Overview

Administering erythromycin eye ointment to newborns is a standard procedure in the United States to prevent ophthalmia neonatorum. Ophthalmia neonatorum is a newborn eye infection that affects 1-2% of newborns in the United States. This infection can be caused by sexually transmitted infections, viruses, and bacteria. As with any intervention, there are pros and cons to consider. This episode examines the evidence on the efficacy and safety of erythromycin eye ointment so you can make an informed choice for your baby.

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Standard Procedures

In the United States, administering erythromycin eye ointment to newborns is standard at all hospitals and birth centers. In most cases, just because something is standard procedure doesn’t always mean it is mandatory. As with any intervention, this should come with informed consent, and you should be able to opt in or out. However, in some U.S. states, erythromycin is mandated, and you do not have the option to opt out. Talk to your doctor or midwife to find out what the law is in your area.

Regardless of the laws in your state, this episode will break down the evidence, pros, and cons so you are informed about erythromycin.

Erythromycin and Ophthalmia Neonatorum 

Erythromycin is an antibiotic ointment that comes in a tube and has a similar texture to Vaseline. Erythromycin is used to prevent ophthalmia neonatorum, which is conjunctivitis or pink eye, in a newborn. Ophthalmia neonatorum can be caused by sexually transmitted infections, viruses, and bacteria. This eye infection leads to blindness in approximately 10,000 babies worldwide every year. This varies significantly by region. In the United States, the incidence of ophthalmia neonatorum is 1-2% of newborns.

Sexually Transmitted and Viral Infections

The sexually transmitted infections that can cause ophthalmia neonatorum are gonorrhea, chlamydia, and the herpes simplex virus. Chlamydia is the leading cause, and in the U.S., this causes between 2-40% of cases. Gonorrhea accounts for less than 1% of cases globally. If a mother does have this STI, up to 48% of newborns will contract ON. The herpes simplex virus causes fewer than 1% of cases.

If you have any of these infections, they can infect your newborn. Untreated, this eye infection can cause permanent eye damage or blindness. Many women infected with an STI do not show any signs of infection, and it has become standard practice to test for these in pregnancy.

Other Causes

Other viral infections can cause ophthalmia neonatorum, such as adenovirus or enterovirus. Many bacteria are thought to cause pink eye in newborns. This bacteria can be transferred from the mother or other people who have contact with the baby in the hospital or at home. Chemicals can also cause eye infections. This is the primary reason silver nitrate is no longer used to prevent neonatal conjunctivitis. Chemical conjunctivitis can also be caused by erythromycin, although I had difficulty tracking down statistics on how common that is. The majority of the research on using erythromycin to prevent ophthalmia neonatorum focuses on it being caused by the sexually transmitted infections of gonorrhea and chlamydia.

Recommendations from Professional Organizations

The U.S. Preventative Services Task Force reaffirmed their recommendation to use prophylactic erythromycin in all newborns in 2019. An intervention to prevent an illness or disease is called prophylactic use. The CDC, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the World Health Organization support this recommendation. Organizations in some other countries take a different approach. The Canadian Pediatric Society recommends against using erythromycin in all newborns. Many European countries, including Denmark, Norway, Sweden, and the United Kingdom, opt for increased screening and treatment prevention rather than treating all newborns. The US Preventative Services Task Force acknowledges that another area for research is whether risk-based prophylaxis of newborns, based on maternal risk factors, is as effective as universal prophylaxis.

Efficacy of Erythromycin

Erythromycin is currently the only FDA-approved medication to prevent ophthalmia neonatorum. The efficacy of this intervention varies on the potential cause of ophthalmia neonatorum. A Cochrane review examined the effectiveness of erythromycin reported in 30 trials with 79,198 babies. The review authors note that their findings are inconsistent with the evidence review supporting the recommendation published by the U.S. Preventive Services Task Force. They found no data on whether prophylaxis for ophthalmia neonatorum prevents serious outcomes such as blindness or any adverse visual outcome. Moderate‐certainty evidence suggests that the use of prophylaxis may lead to a reduction in the incidence of any conjunctivitis in newborns, but the evidence for an effect on conjunctivitis caused by gonorrhea, chlamydia or bacteria was less certain.

Risks of Erythromycin

Potential risks associated with erythromycin include allergic reactions, chemical pink eye, and irritation. Newborns can only see about 8-12 inches away, perfect for seeing your face as you hold them. It can blur your baby’s vision until erythromycin wears away (within 24 hours). Although some parents may see this as a downside, it is temporary.

Antimicrobial Resistance

Although it may not immediately affect your baby, one challenge with the wide use of antibiotics is the growing problem of antimicrobial resistance. Antimicrobial resistance occurs when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicines. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective, and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability, and death. The World Health Organization states this is a top global public health and development threat. According to the CDC, each year in the U.S., more than 2.8 million people are infected with antibiotic-resistant bacteria or fungi, and more than 35,000 people die as a result.

The U.S. Preventative Services Task Force notes it is currently unknown whether gonorrhea (Neisseria gonorrhoeae) has developed resistance to erythromycin ointment in the United States. They state that given the increased antimicrobial resistance noted in other countries, further research is needed to find safe and effective alternatives to erythromycin.

Considerations

There are some considerations to consider when evaluating the risks and benefits of erythromycin eye ointment. Some questions you may want to consider are:

Do you have a sexually transmitted infection? Have you been tested?

Are you in a monogamous relationship?

Are you sure that you and your partner do not have gonorrhea, chlamydia, or herpes? Have you both been tested?

Does your state mandate erythromycin?

Alternatives and Options

In the United States, erythromycin is the only FDA-approved treatment for preventing eye infections in newborns. If you are in another country, please ask your care provider whether other options, like povidone-iodine, are available.

If you opt for erythromycin for your newborn, you can request to delay it so that you and your baby can enjoy time skin-to-skin before the ointment is applied. This intervention can also take place while your baby is on your chest.

Talking to Your Doctor or Midwife

Parenting requires making a lot of decisions that will affect your baby. Thankfully, the doctor or midwife you see for prenatal care is an excellent resource to help you navigate these decisions. If you have any questions about erythromycin eye ointment, please bring them up with your care provider during one of your prenatal appointments. Erythromycin is given to your baby within the first 24 hours of your birth. You do not want to discuss this or be put on the spot to decide shortly after you have your baby.

Including Erythromycin in Your Birth Plan

The only reason to include erythromycin in your birth plan is to opt out of the procedure. A study that examined birth plans found that avoidance of erythromycin is one of the most requested items. If you think erythromycin is a procedure you would like to decline, talk to your care provider about all of the risks and find out if declining it is an option for you and whether your state mandates it. If you opt-out, your care provider, birth center, or hospital may require you to sign a waiver.

The key to having a successful birth plan is working with your care provider throughout your prenatal care. When done right, your doctor or midwife knows your preferences and supports them without ever having to review the actual birth plan document during your labor.

The Pregnancy Podcast has several resources to help you create your birth plan: 

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