Pinkeye in Children – What to Do & When to Get Checked
Just because your child wakes up with eye gunk doesn’t mean it’s pinkeye. Here’s how to tell the difference.
by Steve Silvestro, MD @zendocsteve
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Pinkeye. It’s the scourge of daycare, and the cause of discomfort and missed days of school for older kids and even adults.
Now, pinkeye might seem like a pretty easy topic. In a way, it is—if your child’s eye is pink, then it’s quite possible that she has pinkeye. But there are different types of pinkeye (also called conjunctivitis), and each type is treated differently.
In fact, antibiotic drops or ointment will only work for one particular type of pinkeye—and chances are that if you rush to your pediatrician first thing in the morning when your child woke up with a gunky eye, you just might end up heading home without any treatment at all.
Because waking up with a gunky eye in the morning doesn’t necessarily mean your child has bacterial pinkeye, which is the only type we can fix with antibiotics.
In fact, I often suggest that parents don’t call for an appointment the moment their child wakes up with a goopy eye.
Instead, it’s best to wait to see what’s happening as the morning goes on. We’ll cover why in this article, as well as:
- Quick tour of eye anatomy
- Why eyes are gunky when kids wakeup
- How the drainage throughout the day is the key thing to watch
- Treatment for bacterial, viral, and allergic pinkeye
- When your child can go back to school or daycare
- Times you must go to the doctor
- The special case of babies with gunky eyes
WHAT’S HAPPENING AT THE EYE?
The famous and well-loved TV painter Bob Ross was a wise & entertaining man. And besides talking about “making friends with happy trees,” one of the things he would often say as he’d paint landscapes is “Follow the lay of the land.” So let’s follow the lay of the land for a moment and take a 30-second anatomy lesson to get a better idea of how all this works.
There are at least two things that move across the eye throughout the day. One is tears. Tears are made in a little gland at the upper outside corner of the eye, they run diagonally across the eye and drain in a duct called the nasolacrimal duct at the corner of the eye near the nose. “Naso” for near the nose and “lacrimal” for having to do with tears. That’s actually why you have a runny nose when you cry—it’s your tears that are draining down into your nose—so you cry, and when you blow your nose, it’s usually clear, because it’s all tears.
The second thing that moves across the eye throughout the day is something called “rheum” (sounds like “room”). And this is some mucus, some dead skin cells, oils or debris—all kinds of fun stuff that builds up on the eye, or might be made by the tissue around the eye, or even creep up from the nose or elsewhere. When we blink, we wash our tears across the eye, the tears pick up that rheum, and everything drains down into the ducts and into your nose.
WHY ARE EYES GUNKY WHEN KIDS WAKE UP?
All of this is well and good while your child is awake. But it’s a different story when they’re asleep—so they wake up with gunky eyes.
When you sleep, you’re not blinking at all, and you don’t have the benefit of gravity to help pull the tears from the top corner of the eye down to the duct by the nose. Essentially, you’re not washing as much of this rheum + tear mixture away. The result is that it builds up at the corner of the eye near your nasolacrimal duct. And that’s whyyou might get some crust or a little bit of goop right there when you first wake up.
Now when a child has a cold, the nose is really stuffed up so you basically have a blockage at the end of the nasolacrimal duct. And just like any bit of plumbing, what happens when you have a blocked drain? Nothing goes down. In fact, things start backing up.
So when your child has a cold, in the daytime, she might still be able to get some of that rheum washed down with the help of tears—but at night when they’re not blinking and don’t have gravity helping, that nasal congestion is going to block even more rheum from finding its way down into the duct at all.
That’s why when a child has a cold and is congested, it’s really common for her to wake up in the morning with more gunk in the corner of the eyes than usual. And that is the process that I uncreatively call “a bit of eye goop with a cold.”
Now, the key thing about this is that you’re notgoing to see this goop keep coming back throughout the day—because even though the drain is partially blocked by congestion, the normal action of blinking and tears will wash any rheum down the drain in the daytime. You’re just going to see this gunk build up when your child wakes up from sleep, whether it’s nighttime or a nap.
WHAT’S COMING OUT OF THE EYE IS WHAT COUNTS
The drainage from the eyes is one of the main ways that we tell the difference between the types of pinkeye. So let’s talk about that. What are the main types of pinkeye that kids get? There are three—bacterial conjunctivitis, viral conjunctivitis, and allergic conjunctivitis (there is actually another, chemical conjunctivitis, but that’s a whole different story).
All three types of pinkeye might give you a bit of gunk in the eye when your child wakes up.
However, it’s what you see while your child is awake that determines which type of pinkeye it is.
Here’s what you’ll see:
- Viral pinkeye – no drainage or watery drainage while awake
- Allergic pinkeye – no drainage or watery drainage while awake, usually very itchy
- Bacterial pinkeye – thick, yellow/green goopy drainage all day long
That’s right—bacterial pinkeye, the only one we can actually fix with antibiotic drops or ointment—is going to give you gooey eye drainage all day long. You wipe it away, and it’s back 20 or 30 minutes later.
BACTERIAL PINKEYE: The One Antibiotics Can Fix
Why does bacterial pinkeye cause goopy eye drainage all day long—not just when your child wakes up from sleep?
The reason is that the inflamed, infected conjunctiva and all the tissue around there is making mucousy because of the infection—and it’s so thick and so copious that it can’t drain into the nasolacrimal duct. Try to imagine filling your sink with lemon pudding—that stuff is just not going to go down the drain. So thick, goopy eye drainage that keeps coming back throughout the day is almost always going to be a sign of bacterial pinkeye.
You should know that sometimes a viral or allergic pinkeye can become bacterial. If your child rubs her eyes, then all the bacterial from the skin of the hand and the face can get into the eye and a bacterial infection results.
So if your child’s pinkeye starts off with no drainage or watery drainage, tell him to keep his hands away from his eyes or else he’ll need to put drops or ointment in if it becomes bacterial.
If bacterial pinkeye does develop, kids under 1 will get ointment, and kids over 1 will often get eye drops. For tips on how to get ointment or drops into your child—a challenge in and of itself!—check out this great article here.
Applying a warm compress to your child’s eyes can also help. The warmth ideally opens up the blood vessels and lymphatics around the eye, allowing more of your immune cells to come and fight off the infection, and also allows some of the infection to drain toward the lymph nodes.
Remember, viral pinkeye might give a bit of crust in the morning, but then either no drainage or watery drainage while your child is awake.
For viral pinkeye, like most other viral infections unfortunately, there isn’t much that we can do in terms of medication.
The only real treatment we have besides the frustrating answer of ‘time’ is a warm compress to the eyes as often as you can to help that infection drain.
Allergic pinkye—maybe some crust on waking, then either no drainage or watery drainage and almost always very itchy—can also sometimes make the eyelids get very puffy. The more your child rubs her eyes, the more histamine is released, and the puffier the eyelids will become.
For allergic conjunctivitis, there are some drops that you can get that help with the itchiness. Some are available over the counter and usually have the ingredient “ketotifen,” and some are prescription strength and typically have the ingredient “olopatadine.”
I have allergies myself, and have personally found that the drops work better for the eyes than taking an oral antihistamine, but of course everyone’s different.
With allergic conjunctivitis, we’ll sometimes recommend a coolcompress. The thinking here is that you don’t want more of your immune cells coming up near the eye because with allergies, as it’s your body’s immune system that’s actually causing the problem. So instead, you want to use a cool compress to clamp down on those vessels and slow down the production of any fluid that would lead to swelling and inflammation in that area.
One old-fashioned trick is to take a teabag of chamomile or green tea, dampen it with cool water, and place that on the eye as the compress. These teas are thought to have anti-inflammatory properties, so you get the double-whammy of the cool compress and the anti-inflammatory nature of the tea itself.
WHEN CAN YOUR CHILD GO BACK TO SCHOOL?
The big question that gets asked is when can a child go back to school or daycare?
Well, with allergic pinkeye, it’s not contagious at all, so a child can go back as soon as he feels comfortable again.
With bacterial pinkeye, we usually consider someone no longer contagious after 24 hours of antibiotic drops or ointment.
But for viral pinkeye—that’s the tough one. Like I said, we don’t really have any medicine to treat it. Generally, for a viral pinkeye, we tend to say it might be worth staying home the first day or so. But depending on the specific virus that’s causing it, you can potentially shed that virus for up to 3 WEEKS! Now of course you can’t keep a kid home from school for three weeks, and that’s why some schools require that everyone gets drops even if it’s not bacterial—just to give everyone some peace of mind, even though the drops aren’t actually doing anything. But again, usually the first day of symptoms is all you really need to stay home.
WHEN SHOULD YOU SEE A DOCTOR RIGHT AWAY?
So what are some signs you should watch out for that might be a reason to get checked out more urgently?
The first is pain. While the discomfort of pinkeye might cause some young kids to say that their eyes hurt, with a painful eye we also need to think about a scratch on the cornea, a foreign body stuck in the eye, or even a more serious infection. So any time your child’s eye hurts for more than just a few minutes or if he feels like there’s something stuck in his eye, it’s probably a good idea to get in touch with your pediatrician.
The second sign to watch for is swelling. Again, you can get a little bit of swelling of the eyelids with a bacterial or viral pinkeye. And with an allergic conjunctivitis, you can actually get quite a lot of swelling. I have seen kids come in with eyes swollen shut and puffed out like golf balls during allergy season. But impressive swelling around the eye can also be a sign of a potentially more serious infection called “periorbital cellulitis.”
Periorbital cellulitis is a skin infection around the eye. It usually starts off with a mosquito bite or some small scratch in the skin near the eye, and then that skin soon becomes red, swollen, and warm to touch. The eyelids will often swell to the point of being swollen shut. And while there are other types of infections that can cause swelling and redness near the eye, periorbital cellulitis is one that we fuss about because it can potentially lead to orbital cellulits—which is when the infection creeps back behind the eye and is a very serious matter. So, the long and short of it is that any time your child’s eye is notably swollen, it’s worth to have a doctor take a look.
BABIES WITH GOOPY EYES
I’d like to also touch on the situation of a baby with a goopy eye.
Brand new babies can get a particularly nasty type of pinkeye called “neonatal conjunctivitis.” This usually comes up within the first two weeks after birth, and it’s usually caused by chlamydia passed on during delivery. Luckily, we see this a little less often nowadays because we screen moms for chlamydia during pregnancy, and newborns get antibiotic ointment in their eyes right after delivery just in case.
But over the course of the first few months, babies can have a unique situation that causes gooey eye drainage and makes many people worried about pinkeye, though it usually isn’t actually. And this situation is called dacryostenosis—which is a blocked tear duct.
Babies’ faces are so squished and compact that it’s easy for oils, dead skin, and other debris to build up in the corner of the eye and block the tear duct. And in some babies, the tear duct doesn’t open properly, so tears and rheum can’t drain like they should.
Sometimes antibiotic ointment is prescribed—and what you usually see is that the gooey drainage goes away for a little while, but then it comes back. What’s happening there is that the ointment kills off the normal, healthy bacteria in that area, possibly decreasing some of the rheum that’s made, but as soon as the normal bacteria repopulates, the discharge comes back—because the real cause, a blocked tear duct, doesn’t get fixed by ointment.
How to fix a blocked tear duct?
What we tend to recommend is to use a warm compress and gently massage the corner of the eye with a clean finger to try and help loosen up whatever might be blocking the duct and open it up. A tried and true trick for a breastfeeding mom is to apply a few drops of breastmilk into the eye a few times a day; the thought here is that some of the antibodies in the breastmilk help to clear way whatever might be blocking the duct.
For most babies, the tear ducts open up as they grow, and the problem ultimately goes away on its own. But for some babies, the duct doesn’t quite open enough, so if the problem is still around as your baby approaches a year of age, then your pediatrician might recommend a visit to an Ear, Nose & Throat doctor or Ophthalmologist who can help to open up the duct.
All in all, pinkeye is pretty annoying. Luckily, it’s pretty easy to fix when it’s bacterial, can be calmed when it’s allergic, and will go away on it’s own when it’s viral. Remember, this article is meant to give you an insight into what’s going on with your child, but it cannot replace the wisdom the doctor who knows you. If you ever have any questions or concerns about your child, be sure to contact your pediatrician.