Treatment of Pink Eye in Toddlers
For a toddler with conjunctivitis, treatment depends entirely on the underlying cause: bacterial conjunctivitis requires a 5-7 day course of broad-spectrum topical antibiotic (such as erythromycin ointment or fluoroquinolone drops) applied 4 times daily, viral conjunctivitis requires only supportive care with cold compresses and preservative-free artificial tears, and allergic conjunctivitis requires topical antihistamines with mast cell-stabilizing activity. 1, 2, 3
Initial Assessment: Determine the Etiology
The first critical step is distinguishing between bacterial, viral, and allergic causes, as treatment differs fundamentally 2:
Bacterial conjunctivitis presents with:
- Purulent or mucopurulent discharge with matted eyelids upon waking 2, 4
- Can be unilateral or bilateral 2
- Papillary reaction (not follicular) 2
- May be associated with concurrent otitis media in children 5, 2
Viral conjunctivitis presents with:
- Watery discharge 2, 4
- Follicular reaction on inferior tarsal conjunctiva 2
- Often starts unilateral but becomes sequentially bilateral 2
- May have preauricular lymphadenopathy 2
- Concurrent upper respiratory infection common 2
Allergic conjunctivitis presents with:
- Intense itching as the hallmark symptom 2
- Bilateral involvement 2
- Watery discharge with mild mucous component 2
- History of atopy, asthma, or eczema 2
Treatment by Etiology
Bacterial Conjunctivitis
For uncomplicated bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic applied 4 times daily 1, 3:
Erythromycin 0.5% ophthalmic ointment: Apply approximately 1 cm ribbon to affected eye(s) up to 6 times daily depending on severity 6. This is particularly appropriate for toddlers as ointment is easier to administer than drops.
Fluoroquinolones (for children >12 months): Moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or ofloxacin are effective against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 3. No specific antibiotic has proven superiority over others 3.
Important: If the child has an internal ear exam showing otitis media, consider this when selecting therapy, as bacterial conjunctivitis may be associated with concurrent bacterial infections 5, 2.
Viral Conjunctivitis
Viral conjunctivitis requires supportive care only 1, 2, 3:
- Preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 3
- Cold compresses for comfort and to reduce inflammation 1, 3
- Topical antihistamines (second-generation) may be used for symptomatic relief of itching 2
Critical: Do NOT prescribe antibiotics for viral conjunctivitis—they provide no benefit and may cause unnecessary toxicity and contribute to antibiotic resistance 2, 3.
Allergic Conjunctivitis
First-line treatment includes 2, 3:
- Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 2, 3
- Environmental modifications: Cold compresses, refrigerated preservative-free artificial tears, sunglasses as allergen barrier 2
- Oral antihistamines may be added but are less effective than topical agents for ocular symptoms 2
Red Flags Requiring Immediate Ophthalmology Referral
Refer urgently to an ophthalmologist if ANY of the following are present 5, 1:
- Visual loss or decreased vision
- Moderate or severe pain
- Severe, purulent discharge (consider gonococcal infection)
- Corneal involvement (infiltrate, ulcer, opacity)
- Conjunctival scarring
- Lack of response to therapy after 3-4 days
- Recurrent episodes
- History of herpes simplex virus (HSV) eye disease
- History of immunocompromise
Special consideration for severe purulent discharge: If gonococcal conjunctivitis is suspected (marked eyelid edema, severe purulent discharge, rapid progression), systemic antibiotic therapy is necessary in addition to topical treatment, and daily follow-up is required until resolution 1, 2. Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 5, 1.
Infection Control and Counseling
Strict hand hygiene is essential to prevent transmission to others or to the unaffected eye 1, 3:
- Wash hands frequently with soap and water 5
- Avoid sharing towels, pillows, or personal items 2
- For viral conjunctivitis, avoid close contact for 7-14 days from symptom onset 3
- Discard multiple-dose eyedrop containers after infection resolves to avoid cross-contamination 3
Follow-Up Recommendations
- Return for evaluation if no improvement after 3-4 days of antibiotic treatment 1
- Most cases of bacterial conjunctivitis can be treated effectively in an outpatient setting 5, 1
- For viral conjunctivitis, symptoms typically resolve within 5-14 days without treatment 2
Common Pitfalls to Avoid
- Do not prescribe antibiotics indiscriminately for viral conjunctivitis—this causes unnecessary toxicity and promotes antibiotic resistance 2, 3
- Do not use topical corticosteroids without ophthalmology consultation, as they can prolong adenoviral infections, worsen HSV infections, and cause elevated intraocular pressure 2, 3
- Do not miss gonococcal or chlamydial infection in infants and young children, which require systemic treatment and consideration of sexual abuse 1, 3
- Do not use topical anesthetics for conjunctivitis management 7