Artificial Tears with Preservatives in Children Under 5
Preservative-free artificial tears are strongly preferred for children under 5, and when artificial tears are used more than four times daily, preservative-free formulations should be used to avoid preservative toxicity. 1
Key Recommendation
- Use preservative-free artificial tears for children under 5 years old, particularly when frequent application is needed (more than 4 times daily), as preservatives can cause ocular surface toxicity and additional irritation 1, 2
Rationale for Preservative-Free Formulations
Preserved artificial tears may be sufficient only for mild symptoms with infrequent use (less than 4 times daily) in patients with an otherwise healthy ocular surface, but this applies primarily to adults 1
Children have more vulnerable ocular surfaces and are at higher risk for preservative-related complications, making preservative-free options the safer choice 3
Benzalkonium chloride (BAK) and other preservatives can cause superficial punctate keratitis, reduce goblet cell counts, and worsen dry eye symptoms even with "soft" or "vanishing" preservatives 3, 4
Clinical Evidence Supporting Preservative-Free Use
Switching from preserved to preservative-free artificial tears dramatically improves outcomes, with studies showing reduction in superficial punctate keratitis from 73% to 46.1% of patients and significant improvement in symptom scores 3
Even "soft" preservatives (like polyquaternium-1 or purite) produce the same clinical pattern of ocular surface damage as traditional preservatives like BAK when used chronically 3
Preservative-free formulations reduce inflammatory cell infiltration and promote better corneal healing compared to preserved alternatives 4
Practical Application
For any child under 5 requiring artificial tears, prescribe preservative-free single-dose units or multi-dose preservative-free bottles 1, 5
If cost or access is a barrier and preserved tears must be used temporarily, limit use to no more than 4 times daily and monitor closely for signs of toxicity (redness, increased irritation, punctate keratitis) 1
Refrigerated preservative-free artificial tears provide additional comfort through cooling effect and are particularly useful for allergic or inflammatory conditions 2, 6
Important Caveats
Avoid multi-dose preserved formulations in children due to cumulative toxicity risk with the developing ocular surface 3, 4
Preservative-free does not mean sterile after opening - instruct caregivers on proper technique to avoid touching the tip to the eye and to discard opened bottles according to manufacturer instructions 6
Monitor for contamination risk with preservative-free multi-dose bottles, though modern designs have significantly reduced this concern 7, 5