin A (IgA) in tears, decreased immunological function, absence of lymphoid tissue in the conjunctiva, and decreased lysozyme activity, leave newborns at higher risk of conjunctivitis.²

Risk factors include:²

• Premature membrane rupture
• Protracted labour
• Premature newborn
• Inadequate prenatal care
• Sexually transmitted infections in the mother
• Mechanical ventilation 
• Unhygienic surroundings, prior midwife intervention 
• And an HIV-positive mother

Symptoms of neonatal conjunctivitis

Conjunctivitis causes discharge from the eyes of newborns, which can appear a few days to several weeks after delivery. Their eyelids become red, swollen, and sensitive.³ Neonates with viral conjunctivitis are more likely to have a watery discharge, while those with bacterial conjunctivitis usually appear with a purulent discharge. The majority of instances of newborn conjunctivitis are caused by bacteria, with Chlamydia trachomatis accounting for 40% of all cases.

Five days to two weeks after birth is when Chlamydial conjunctivitis usually manifests as unilateral or bilateral conjunctival redness and watery discharge. Purulent discharge and the development of pseudomembranes, which are yellow-white membranes that are visible on the tarsal conjunctiva, may follow in the future.⁴  

Another cause of bacterial conjunctivitis that causes noticeable redness and swelling, lid oedema, and purulent discharge is Neisseria gonorrhoeae. Herpes simplex virus (HSV) is the primary cause of newborn conjunctivitis, which accounts for a substantially smaller number of cases. HSV conjunctivitis in newborns is mainly caused by infection in the birth canal, and a neonate who develops conjunctivitis after having been exposed to HSV should be given special care.⁴   

Causes of neonatal conjunctivitis

The causes of neonatal conjunctivitis can be classified into three types:³

• Bacterial infection
• Chemical
• Other causes

1. Bacterial infection

The causative agents of bacterial infection include:³

Chlamydia trachomatis 

Chlamydia trachomatis is known to cause inclusion conjunctivitis and genital infections. A woman who has untreated chlamydia can transmit the germs to her child during childbirth. Symptoms of inclusion conjunctivitis include redness of the eye(s), swelling of the eyelids, and pus drainage. Symptoms typically emerge 5 to 12 days after birth. Some neonates with chlamydial conjunctivitis may have the illness in other parts of their body. 

Neisseria gonorrhoeae

Neisseria gonorrhoeae can cause both gonococcal conjunctivitis and gonorrhoea, a sexually transmitted infection. A woman with untreated gonorrhoea can transmit the bacterium to her baby during childbirth. Symptoms typically include red eyes, thick pus in the eyes, and swelling of the eyelids. This kind of conjunctivitis usually appears within the first two to five days of life.  

2. Chemical causes

When newborns are given eye drops to prevent bacterial infections, their eyes may get infected. This could be identified as chemical conjunctivitis. Chemical conjunctivitis symptoms include mildly red eyes and swelling of the eyelids. Symptoms are expected to last only 24 to 36 hours.³

3. Other causes

Conjunctivitis can be caused by viruses and bacteria in addition to Chlamydia trachomatis and Neisseria gonorrhoeae. For example, bacteria that ordinarily exist in a woman's vagina but are not sexually transmitted can induce conjunctivitis. Furthermore, the viruses that cause vaginal and oral herpes can induce newborn conjunctivitis and serious vision loss. During childbirth, the mother may transmit infections to her infant. 

Herpes conjunctivitis is less prevalent than gonorrhoea or chlamydia conjunctivitis. Symptoms typically include red eyes and puffy eyelids with pus.³

Diagnosis and treatment of neonatal conjunctivitis

Ophthalmia neonatorum is diagnosed clinically based on the observation of signs and symptoms. The clinical differentiation between various types of neonatal conjunctivitis can be difficult. Therefore, laboratory diagnosis is crucial to making the right diagnosis and starting the appropriate course of treatment.

Every newborn with neonatal conjunctivitis should have conjunctival scrapings taken from their palpebral conjunctiva for the gram and giemsa stain analyses. Based on the analysis, the causative agent of conjunctivitis is found and further treatment is proceeded. Since ophthalmia neonatorum is an eye emergency, all newborns with neonatal conjunctivitis must be admitted.¹ 

Different forms of newborn conjunctivitis can be treated with different modalities; the clinical picture and laboratory diagnosis (using the giemsa and gramstain) should provide the course of treatment. To stop the organism from spreading throughout the body, it's crucial to treat the infants with systemic rather than topical medications. Treatment for both the mother and her sexual partner is essential since the causative organism is sexually transmitted. The treatment varies depending on the cause of conjunctivitis and it is discussed further:¹

Treatment for infection due to Chlamydia trachomatis

The American Academy of Paediatrics and WHO recommend oral erythromycin syrup at a dose of 50 mg/kg per day for 14 days, divided into 4 doses. As an adjuvant therapy, topical erythromycin or tetracycline can be used. The benefits of oral Erythromycin include treating concomitant pneumonitis, eliminating nasopharyngeal carriers, and preventing conjunctivitis relapse better than topical medication.¹

Treatment for infection due to Neisseria gonorrhoeae

Treatment for N. gonorrhoeae-induced conjunctivitis involves a single dose of a third-generation cephalosporin, such as ceftriaxone. This is initiated in conjunction with regular saline irrigation of the eyes in an attempt to eliminate the mucopurulent discharge that is usually present. Considering the risk of co-infection, neonates treated for gonococcal conjunctivitis should, as in most cases, also receive treatment for chlamydial conjunctivitis.¹

Treatment for chemical conjunctivitis

Chemical conjunctivitis does not require any specific treatment and is resolved within two to four days.⁴

Treatment for infection due to herpes simplex virus

To stop the infection from spreading, newborns suspected of having herpes simplex conjunctivitis should receive treatment for at least two weeks with low-dose systemic aciclovir (30mg/kg/day IV divided 3 times a day) or Vidarabine (30 mg/kg/day in divided doses IV) for at least two weeks. Trifluridine eye drops or Vidarabine ointment are two possible topical treatments.¹

FAQs

1. Is neonatal conjunctivitis a serious concern?

Neonatal conjunctivitis should be considered and treated immediately as it may cause disruption to the eyelids and irritate the newborn. In some cases if left untreated it may lead to vision loss, hence it has to be treated at the earliest.

2. Can we cure neonatal conjunctivitis?

Yes. It is curable when the root cause is found and treated immediately. If you find any signs and symptoms in your newborn, reach out to the healthcare provider and diagnose it.

3. What are the complications of neonatal conjunctivitis?

The infection caused in the eyes can also enter the systemic circulation and further spread to other parts of the body. Hence, the treatment should be appropriate so that it can be cured.

Summary

Neonates are prone to various infections at the early stage and it is important to diagnose and treat the newborn at the earliest so that further complications such as vision impairment can be avoided. The important aspect is to find the specific cause of infection and treat it accordingly so that the infection can be cured.