Ophthalmia neonatorum is a newborn eye infection and in the United States occurs in 1-2% of newborns. This infection can be caused by sexually transmitted infections, viruses, and bacteria. Administering erythromycin eye ointment to newborns is standard procedure in the United States to prevent ophthalmia neonatorum. As with any intervention, there are pros and cons to consider. This article 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 procedure 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 opt-out. However, in some U.S. states, erythromycin is mandated, and you do not have the option to opt-out. Regardless of the laws in your state, this episode will break down the evidence, pros, and cons, so you are informed about erythromycin.


Erythromycin is an antibiotic ointment that comes in a tube and has a similar texture to Vaseline. It has become standard procedure for erythromycin eye ointment to be placed on newborns’ eyes within 24 hours after birth.

Erythromycin Mandates

In the United States, many states require by law that newborns are given erythromycin. If this is the case in your state, it may not be an option to opt-out. I recommend talking about it with your doctor or midwife to find out what the law says in your area.

Ophthalmia Neonatorum 

The use of erythromycin is to prevent ophthalmia neonatorum, which is conjunctivitis, or pink eye, in a newborn. 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 is 1-2% of newborns. Ophthalmia neonatorum can be caused by sexually transmitted infections, viruses, and bacteria.

Sexually Transmitted and Viral Infections

The sexually transmitted infections that can cause this are gonorrhea, chlamydia, and the herpes simplex virus. Chlamydia is the leading cause of ON, 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 like adenovirus or enterovirus. There are many bacteria that 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 for preventing 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 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. The use of 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 recommendation from the USPSTF is based on the evidence available as of 2019. The organization does acknowledge that another area for research is whether risk-based prophylaxis of newborns, based on maternal risk factors, is as effective as universal prophylaxis. Hopefully, we will have more research available in the future.

Efficacy of Erythromycin

The goal of applying erythromycin eye ointment to newborns is to prevent ophthalmia neonatorum. 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 whether using erythromycin was effective in preventing ophthalmia neonatorum. This review included 30 trials with a total of 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

The potential risks of erythromycin are allergic reaction, chemical pink eye, irritation, and blurred vision. The ointment will wear away within about 24 hours.

One challenge with the wide use of antibiotics is the growing problem of antibiotic resistance. Antibiotics are used to treat bacterial infections. Over time and with increased use, bacteria can develop resistance to these drugs. The World Health Organization states that antibiotic resistance is one of the biggest threats to global health, food security, and development today. According to the CDC, each year in the U.S., at least 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 increased antimicrobial resistance noted in other countries, further research is needed to find safe and effective alternatives to erythromycin.


There are some considerations to take into account 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?

Are you in a monogamous relationship?

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

Is erythromycin mandated by your state?

Alternatives and Options

In the United States, erythromycin is the only FDA-approved treatment for preventing pink eye 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.

Why Some Parents Opt-Out 

Some parents choose to opt out of this procedure. In a controlled trial that looked at mothers who had birth plans, 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.

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. This is not something you want to discuss 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 eye ointment in your birth plan is to opt out of the procedure. If you want to opt-out, this is something you should discuss with your care provider in advance to make sure they are supportive of your preference. 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.

If you have seen a copy of my birth plan, then you know that I chose to opt-out of erythromycin. That was a choice my husband and I made after we researched it and what we felt was best for us at that time. In California, it is not mandatory, so we could opt out. Just because it was the right choice for me does not necessarily mean it is the right choice. If you would like to see a copy of my birth plan, you can request it here. The Your Birth Plan book is also an excellent resource for creating and writing your birth plan.

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