Pediatric Childcare

•   Are you concerned about your child's ability to see?
  
•   Are you concerned that your child's eyes "look funny"?
  
•   Are you concerned because your child is having trouble reading   and writing?
  
•   Has your child been diagnosed as having ADHD, but you are   unsure of the diagnosis?

You've come to the right site.
Childhood Vision Problems are Common!

•   About 20 out of every 100 school-aged children are near-sighted   or far-sighted.
•   About 5 to 10 out of every 100 children have other types of vision   problems.

Vision problems in children often go undetected. Why?

•   Children may not realize that they are seeing differently than   other people. 
•   Adults may not know the signs of poor vision. 
•   Sometimes vision problems are confused with other illnesses   such as attention deficit hyperactivity disorder (ADHD).

Good vision is more than 20/20 vision:
Good vision means:

•   The eyes are healthy (disease-free) 
•   The eyes can see things clearly up close and far away 
•   The eyes work together to focus on a single object 
•   The eyes move smoothly and accurately together 
•   The information seen by the eyes is understood and gives   meaning to what is seen 

Infants Can Be Born with an Eye Disease
When we think of eye diseases, we often think of older people. But infants and children can have eye diseases, also. To prevent vision loss or blindness, these diseases need to be diagnosed and treated early.

Not all eye diseases are obvious just by looking at the child. Often, children will not realize they have a vision problem. They assume everyone sees the way they do. Some children may realize that they have problems seeing, but won't know how to describe what they see to others.
While eye disease is uncommon in children, it is more likely to occur if:

•   The child weighed less than 2 pounds at birth
•   Eye disease runs in the family.

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Childhood Eye Diseases
If a child has one of the problems listed below, he or she should have an eye exam by an eye doctor as soon as possible. No infant or child is too young to have an eye exam.

•   A white pupil 
•   A lump, swelling or drooping of the eyelid 
•   The clear outside layer of the eye (cornea) is large in one or both   eyes (the eye will look unusually big)
•   One or both eyes look in or out 
•   There is tearing, discharge or redness of the eyes 
•   The eyes seem to jiggle or rotate 
•   One pupil (the black center of the eye) is larger than the other 
•   The baby or child almost always tilts his head to look at things 
•   Part of the iris (the colored ring of the eye) is missing 

Treatment 
The sooner an eye disease is treated, the better. Early treatment can prevent vision loss. In some cases, if the disease is not treated, the child could lose his or her ability to see.
Treatment for eye diseases could include one or more of the following:

•   Medications 
•   Surgery 
•   Eye patches or exercises 

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Vision Acuity
About 20 percent of school children are either near-sighted or far-sighted. These problems typically occur between the age of 6 and adolescence.
Children may complain that they can not read the chalkboard at school or you may notice that they sit close to the television. Sometimes the child may say that words look blurry.
Children with these problems need to have an exam by an eye doctor. These problems can often be corrected with eyeglasses.
Other Vision Problems
Glasses can not correct every vision problem. Below is a list of other types of vision problems that children can have. In children with these problems, the eye itself may be fine, but the brain and the eye may not be working well together. Just as children need to learn hand-eye coordination to catch a ball, their eyes and brain need to learn to work together to properly visualize and understand words and numbers.

These problems may not be obvious by looking at the child's eye. An eye exam is needed to determine if they have a vision problems. Eyeglasses do not correct the problem.

•   Accommodation disorder - inability to focus for clarity with   changes in position, distance or posture; child has trouble   copying from chalkboard to paper
•   Ambliopia - poor vision in an eye that did not develop normal   sight during early childhood, sometimes called "lazy eye."
•   Binocular dysfunction - inability of both eyes to act as a team;   vision is blurred
•   Directionality disorder - lack of understanding an object's position   in space in relationship to ourselves; may lead to letter or   number reversals.
•   Eye tracking disorder - the inability of the eyes to look at and   accurately follow an object; results in skipped letters, words or   lines when reading
•   Strabismus - eyes are misaligned or crossed; can lead to vision   loss

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What a Child Sees
The following sites show examples of what children may see if they have a vision problem.
Symptoms of Vision Problems
These types of problems may not be noticed by just looking at the eyes. It is the child's behavior that may suggest that he has a vision problem.
If a child has any of the following symptoms, he should have an eye exam by an eye doctor that specializes in children's vision.

Vision Screenings & Exams  
Vision screenings and exams should be a routine part of the health care a child receives.
Vision screenings
Vision screenings are a general check for eye or vision problems. Pediatricians, school nurses or others with specialized training may do screenings.
A screening can tell whether there might be an eye or vision problem. A screening can not tell for sure whether a problem exists. If a child does not pass a screening, he should have an eye exam.
Screenings Begin at Birth
When a baby is first born, he or she should be checked to see if they are healthy.
Vision screenings can be done for children as young as 3 months old.
It is recommended that a very basic eye exam be done on children beginning at 6 months of age. They should be done each year since vision problems can occur as children grow.
School Screenings
School screenings may find only 20 to 30 percent of vision problems in children.
If your child passes an eye screening, but you still think your child has an eye or vision problem, your child should have an eye exam by an eye doctor.
Vision Exams
No infant or child is too young for an eye exam by an eye doctor. Vision exams may take up to an hour to complete. An exam should check to see how clearly a child sees and how well the child is able to use his or her eyes.

•   What an exam checks for:
•   Signs of eye disease
•   The ability to see clearly at a distance and close-up
•   The ability of the eyes to focus when looking from near to far and   from far to near
•   The ability of the eyes to work together to focus on things such   as pictures and words
•   The ability of the eyes to move smoothly without any jerking   movements
•   The ability to detect depth and color perception
•   Developmental vision exam

A development vision exam includes all the tests of a regular exam plus more tests. These tests check for such things as:

•   Blurred vision
•   Erratic eye movements
•   The ability to focus from far to near and far to near in a short   amount of time
•   The ability to remember what is seen
•   The ability to correctly visualize a figure or picture
•   The ability to scan words or pictures

Eye Health & Vision and First Aid
The child's vision system is dynamic, constantly changing and adapting to both the body's growth and development cycle as well as the visual world outside.

This article discusses the development of the vision system, recommendations for early detection and prevention and guidelines for pediatric vision care. There's also a section on "first aid and emergencies" and discussion about some common childhood eye problems.

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Children's Vision Development

The human vision system at birth is poorly developed, but rapidly becomes the remarkable combination of nerve tissue, muscles and optical lenses that provide us with the sense of vision. The information processed by the eyes is sent directly to the brain and is interpreted as vision. That information is also used to provide us with the awareness of space and location. The eyes learn to move and scan across the visual world, sensing time and space. Colors and shapes become valuable clues to help us understand our environment.

By six months of age, most of these systems are fully or nearly fully developed. But there's a lot of fine tuning and structural changes going on which need to be monitored as the child grows into adolescence and adulthood.

It was previously thought that infants didn't see all that well, not reaching the 20/20 standard until later childhood. In the last few years, our knowledge of the infant's and toddler's visual world has expanded. We now know that even at 1 month, the infant sees quite clearly----at least to about 20 inches (50 cm). They just don't need or care to process information from further away than their mother's and father's faces, or mother's breasts. Pretty soon thereafter, probably by 3 months, the infant's vision system is developed to the point of providing pretty good quality vision, specially tuned for her/his needs!

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Checking Children's Eyes
What the doctor looks for:

The primary care physician should be observing the eyes for anatomical, functional and perceptual development. The eye structures are examined. The eyelids are checked to be sure they are opening and closing properly, the ocular surface is checked to see if there is adequate tear fluid production, the pupil/iris observed for normal formation and reaction. The eye muscles are checked for coordination and alignment. We also look to see if the child fixates on, (pays attention to) objects in the his/her visual space, and to what degree he/she recognizes and understands what is being seen.

The parents should also be the examiners of their children. Report any unusual findings to your primary care provider or eye doctor.

What the parents should look for:

With very young infants, it is normal to notice one eyelid not working in coordination with the other, or observe the eyes misaligned at times. By three months, the eyes should look straight and appear attending to the task of seeing. By six months, the system works pretty well. Parents should report any obvious problems, such as: one eye more often than not "stuck" in one position or apparently operating independently of the other; an eyelid not blinking; cloudiness of the eyes; dark brown areas on the otherwise light-colored iris; one eye "bulging out" or more prominent than the other; obviously unequally sized pupils; or the infant rubbing his/her eyes.

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Early Detection and Prevention

Early detection of an eye problem can often facilitate the treatment of the condition, thereby helping the vision system to develop more normally. Sometimes intervention can prevent a problem from having a more significant impact later on in the child's development. Errors in the development of the human vision system and other eye health problems include:

Vision: You observe that your child can't see well. She/he stumbles beyond "normal" clumsiness or doesn't recognize people or things at certain distances.
Farsighted optics (hyperopia) sometimes cause the eyes to turn in, causing esotropia, a form of strabismus. High degrees of hyperopia can also cause eye fatigue and blurred near vision. Nearsighted optics (myopia) cause distance vision to be blurred. A significant difference between the two eyes (anisometropia) can result in a condition which causes amblyopia (poor best possible vision) and mis-coordination.

Squinting:
1. In normal lighting: Often is an attempt to see more clearly, or a neurological problem with eye lid muscle control.
2. A greater than expected reaction to light: This can be a sign of an injury to the exposed parts of the eye or internal infection.

Eye Turning:
1. Turned-in (crossed) or turned-out (wall) eyes. Improper position or incorrect muscle length can result in one or both eyes being misaligned or unable to track. This is called strabismus. This type of problem can cause poor spatial perception, clumsiness, and reading disabilities.
2. Eyes that roam in rhythmic, sometimes rapid movements is a condition called nystagmus. This can be a sign of neurological disorders of the eye or brain.

Excessive or Insufficient Blinking: Eyelid blink reflex problems can result in or be caused by dry eyes, irritation, infection or neurological dysfunction.

Neurological Developmental Problems: Symptoms are often similar to the problems outlined above. Lack of development of good visual acuity from misalignment or from a neurological anomaly, is called amblyopia. Also, there may be fixation problems, attention deficits, and binocular vision (3-D, stereopsis) defects.

Pupil Abnormalities. 1. Reflexes. The black-appearing pupils should be of equal size at any light level, clearly smaller when a penlight is shined onto the eye and larger when it is removed. 2. A white or cloudy looking pupil is a sign of potentially serious illness.

Swelling and redness of the eyelids. Many things can cause this, including insect bites, allergies and minor infections. May resolve without treatment. If the swelling is painful and warm to the touch, rapidly worsens and/or is accompanied by fever, seek immediate medical attention. Call 911. This could be a rare, but serious, potentially life-threatening condition in children.

Redness of the "white of the eye"(sclera) and inside of lids. "Pink Eye" Conjunctivitis (inflammation of the thin, normally transparent membrane which lines the outside of the eye and inside of the eyelids) can be caused by chemical or particle irritation, bacteria, virus or allergies.

Bacteria-caused infections often have mucous discharge which is yellowish, sometimes tinged with green. The discharge often dries on the lashes, forming crusting and "glued shut" eyes upon awakening. The child is clearly uncomfortable. Sometimes, the condition will resolve on its own but often antibiotic drops or ointments are used to quickly kill the bacteria and help the tissues heal. If signs and symptoms last more than three days, appear to be worsening, is accompanied by fever or other illness (e.g.: sinus, ear infection), seek medical attention.

Virus-caused infection may cause the eye to appear very red, often with tearing but little or no pain. The eye often looks much worse than it feels. Sometimes the child is hardly aware of the problem, but is spreading the infection, eye to hand to someone else's hand and then to his/her eye. The infection goes away on its own. Hygiene (keeping hands away from eyes, hand washing, no shared towels) helps with the prevention of the spread of the virus is the goal here. There is no effective drug treatment for virus infections, except for herpes virus, which is often quite painful before treatment.
Some doctors prescribe antibiotics, which have no effect except perhaps preventing secondary bacterial infection, a valuable treatment for ill children, but otherwise a questionable practice.

Allergy-caused conjunctivitis: The eyes are red , often tearing and always itching, often intensely. Washing out the irritant and lubricating, non-medicated eye drops are used to limit the reaction and help with the symptoms. Sometimes oral antihistamine medication is recommended. Medicated eye drops are now available for adults, perhaps soon to be approved for children.

Excessive tearing, in the absence of obvious infection: Some children are born with narrow or closed puncta (the small opennings in the eyelids through which tears drain into a ductwork called nasal-lacrimal system. Others develope the condition as the result of infection or injury. Treatments include: warm compresses and massage of the lid, mechanical dilation of the openning, antibiotics (for infection-caused condition). Sometimes the situation resolves by itself.

When Should Children Be Examined?
Below are the guidelines based upon recommendations from the American Optometric Association and commonly practiced by most eye doctors:

Age Birth to 2 years: By six months of age, by a capable pediatrician or by an eye doctor if there are risk factors or observed problems.

2-5 years: At age 3 or as recommended if there are risk factors.

6-18 years: Before entering the first grade and every two years thereafter. Annually or as recommended if there are risk factors.

Factors placing an infant or toddler at risk include:

1) Premature delivery, low birth weight, oxygen given at birth, grade III or higher intraventricular hemorrhage
2)  Family history of retinoblastoma, congenital cataracts, or metabolic or genetic diseases, including hyperthyroid, diabetes and heart disease

3) Infection during pregnancy, especially rubella, toxoplasmosis, syphillis, gonorrhea, herpes, cytomegalovirus, HIV
4) Difficult or assisted labor, low Apgar scores
5) Known or suspected central nervous system dysfunction, e.g.: developmental delays, cerebral palsy, seizure disorder, hydrocephalus
6) High refractive errors, anisometropia (large difference between eyes)

7) Strabismus (crossed, uncrossed eye position)