What is the recommended course of action for an infant less than 12 months old with eye drainage?

Management of Eye Drainage in Infants

For an infant under 12 months with eye drainage, the primary approach depends on the clinical context: apply warm compresses and gentle eyelid cleansing with diluted baby shampoo, followed by topical erythromycin ophthalmic ointment (approximately 1 cm) applied to the affected eye(s) up to six times daily for superficial bacterial conjunctivitis. 1

Initial Assessment and Triage

The first critical step is determining whether this represents a simple conjunctivitis versus a more serious condition requiring urgent ophthalmology referral. Look for these specific red flags:

• Significant vision impairment or abnormal visual behavior - requires immediate pediatric ophthalmology referral 2, 3
• Structural abnormalities (corneal opacity, cataract, ptosis) - refer to pediatric ophthalmologist 3
• History of eye trauma with periorbital swelling - immediate ophthalmology referral 2
• Concurrent purulent conjunctivitis with acute otitis media - treat with antibiotic with β-lactamase coverage 4

Treatment Algorithm for Simple Conjunctivitis

Step 1: Eyelid Hygiene (First-Line)

• Apply warm compresses using hot tap water on a clean washcloth for several minutes to soften crusts - ensure compresses are not hot enough to burn the skin 5
• Perform gentle eyelid cleansing after warm compresses by rubbing the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball or clean fingertip 5
• Rub eyelid margins side to side to remove crusting from the eyelashes 5

Step 2: Topical Antibiotic Therapy

• Erythromycin ophthalmic ointment approximately 1 cm should be applied directly to the infected eye(s) up to six times daily, depending on severity 1
• This is indicated for superficial ocular infections involving the conjunctiva and/or cornea caused by organisms susceptible to erythromycin 1
• Bacitracin ointment is an alternative topical antibiotic that can be applied to eyelid margins one or more times daily 5

Step 3: Treatment Duration and Follow-up

• Once- or twice-daily compresses and cleansing is generally adequate for chronic cases 5
• Reassess within 48-72 hours if symptoms persist or worsen 4
• Parents should understand that symptoms often recur when treatment is discontinued, and long-term eyelid hygiene may be required 5

Special Considerations for Neonates

For prophylaxis of neonatal ophthalmia (not treatment of established infection):

• A ribbon of erythromycin ointment approximately 1 cm should be instilled into each lower conjunctival sac 1
• The ointment should not be flushed from the eye following instillation 1
• For infants born to mothers with clinically apparent gonorrhea, topical prophylaxis alone is inadequate - these infants require intravenous or intramuscular aqueous crystalline penicillin G (50,000 units for term infants or 20,000 units for low birth weight infants) 1

Critical Pitfalls to Avoid

• Never delay ophthalmology referral for infants with structural abnormalities, vision impairment, or trauma - these can progress to permanent vision loss 2, 3
• Avoid aggressive eyelid pressure in any infant, as this could potentially cause injury 5
• Do not rely solely on topical erythromycin for neonatal gonococcal conjunctivitis when maternal gonorrhea is known - systemic antibiotics are mandatory 1
• Be aware that long-term antibiotic treatment may result in resistant organisms 5

When to Escalate Care

Refer to pediatric ophthalmologist if:

• No improvement after 48-72 hours of appropriate treatment 4
• Any structural eye abnormality detected 3
• Unilateral presentation that persists (may go unnoticed by parents but can indicate serious pathology) 6
• Associated systemic symptoms or concurrent purulent conjunctivitis with otitis media 4