What is the recommended management for acute conjunctivitis in a child?

Management of Acute Conjunctivitis in Children

The recommended management for acute conjunctivitis in children includes topical antibiotics for bacterial cases, supportive care for viral cases, and appropriate referral to ophthalmology for severe presentations. 1, 2

Diagnosis and Classification

First, determine the likely etiology of conjunctivitis:

• Bacterial conjunctivitis: Purulent discharge, matting of eyelids, often unilateral initially 3
• Viral conjunctivitis: Watery discharge, burning sensation, often associated with upper respiratory infection 1
• Allergic conjunctivitis: Bilateral itching, watery discharge, seasonal pattern 3

Treatment Algorithm

Bacterial Conjunctivitis

1. Topical antibiotics are recommended as they reduce symptom duration and promote faster resolution 2, 4

   • Options include gentamicin, tetracycline, ofloxacin, or erythromycin ointment 2
   • Apply 2-3 times daily for 5-7 days 2

2. Consider oral antibiotics if:

   • Signs of "conjunctivitis-otitis syndrome" (concurrent ear infection) as H. influenzae is often the causative agent 5, 6
   • Oral antibiotics are more effective than topical treatment in preventing associated otitis media 5

Viral Conjunctivitis

1. Supportive care is the mainstay of treatment 3

   • Cool compresses
   • Artificial tears for comfort
   • Patient education on hygiene to prevent spread

2. Avoid antibiotics unless secondary bacterial infection is suspected 1

Allergic Conjunctivitis

1. Topical lubricants
2. Topical antihistamines
3. Systemic antihistamines for more severe cases 3

Special Considerations

When to Refer to Ophthalmology

Immediate referral is necessary for children with 1:

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy within 3 weeks
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised status

Neonatal Conjunctivitis

Requires special attention as it may indicate serious systemic infection 2:

• 1-7 days after birth: Consider gonococcal infection
• 5-19 days: Consider chlamydial infection
• First week: Common bacterial pathogens (S. aureus, Enterococcus, etc.)

Systemic antibiotics are mandatory for gonococcal and chlamydial infections 2

Contact Lens Wearers

• Always treat for bacterial conjunctivitis
• Refer to evaluate for corneal ulcers
• Avoid patching or using therapeutic contact lens 2

Prevention and Patient Education

1. Hand hygiene is critical to prevent spread 1, 2
2. Avoid sharing towels, washcloths, and pillows 1
3. School attendance: Children can typically return to school after 24 hours of antibiotic treatment for bacterial conjunctivitis 1

Important Caveats

• Despite high rates of spontaneous resolution (65% within 2-5 days), topical antibiotics improve clinical recovery, particularly in the first 2-5 days (NNT = 6) 7
• Bacterial resistance is concerning, with β-lactamase production in 29% of H. influenzae isolates and penicillin non-susceptibility in 60% of S. pneumoniae isolates 6
• The "conjunctivitis-otitis syndrome" occurs in approximately 32% of pediatric conjunctivitis cases, with H. influenzae as the predominant pathogen in 82% of these cases 6

Remember that while most cases of conjunctivitis are self-limiting, proper treatment can reduce symptom duration and prevent complications like otitis media in children.