Neonatal Eye Ointment and the Canadian Controversy

Local mommy groups are abuzz this week after Canadian news outlet, Global, reported that the mandatory application of prophylactic eye ointment to newborns was “ineffective, outdated and unethical.” What followed were two camps: happy hippies, and a lot of pissed off doctors. All of this suggesting to me that a lot has been misunderstood.

Here’s why this is a really big deal.

Antibiotic eye ointment is mandatory in many states and Canadian provinces. In some places, parents who refuse it on behalf of their newborns can be reported to Child Protective Services. In Texas, medical staff who fail to give it can be criminally charged for a class B misdemeanor. That sends a pretty clear message to the public and to the medical community that antibiotic eye ointment is considered REALLY IMPORTANT, and that the benefits must inarguably outweigh the risks. Unfortunately, not everyone agrees.
Now often in matters of health and wellness, we have people who disagree, even with messages as clear as this one. But this time, it’s not just anybody (cough, cough Jenny McCarthy). This time, it’s the Canadian Society for Pediatrics. In March 2015, they came out with a position statement quite clearly stating that erythromycin eye ointment should not be routinely recommended. Have the Canadians gone completely insane?

Back up. Why do we give infants eye ointment, anyway?

The reason we give infants eye ointment is to prevent something called ophthalmia neonatorum. Ophthalmia neonatorum is an eye infection that occurs in babies in their first month of life, and generally, it’s no big deal. Except for when it’s caused by an organism called N gonorrhoeae (the same bug that causes gonorrhea). In those cases, it very often progresses rapidly to a devastating eye illness and eventually blindness. The way a baby would get gonorrhea in their eye would be from passing through the birth canal of an infected mother, or even from a Cesarean delivery where the bugs crawl up the cervix into the uterus. Because a woman doesn’t always know if she is infected with N gonorrhoeae, and because it used to be pretty common, it was a no-brainer to give all babies ointment to prevent an infection that could otherwise lead to blindness.

So what’s the issue?

In the past, gonorrheal infection was a lot more common than it is now. Nowadays, the vast majority of cases of ophthalmia neonatorum (like, 99% of them) are caused by other organisms. Though erythromycin eye ointment may very well kill some of those other bugs, it’s not really necessary since those other bugs don’t cause a severe illness or blindness, the way N gonorrhoeae does.
The issue brought to light by the Canadian position statement is that it’s not really clear that erythromycin eye ointment actually works to prevent ophthalmia neonatorum caused by N gonorrhoeae, which is sort of the whole point of using it. The reason for this is that emerging strains of N gonorrhoeae are resistant (about 25%).  Does overuse of erythromycin eye ointment breed this resistance? Unclear. And just to add more murk to these waters, one recent meta-analysis, which is a study that looks at the quality and findings of all the other studies on this topic, showed that the quality of all of the evidence pretty much sucked, and the prophylactic agents (like erythromycin eye ointment) had significant failure rates at preventing the disease they were being given for.  So I know when I said that the vast majority of cases of ophthalmia were not caused by N gonorrhoeae anymore, many of you probably thought—well duh, that’s because we give prophylactic eye ointment now. But this argues against that—it argues that it’s not doing much at all.

But my 3 kids got erythromycin eye ointment and they’re fine.

So here is where many of the media reports missed the point. This wasn’t a discussion about the safety of erythromycin eye ointment. Some groups argue that it could blur vision and interfere with mother-baby bonding. It can also cause eye irritation in rare cases. But that wasn’t the point of the position statement. They didn’t argue that we should stop using it because it’s harmful. They argued that we should stop using it because it doesn’t work.

So why not just use it anyway? I’d take the risk of some minor eye irritation to prevent a devastating infection and blindness.

According to the Canadian Pediatrics Society (and by the way, also Denmark, Norway, Sweden and the United Kingdom, who haven’t mandated universal ocular prophylaxis in decades), there’s no reason to do something that doesn’t work. It’s like saying why not just stand on your head when you have a flat tire.
Now, the other thing they aren’t saying is that we just suck it up and deal with a small percentage of blind babies. The Canadians, like Texas, agree that gonococcal ophthalmia is really, really important. The whole point of their article was to find the best, most effective way way to prevent its devastating consequences. They went on the suggest strategies that might be better at preventing gonococcal ophthalmia, like more aggressive maternal and infant screening strategies, more aggressive medical prophylaxis for at-risk babies, early aggressive treatment when infection is identified, education, and close follow-up.

OK, so we’re good with the new plan then?

Well, not really. And this is where I think a lot of the confusion lies, and a lot of the backlash.
It’s all well and good to suggest, as the Canadian Pediatrics Society did, that we screen pregnant women for gonorrhea and treat them, and this way you’re actually preventing N gonorrhoeae from being where it shouldn’t be. The real problem is that we have no idea if this is actually an effective strategy AND it raises a whole slew of other problems.
Some people refuse testing because they don’t believe they’re at risk. But, as any doc can tell you, we’ve all seen the pregnant nun in the office, or the little old happily married lady with syphilis.  Some sexual partners lie, and unfortunately, you often don’t know until something bad happens. Like your baby going blind from a gonorrheal eye infection. Also, sexually transmitted infections like gonorrhea are gifts that keep on giving. You have to treat ALL the partners. Meaning that poor pregnant lady whose partner would never cheat on her needs to be treated, but so does her husband who swears he picked it up on a public toilet seat. And probably also the women he’s adamant he’s not sleeping with.
See how this can get really tricky? So even if you manage to identify and treat the pregnant mom, you can’t control that they won’t get reinfected the next day. You know the great old wives tale of the best thing you can do to bring on labour? Well, you can even contract gonorrhea then (and no, I’m not talking about jumping up and down. Or about Flamin’ Hot Cheetos, though I’m 99% sure those worked for me.)

Did anyone ask the experts?

So, it’s cool that Global news asked a midwife what she thought. But what about the people who actually treat babies with gonococcal eye infection? Turns out, they think the Canadian Pediatrics Society’s position statement is a load of crap. The President of the Canadian Association of Pediatric Ophthalmology and Strabismus published a letter to the editor of the Canadian Journal of Ophthalmology, in which he expressed his feeling that the statement failed to recognize that gonococcal ophthalmia is a lot more common than we think because it often goes unreported, and that c trachomatis (aka chlamydia) can also cause serious problems when it finds it way into a newborn’s eye and can also be prevented with eye ointment. Additionally, it fails to consider the risks of stopping prophylactic eye ointment, and fails to present any evidence that the proposed alternatives are effective. Most importantly, it fails to adequately review the evidence. Meaning that that meta-analysis I told you about? They eye doctors interpreted the findings to say the exact opposite of what the pediatricians reported. So basically, the eye doctors think the report is a giant failure in all aspects. The author ends the letter by urging the Canadian Pediatrics Society to reconsider their position statement, and retract their recommendation to stop eye prophylaxis. Oh, and they suggested that next time the pediatricians write a position statement about eye prophylaxis, they talk it over with the eye doctors first.

Here’s the story behind the story.

What the Canadian Pediatrics Society is ACTUALLY suggesting is not to avoid the evils of Western medicine, but rather to aggressively prevent and treat infection in at-risk babies with a shot or infused antibiotics; and aggressively screen and treat pregnant moms.
As you can see, the alternative to eye ointment is fraught with a lot of potential problems, not the least of which being that the eye doctors don’t agree that it’s even necessary. I don’t know what the “right answer” is here, nor was my goal to force my opinions onto you. The purpose here was just to make sure we’re all on the same page about what the Canadians actually said. So now you know, eh?

The post Oh, Canada: The Controversy Over Neonatal Eye Ointment appeared first on Talia Zenlea.

Last week, the journal Pediatrics published a study describing the characteristics of physicians who dismiss families for refusing vaccines. Perhaps most shocking was the finding that 83% of the over 500 physicians surveyed reported that in a typical month, at least 1% of parents in their practice refused at least 1 infant vaccine.  Many personal stories from doctors followed in the news, and as I read them, my first thought was – how terrible. How could a doctor refuse to care for a whole group of patients?  Especially vulnerable children, who had no say in the decision. It goes against everything we’ve been taught.

But then I read on.

One of these doctors instituted the policy of refusing to care for unvaccinated families after an unvaccinated child showed up in his waiting room with whooping cough, exposing several infants and another child with leukemia to this potentially fatal and preventable illness.

It hit a chord. As the mom of 3 young boys, someone is always sick in my household. We’re cautious, but not over-the-top about germs. I know kids get sick, and I know they can fight colds with strong immune systems, and that it’s not the end of the world. I’ve had the flu, I even had chicken pox, and I lived to tell.

But whooping cough, influenza, chicken pox, measles, and many other vaccine-preventable infections aren’t “just colds.” They are serious infections that can kill people. And just because one of these didn’t cause a debilitating illness in me or you, it doesn’t mean that if or when we get them we can’t pass them on to someone who doesn’t have the immune strength to fight them. You may have already read about why I chose to get a flu shot this year  – to protect my son, my grandmother, and my good friend, all of whom could die from the infection that in me might only feel like a no-big-deal-kinda-cold.

The recent study in Pediatrics showed that in the states where doctors were less likely to dismiss patients for refusing vaccines, there were lower vaccination rates and higher rates of vaccine-preventable diseases. So while my gut reaction was at first that these doctors were betraying their patients by dismissing them, I then thought about all of the other vulnerable children in their practices that they were protecting. And I thought about the Hippocratic oath we all took in medical school – where we vowed to “take care that [our patients] suffer no hurt or damage.” And things got a lot less obvious.

As an adult gastroenterologist, I don’t have a ton of conversations about vaccinating children, but every day I talk to people about illnesses and various ways of treating them. And my stance has never been to be someone who paternalistically dictates a treatment plan to a patient. My patients are adults, my peers, and I respect their intelligence. I think it’s overstepping my boundaries to be telling them what to do. Instead, I see it as my job to provide them with all the info they need, so that they can make educated decisions for themselves. Except in really unique circumstances, most of the people I see are competent adults, who have the right to make their own decisions, even ones that I don’t agree with.

For the most part, I feel that way because their health decisions are their business and don’t have much direct impact on the physical health of anyone except themselves. But what I’ve realized is that when it comes to vaccines, that’s just not true. Those decisions impact the people around them far more than they impact themselves. So I really feel for those pediatricians who face this everyday. They’re trying to “do no harm.” Aren’t they doing a ton of harm by allowing unsuspecting vulnerable children to sit in their waiting rooms with people who could realistically be carrying preventable and life-threatening infections?

So why is it that people are more and more refusing to get vaccines for themselves and their kids? The short answer is, I have no idea. I set out to write a few of the most common reasons, and explain whether they are valid or not. But as I did, I realized I sounded like Charlie Brown’s teacher (whaamp-whaamp-whaamp) – this is really, really old news, and did I really need to be belabouring these points? I can’t imagine that anyone, especially someone who had made the conscious choice to refuse the vaccines the pediatrician was recommending for their child, would not know that the study showing a link between thimerosal and autism was retracted and the author totally discredited (but if you’re curious, the top three reasons people refuse vaccines article can be found here). I think it goes deeper – an inherent mistrust of mainstream science and medicine, maybe that all of this “good information” is just part of a giant conspiracy theory, or some sort of secret arrangement between every doctor and the companies that manufacture vaccines. How can a doctor carry on a relationship with a patient or family who feels this way? Mutual trust is fundamental to a sound doctor-patient relationship.

Like I said, I’m a mom to 3 young boys, and my main concern is to keep them safe and happy. I’ve chosen to vaccinate them because I am overwhelmed with the amount of sound data supporting the benefits of vaccines. I don’t want my boys to get sick from whooping cough, measles, or mumps.  I don’t want any potential future daughters-in-law to get cervical cancer. And I haven’t seen any compelling quality evidence to suggest that vaccines are bad. I’m a doctor and so are 90% of the people I know, and no one I know gets kickbacks of any sort from anyone for recommending or administering vaccines. The only juice we all drank was the one called I Practice Evidence Based Medicine. And as for the unvaccinated children sharing a pediatricians waiting room with my kids? I think it’s scary. Really scary. I’m comforted because I know my kids are most likely immune to those infections. Because I’m lucky and my kids are healthy. But that’s not the case for everyone, and if it weren’t for me, I’d be out of that waiting room in a heartbeat.

Oh, and Bellyblog’s very own media producer Dr. Seema Marwaha made this video that might help explain some of those misconceptions I talked about.

The post What You Don’t Know About Vaccines appeared first on Talia Zenlea.