Pinkeye

Pinkeye (or conjunctivitis) is very common in children and highly contagious. It has many causes.

In the vast majority of cases, pinkeye simply needs time and not antibiotic treatment. But there is a lot of confusion -even amongst healthcare providers, but also amongst schools and daycares- about return to school guidelines when it comes to conjunctivitis.

What is it?

Conjunctivitis - more often called “pinkeye” - is exactly what it sounds like. The conjunctiva, which is the covering of the white part of the eye, gets inflamed and begins to look pink or red. It may or may not be accompanied by eye discharge, eye discomfort, or a gritty sensation.

Why does it happen?

Many different things can cause conjunctivitis, including irritation from chemicals or foreign bodies, infection, or even inflammation from allergies. What is often confusing is that it can be hard to determine the cause just by looking at the eye; as with many other conditions, the history is super important to figure out what is going on.

With that said, there are certain typical characteristics that can help us determine the cause.

Viral

Common causes

Many different viruses can cause pinkeye, but the most common is Adenovirus. Some of these viral infections can be serious, such as those caused by HSV.

Symptoms

• Eye discharge usually thinner/mucuousy and does not re-accumulate as frequently (typically eyes will have more crust shortly after waking).

• Can be one side or both

• Often presents with other viral symptoms such as a runny nose, cough, sore throat, swollen nodes, fever or vomiting/diarrhea.

Transmission

• Highly contagious, spreads via direct contact with bodily fluids or on surfaces (adenovirus can live on surfaces for lengthy periods of time). It can also spread via large respiratory droplets.

• Best way to prevent transmission is to wash hands, avoid touching the face, and to wipe countertops and other surfaces frequently. Avoiding sharing towels, pillows, etc.

Treatment

• Most of the time this needs to run its course. Symptoms may get worse within the first 3-4 days and then slowly improve over 1-2 weeks (similar to other upper respiratory symptoms).

• Antibiotic drops/ointment will not treat it

• Best way to prevent transmission is to wash hands, avoid touching the face, and to wipe countertops and other surfaces frequently. Avoiding sharing towels, pillows, etc.

Bacterial

Bacterial conjunctivitis is what many schools and daycares fear. As a pediatrician mom, I dislike viral conjunctivitis more, but both kind of suck.

Common causes

Many different bacteria can cause pinkeye, including Staph aureus, Strep pneumo, Moraxella, and even Chlamydia or or Gonorrhea.

Symptoms

• Eye discharge is thicker and looks like pus (can be white, yellow or green). Re-accumulates quickly, often within 5-20 minutes after wiping it off.

• Eyes are often “stuck shut” in the morning.

• Can be one side or both

Transmission

• Highly contagious, spreads via direct contact with bodily fluids or on surfaces.

• Best way to prevent transmission is to wash hands, avoid touching the face, and to wipe countertops and other surfaces frequently. Avoiding sharing towels, pillows, etc.

Treatment

• Believe it or not, even bacterial pink-eye is usually a self-limited diagnosis (ie. it gets better on its own). With that said, treating with antibiotics can shorten symptom duration.

• Many schools and daycares require treatment for 24-48h to return to school (see your school’s policy)

Hacks for giving eye medications to uncooperative children

Eye drops

• Rub the bottle between your palms if it was in the fridge - bring to room temp.

• Have your child lay down with their eyes closed

• Put the drop of medicine on the inner corner of the eyelid while their eyes are closed, and then have them open their eyes. It will roll right in.

• Make sure not to let the top of the bottle touch the eye.

• Wash your hands before and after!

Eye ointment

• Pull down gently on the lower eyelid to create a pocket

• Apply a thin ribbon of ointment into the inside of the lower lid.

• Try not to let the top of the tube touch the eye.

• Close the eye for a few seconds. Ointment may go everywhere but enough will get in.

• Wash your hands before and after!

The Pediatrician Mom Tip: Wrapping a little one in a towel (like a burrito) is a strategy often used in the ER to keep them immobile if needed!

Allergic

This is an often dismissed cause of conjunctivitis, but it is very common and can be quite uncomfortable.

Common causes

Inflammation can occur as a result of pollen, dust, mold, pet dander, or even cosmetics.

Symptoms

• Eye discharge is usually thin or scant. Any crusting is usually most noticeable in the morning.

• Can occur in one or both eyes

• Sometimes patients complain of itchy sensation or grittiness

• May have seasonal pattern

Transmission

• Not contagious.

Treatment

• Try to minimize ongoing exposure to the triggers

• Use either antihistamine drops or an oral antihistamine as recommended by your healthcare provider

Irritant

Anything that physically irritates the eye can lead to inflammation and redness. Contact lenses and other foreign bodies (such as sand) are common causes of this type of conjunctivitis. Chronic dry eyes can also do this. This type of conjunctivitis is NOT contagious.

Common causes

Contact lenses and other foreign bodies (such as sand). Chronic dry eyes can also do this.

Symptoms

• Vary

• Can be one or both eyes

Treatment

• May need evaluation from a healthcare provider, but often starting with a rinse or eye flush to remove the offending object can be helpful.

• The eye cups we keep on hand are linked in my medicine cabinet recommendations.

Things to try

At the end of the day, there are a few things you can try to help. Remember - if your child is unbothered by their symptoms, it is okay to leave them alone. But if they seem uncomfortable, you can:

• Wipe away the crust gently using a warm washcloth. Make sure you wipe from the inside of the eye towards the outside.

• Cool compresses a few times a day can decrease inflammation

• Use pain medications such as Acetaminophen or Ibuprofen as needed (dosing available here under guides).

The Pediatrician Mom Tip: Newborn conjunctivitis is a separate and important category of pinkeye. Gonorrhea and Chlamydia are infectious causes of newborn conjunctivitis that can lead to serious widespread disease and even blindness - this is why all newborns receive antibiotic eye ointment shortly after birth. Other more benign causes of newborn conjunctivitis include blocked tear ducts.

When to call the pediatrician

This is not a comprehensive list. In general, always err on the side of calling your pediatrician if you have any concerns about your child. There is a lot to be said for a parent’s gut instinct, and I promise: your pediatrician would rather you called!

Although in many cases, pinkeye is a self-limited (albeit annoying) problem, there are some serious causes of red eyes. If your child is not improving within a few days, or if they seem to be getting worse, call your pediatrician. Other concerning symptoms include:

• Severe pain or difficulty being consoled

• Light sensitivity

• Whether vision is affected (can be tricky to tell in young kids…always err on the side of caution)

• Foreign body sensation

• Any suspicion of trauma to the eye

• Contact lens use

• Anything else tickling your spidey sense!!

FAQs

What about school or daycare?

Many schools have conjunctivitis policies in place. And there is a lot of confusion around pink-eye, even amongst healthcare providers.

The guidelines from the AAP no longer recommend exclusion for pink eye (or even eye discharge) if there is no fever or behavioral change. The reason for this is that we don’t have great evidence that keeping a child home makes much of a difference when it comes to transmission to others - similar to cold symptoms, for viral conjunctivitis in particular by the time symptoms occur, the ship has sailed.

Even for bacterial conjunctivitis, antibiotic treatment and exclusion from school are not necessarily recommended. This is a judgment call on the part of your clinician and school though.

How do I prevent spread? 

• Good hand washing. Use soap and water and wash for 20 seconds each time. Keep in mind that adenovirus can live on surfaces for extended periods of time.

• Disinfect frequently touched household surfaces at least 1-2 times per day (doorknobs, counters, etc).

• For toys: either run them through the sanicycle in your dishwasher, or if they are more delicate, wash with soap and water or a cleaning product that contains bleach.

• Avoid sharing bedding, towels, etc

• Try to encourage your child not to rub at their eyes or repeatedly touch their face (I know, I know…)

Pinkeye can be so frustrating! I wish I could say that once you overcome it, you never have to deal with it again, but this is not true.

But my hope is that with these tips, you will be able to get through it more easily! Good luck!