Gray Baby Syndrome: Causes, Symptoms, Treatment And Prevention

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Gray baby syndrome (GBS) is a rare side effect of high levels of antibiotic chloramphenicol in the body of term and premature neonates. Chloramphenicol is used to treat several bacterial infections, such as meningitis, typhoid, etc.

GBS can cause several symptoms and severe complications, but the condition is preventable. Read this MomJunction post to know more about the causes, symptoms, risk factors, complications, diagnosis, treatment, prevention, and outcomes of the gray baby syndrome.

Causes Of The Gray Baby Syndrome

The primary cause is the accumulation of the antibiotic chloramphenicol in the blood serum of an infant.  Blood serum levels of chloramphenicol higher than 50mcg/mL is associated with gray baby syndrome. Toxic levels of chloramphenicol may cause a circulatory collapse that leads to mottling (smears of color) of the skin in ashen-gray color (1). This disease is named after the appearance of gray-colored skin in newborn babies.

Gray baby syndrome can be due to the following deficiencies in neonates (1).

  • The immature liver may not be able to metabolize the chloramphenicol.
  • Newborn’s kidneys are not efficient enough to excrete chloramphenicol and its metabolic products from the body.

A well-functioning liver and kidneys can metabolize and excrete the chloramphenicol. However, it may not be the case in babies. This could be a reason that premature neonates are more vulnerable to gray baby syndrome than healthy and full-term infants.

Risk Factors For Gray Baby Syndrome

The following risk factors may play a vital role in the development of gray baby syndrome during the neonatal period.

  • Reduced liver (hepatic) function
  • Reduced kidney (renal) function
  • High dose of chloramphenicol
  • Longer duration of chloramphenicol treatment
  • Maternal use may cause chloramphenicol to reach the baby through breast milk
  • Underweight and malnourished children

Pediatricians decide chloramphenicol dose based on weight. This weight-based dosage may vary among newborns until the first 15 days. There may also be variations in dosage in babies up to four weeks old and those older than a month.

Note: Chloramphenicol is contraindicated in breastfeeding mothers due to infant toxicity, and this is also a category C drug that may cause risk in pregnant women (2).

Symptoms Of The Gray Baby Syndrome

Gray baby syndrome may occur after two to nine days of chloramphenicol treatment. The onset and severity may vary based on drug levels and hepatorenal functions.

Gray baby syndrome symptoms may include (3) (4):

  • Fussiness
  • Poor feeding
  • Weakness
  • Vomiting
  • Changes in mental status such as lethargy and less alertness (obtundation)
  • Pale appearance (pallor)
  • Ashen-gray color of the skin
  • Abdominal tenderness
  • Abdominal distention
  • Hypotension (low blood pressure)
  • Cyanosis causing blue lips, blue nails and bluish skin
  • Respiratory distress
  • Low body temperature

Seek medical advice if you notice any signs and symptoms of toxicity in newborns due to direct or maternal intake of chloramphenicol antibiotic.

Complications Of The Gray Baby Syndrome

The following complications can be associated with chloramphenicol toxicity (1) (5):

  • Bleeding
  • Liver failure
  • Renal failure
  • Aplastic anemia due to bone marrow toxicity (6)
  • Inflammation of the optic nerve (optic neuritis) and vision problems
  • Problems with peripheral nerves (Peripheral neuritis)
  • Cardiovascular collapse or shock
  • Infection
  • Brain damage

Chloramphenicol could displace bilirubin (formed by the breakdown of red blood cells) from albumin (main blood protein). Free or non-albumin bound bilirubin may lead to jaundice (yellow skin and eyes) and permanent brain damage known as kernicterus (1)

Diagnosis Of Gray Baby Syndrome

Diagnosis of the gray baby syndrome can be made from the ashen-gray appearance of the skin along with the history of exposure to chloramphenicol in babies. Neonatologists or pediatricians may also look for signs of toxicity during physical examination.

The following tests are ordered to confirm the diagnosis of the gray baby syndrome (1):

  • Blood tests could show the levels of chloramphenicol in the blood. Cardiac biomarkers, arterial blood gas, metabolic profile, etc., are based on blood tests to identify or exclude conditions that can be present with neonatal cyanosis.
  • CT scan, abdominal X-rays, or abdominal ultrasound are conducted depending on the symptoms.
  • Electrocardiography (ECG) and echocardiography are often done to exclude cardiac causes of circulatory collapse and skin discoloration.

Your doctor may perform these tests to look for neonatal sepsis, trauma, volvulus, heart diseases, and metabolic syndromes to make a differential diagnosis, since these conditions may also cause cyanosis in babies.

Treatment For Gray Baby Syndrome

The treatment for gray baby syndrome is intensive support therapy with the withdrawal of chloramphenicol. Babies with problems in the blood and circulatory system receive aggressive resuscitation in intensive care units. They may receive appropriate oxygen therapy, ventilation, and early intubation, depending on the requirement.

If the baby develops hypothermia, then they will require rewarming. Hypoglycemia will require glucose correction.

The direct removal of antibiotic chloramphenicol molecules from the blood can be achieved by the following treatments (4).

  • Activated charcoal hemoperfusion: This is an extracorporeal (outside the body) method to filter the toxin from the body.
  • Exchange transfusion: This life-saving procedure involves the replacement of patient’s blood with fresh donor plasma or blood.

Third-generation cephalosporin and phenobarbital medications are also used for treating gray syndrome (3).

Prognosis Of Gray Baby Syndrome

The prognosis or outcomes are good if the gray baby syndrome is diagnosed earlier, and the chloramphenicol treatment is discontinued. However, if the baby has developed organ failure before diagnosis, then there is a high risk of worse prognosis.

Prevention Of Gray Syndrome

Avoiding chloramphenicol exposure is a way to prevent gray baby syndrome. This can be achieved by practicing the following steps.

  • Pediatricians and infectious disease experts try to give other safer antibiotics instead of chloramphenicol to babies.
  • Expecting mothers and nursing mothers should go for treatment with newer antibiotics instead of chloramphenicol since it may cause birth defects in unborn babies and neonatal toxicity.
  • If required, lower doses of chloramphenicol for a long duration are often prescribed for babies to prevent toxic effects.

Healthy babies and premature infants are carefully monitored for drug levels in the blood if they are treated with chloramphenicol antibiotic.

Long-term therapy with oral or intravenous chloramphenicol may result in gray baby syndrome. You may also seek a healthcare provider’s advice before using chloramphenicol eye drops for bacterial conjunctivitis in infants and children since this may also result in toxicity (7). Pediatric drug therapy with chloramphenicol is only considered when it is an absolute requirement.

The use of chloramphenicol is limited. It is mostly used in eye drops and some topical ointments at times. It might still be considered in specific infections like tick borne rickettsial infections and typhoid fever. Even in these circumstances there are other drugs that can be considered. Always discuss the options with your healthcare provider.


MomJunction's articles are written after analyzing the research works of expert authors and institutions. Our references consist of resources established by authorities in their respective fields. You can learn more about the authenticity of the information we present in our editorial policy.
1. Earl D. Cummings and Mary Ann Edens; Gray Baby Syndrome; The United States National Library of Medicine (NLM)
2. Chloramphenicol; Drugs and Lactation Database (LactMed); The United States National Library of Medicine (NLM)
3. Mahendra Kumar BJ, et al., Drug Induced Syndromes: An Overview; Indian Journal of Pharmacy Practice
4. Gray baby syndrome; Sciencedirect
5. WHO Food Additives Series: 53; Chloramphenicol; International Programme On Chemical Safety (IPCS)
6. Chloramphenicol-Induced Bone-Marrow Aplasia; The New England Journal of Medicine
7. Tim Lancaster, et al., Risk of serious haematological toxicity with use of chloramphenicol eye drops in a British general practice database;  The British Medical Journal
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Dr. Wayne Hough

(MBChB, MMed, FC Paeds)
Dr. Wayne Hough is a pediatrician currently based in the Northern Suburbs of Cape Town in South Africa. He got his medical degree from the University of Stellenbosch. He then worked at the Tygerberg Children's Hospital before completing his pediatric training and qualification from the South African College of Medicine. Dr. Hough also holds a MMed degree in pediatrics from... more

Dr Bisny T. Joseph

Dr. Bisny T. Joseph is a Georgian Board-certified physician. She has completed her professional graduate degree as a medical doctor from Tbilisi State Medical University, Georgia. She has 3+ years of experience in various sectors of medical affairs as a physician, medical reviewer, medical writer, health coach, and Q&A expert. Her interest in digital medical education and patient education made... more