What is the treatment for conjunctivitis (pink eye) in a toddler?

Treatment of Pink Eye (Conjunctivitis) in Toddlers

For bacterial conjunctivitis in toddlers over 12 months, start topical fluoroquinolone antibiotic eye drops 4 times daily for 5-7 days, which shortens symptom duration from 7 to 5 days and allows earlier return to daycare or school. 1, 2

First-Line Antibiotic Treatment

• Topical fluoroquinolones are the recommended first-line agents for children older than 12 months, including levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, or besifloxacin 2
• Polymyxin B/trimethoprim is an effective alternative option 1
• Apply the chosen antibiotic 4 times daily for 5-7 days 1, 2

The evidence strongly supports antibiotic use in bacterial conjunctivitis as it reduces symptom duration, improves clinical outcomes, and prevents transmission 1. While some research suggests bacterial conjunctivitis can be self-limited 3, 4, current guidelines from the American Academy of Pediatrics and American Academy of Ophthalmology prioritize treatment to minimize complications and allow faster return to normal activities 1, 2.

When to Suspect Specific Pathogens Requiring Different Treatment

Gonococcal Conjunctivitis (Red Flags)

• Requires systemic antibiotics in addition to topical treatment 1, 2
• Give Ceftriaxone 125 mg IM for children weighing less than 45 kg 1
• Requires daily follow-up until complete resolution 1
• Always consider sexual abuse in any child with gonococcal conjunctivitis 1, 5

Chlamydial Conjunctivitis (Red Flags)

• Requires systemic antibiotics rather than topical treatment alone 1, 2
• For children under 45 kg: erythromycin base or ethylsuccinate 50 mg/kg/day divided into 4 doses for 14 days 5
• For children 8 years and older: azithromycin or doxycycline 1
• Always consider sexual abuse in any child with chlamydial conjunctivitis 1, 5

Supportive Care Measures

• Strict hand hygiene is crucial to prevent transmission to others or the unaffected eye 5, 2
• Avoid sharing towels or close contact during the contagious period 5, 2
• Children can return to school/daycare once treatment has been initiated for 24 hours and symptoms begin improving 1, 2

When to Refer to Ophthalmology Immediately

Refer urgently if any of the following are present: 1, 5

• Visual loss or decreased vision
• Moderate to severe pain (not just mild irritation)
• Corneal involvement or infiltrates
• Severe purulent discharge
• Lack of response to therapy after 3-4 days

Follow-Up Protocol

• Return for evaluation if no improvement after 3-4 days of treatment 1, 2
• If symptoms persist despite appropriate treatment, consider alternative diagnoses or resistant organisms 1, 2
• Bacterial resistance, particularly methicillin-resistant S. aureus (MRSA), is an increasing concern and may require alternative antibiotics 1, 2

Common Pitfalls to Avoid

• Do not use topical corticosteroids indiscriminately in pediatric conjunctivitis 5
• Do not miss gonococcal or chlamydial infection in infants and young children, which requires systemic treatment 5
• Do not delay referral when there are signs of severe infection or lack of improvement 5
• Obtain conjunctival cultures before starting treatment only if severe purulent discharge is present 1, 2

Special Consideration for Viral Conjunctivitis

If the presentation suggests viral etiology (watery discharge, burning/gritty sensation, often bilateral), treatment is supportive only with artificial tears and cool compresses 6, 4. However, in toddlers where bacterial versus viral distinction is difficult clinically, the threshold for antibiotic treatment should be low given the benefits of shortened duration and reduced transmission 1.