Often called the “golden hour,” the first 60 minutes after birth are a crucial bonding time for a mother and her baby. Unless there’s a medical emergency or the mother or baby is unstable, medical providers should delay all procedures and interventions until after the newborn’s first feeding or at least one hour after delivery.¹ However, there are some procedures and interventions recommended very soon after birth. As a NICU nurse, one of the first interventions we perform when new babies arrive at the unit is “eyes and thighs.” The “eyes” refers to erythromycin eye ointment, and “thighs” refers to a shot of vitamin K in the thigh.^19,20 Erythromycin eye ointment is routinely given to newborns after birth to prevent and treat bacterial infections.²⁰

What Is Erythromycin Eye Ointment?

Erythromycin is a macrolide antibiotic for treating certain bacterial infections such as strep, gonorrhea, chlamydia, and Haemophilus influenzae type b (HiB). This type of antibiotic works by stopping the growth of bacteria.^2,3 Erythromycin ointment is a topical formulation of this antibiotic. This means that instead of administering it through the mouth, vein, or muscle, we apply it to the eye’s mucous membrane, and the body absorbs it that way. It provides localized treatment to protect the eyes from bacterial harm.⁴ Topical erythromycin eye ointment can also prevent a condition in newborn babies called ophthalmia neonatorum.⁵

What Is Ophthalmia Neonatorum?

Ophthalmia neonatorum, or neonatal conjunctivitis, is when a baby gets conjunctivitis or pink eye within the first month of life. Pink eye in newborns is commonly due to the Neisseria gonorrhoeae bacterium, which causes sexually transmitted gonorrhea infection.⁵ Gonorrhea in women typically doesn’t cause any symptoms, so a pregnant mother may not even know she has it. Therefore, she wouldn’t know to seek treatment. If a mother has untreated gonorrhea, her baby has a 30-50% chance of catching it from her during birth, called vertical transmission. Babies who contract gonorrhea from their mothers during delivery will develop ophthalmia neonatorum.^5,6

Ophthalmia neonatorum causes symptoms such as eye redness, profuse discharge, severe swelling of the eyelids, corneal scarring, ocular perforation, and blindness. Symptoms can begin as soon as 24 hours after infection and typically appear within two to five days. One eye may be worse than the other, but it often affects both eyes. Neonatal pink eye progresses rapidly and can cause permanent damage to the eyes.^5,7,8,9 If left untreated, ophthalmia neonatorum can progress to systemic disease, causing symptoms such as sepsis and arthritis.¹⁰

Although gonorrhea is the most common cause of ophthalmia neonatorum, other bacteria and pathogens can also cause this condition. For instance, chlamydia is becoming another common cause of neonatal pink eye. Erythromycin doesn’t prevent or treat other causes of this condition as effectively as it treats the gonorrheal cause of pink eye.^7,11

When Will the Ointment Be Applied?

Since symptoms of neonatal pink eye can begin as soon as 24 hours after birth, doctors or nurses should apply erythromycin ointment as soon as possible after the baby is born. The Centers for Disease Control and Prevention (CDC) recommends administration within the first two to three hours of life, but many hospitals aim for even sooner.^9,10 However, the baby must not be moved from the mother’s chest to administer erythromycin. Ointment administration shouldn’t interrupt the golden hour.²¹

Ingredients in Erythromycin Eye Ointment

Besides 0.5% erythromycin, here are the other ingredients in this ointment:¹⁴

• Mineral oil: This is a liquid obtained from petroleum. The Environmental Working Group (EWG) rates this product as having a low risk for cancer and developmental and reproductive toxicity. It has a moderate risk for allergy and immunotoxicity, especially if inhaled. The mineral oil in erythromycin eye ointment is applied topically with little chance of inhalation.¹²
• White petrolatum: This is a semisolid mixture obtained from petroleum. The EWG rates this product as low risk for cancer, allergies, immunotoxicity, and developmental and reproductive toxicity.¹³

Side Effects and Risks

Erythromycin eye ointment is generally considered safe. Some experts, however, suspect that it causes temporary blurry vision for the newborn. This may impair bonding by affecting eye contact between the infant and parents. The ointment can cause the appearance of cloudy eyes, and it can also cause eye redness, swelling, and irritation.¹⁵

Rarely can an allergic reaction to erythromycin eye ointment occur. If it does, an allergic reaction causes eye discharge in the first few weeks. However, it’s infrequent for a baby to have an allergic reaction to their first exposure to an antibiotic.¹⁶

Another potential side effect of the erythromycin eye ointment is antibiotic resistance, which occurs when bacteria adapt to survive treatment. This makes antibiotics less effective over time and explains why we shouldn’t use them when they’re unnecessary. It’s unknown whether gonorrhea has developed resistance to erythromycin, but the United States Preventative Services Task Force has identified this as an important area for further research.⁵

Who Should Get Erythromycin Eye Ointment?

The American Academy of Family Physicians (AAFP) recommends that all newborns receive erythromycin eye ointment to prevent gonorrheal neonatal pink eye. Because many women with gonorrhea have no symptoms and some either don’t receive prenatal care or have poor care, the AAFP believes erythromycin eye ointment is a safe and simple way to prevent the severe consequences of ophthalmia neonatorum, including blindness.¹⁷

Is the Ointment Mandatory?

Erythromycin eye ointment is the standard of care in the U.S. Most states mandate its use, and your provider or pediatrician should know your state’s laws and the policies at the hospital where you plan to deliver.^5,17 If you want to decline treatment with erythromycin eye ointment, you may have to sign a waiver stating that you understand the risks.⁵

Alternatives to Erythromycin Eye Ointment

Since gonorrhea is the most common cause of ophthalmia neonatorum, a potential alternative to universal prophylaxis would be screening all pregnant women for gonorrhea and treating the mother, if infected, before delivery. Currently, experts recommend screening for gonorrhea for pregnant women under 25 and pregnant women at high risk for gonorrheal infection. However, not all pregnant women receive prenatal care, and those who don’t may have asymptomatic gonorrhea that passes to their babies during delivery.^5,18

Other alternatives, such as povidone-iodine, silver nitrate, and tetracycline antibiotic ointment, are no longer available in the United States. An alternative antibiotic ointment called gentamicin can cause eye reactions from its administration.¹⁸ During a recent erythromycin shortage, the CDC recommended that a weight-based dose of the antibiotic ceftriaxone be administered intravenously or intramuscularly to high-risk mothers or those with no prenatal care.¹⁸

The Bottom Line

Ultimately, erythromycin eye ointment for newborns is low-risk and very effective at preventing ophthalmia neonatorum and subsequent blindness in newborns.^17,18 However, if you’re confident that you don’t have gonorrhea, it may be an unnecessary early intervention for your baby. If you’re planning to deliver in a hospital, you may not have a choice of whether your baby gets this medicine because it depends on your state.²¹

If you have questions or concerns, it’s always best to talk to your medical provider or pediatrician. But going into these conversations with some background is helpful. By learning the purpose, ingredients, side effects, and alternatives of erythromycin eye ointment, you’re one step closer to making an informed health decision for your new little one.