paediatric optometry - lecture 6 paediatric development

What ocular conditions might be attributed to complications in paediatric development?

- retinopathy

- myopia

- tropia

- amblyopia

What are the 3 phases of growth and development?

- psychomotor: including physical and sensory perceptual

- Cognitive: including language

- Affective: including emotional, social, personality and moral

What are the goals of child health supervision?

•Growth

•Language

•Assessment tools

•Nutrition

•Dentition

•Feet and walking

•Hearing screening

•lowered child mortality

•reduced disability and morbidity

•promotion of optimum growth and development

•help for children to achieve longer, fuller, more productive lives, i.e., maximise their potential

How are the goals of child health supervision achieved by?

•measurement and recording of physical growth

•monitoring of developmental progress

•administration of screening tests

•offering and arranging intervention when required

•prevention of disease by immunisation

•information and support to parents

•health education

Define 'growth' and 'development'?

growth - the increase in the number and size of cells

Development - the maturation of the organs and systems of the body and acquisition of skills

ways to determine growth

standard growth charts - compare a child with

• other children, note rate of growth; failure to

thrive;

• short stature; tall stature

What is normal/abnormal in a child in regards to feet and walking?

•Flat feet - normal in a toddler

•Toeing in - normal in young children (decreases with age)

•Toe walking - may be part of normal progression

•Bow-legged - normal in first 3 years (concern if excessive or family history)

•'Knock kneed' - normal ages 3-6 years, straight - ages 7-8 years and beyond

•Limps - foot, knee or hip: concern if accompanied by fever

When can majority of hearing impaired children be recognised?

- ages of 3 to 7 years.

Delay or failure to identify can lead to problems in speech, language, academic, intellectual and social development of children

hearing impairment stats

• new-borns: 1 in 1000 have a serious hearing impairment

• children 5-19: 3 in 4000 totally deaf, 1 in 200 hearing

impaired

• age 65+: 25-40% are hearing impaired

• age 90+ : 90% are hearing impaired

Hearing screenin

What is meant by receptive and expressive?

Receptive: listening. can they understand?

1 year old should follow 1 step command

expressive: verbalising.

2 years 2 word sentences

• 3 years 3 word sentences

Language

When does a baby get their first teeth?

5 to 9 months

first dental visit at age 3

- children lose baby teeth at around 5 - 6 years

- important for fluoride use

What does the denver developmental screening test assess?

•Gross motor

•Language

•Fine motor-adaptive

•Personal-social

Describe the information for a newborn to birth baby?

•Sleeps for much of the 24 hours

•Baby yawns, coughs, hiccoughs, sneezes, stretches and salivates.

•Baby can suck, swallow, smell, taste, hear and see.

•Shows a variety of primitive reflexes, e.g.

•Moro reflex, Grasp reflex, Walking reflex

•Cardinal points: a variety of mouth and lip reflexes

•"rooting reflex" - searching for mother's milk

•Blink reflexes - various stimuli provoke blinking

What is the moro reflex?

•Moro reflex: seen when the baby is suddenly moved. It consists of rapid abduction and extension of the arms with opening of the hands. The arms then come together as in an embrace.

- gives an indication of muscle tone

- usually disappears within 2 to 3 months

What is the grasp reflex?

•Grasp reflex when baby's palm is stimulated, the hand closes.

•Baby's grasp at this stage is strong and could support its weight.

•However, the strength disappears overnight, although the reflex itself persists for up to 2-3 months.

What is the walking reflex?

Walking reflex: when the sole of the foot is pressed on the floor the baby walks.

Disappears after 3-4 weeks

What are the different aspects in child skill aquisition?

•Gross motor

•Fine motor

•Adaptive

•Language

Personal-social (affective)

What is the skill acquisition of a 4 week old?

Gross motor: head flops forwards when sat up

Fine motor: hands clench on contact

Adaptive: looks at object in line of sight

What is the skill acquisition of a 16 week old?

Gross motor: head steady on sitting. Lifts head when prone on forearms

Fine motor: hands clutch, scratches

Adaptive: slow pursuits, hypometric saccades, holds and looks, oral

Language: laughs, excited noises

Personal/social: social smiles, recognises food

What is the skill acquisition of a 28 week old?

Gross motor: sits briefly, with help from hands

Fine motor: radial palmar grasp

Adaptuve: one handed approach and grasp. Bangs and shakes

Language: vocalises when crying. Baby babble

Personal/ social: feet in mouth, reaches for mirror image

What is the skill acquisition of a 40 week old?

Gross motor: sits steady, pulls to feet

Fine motor: thumb and index grip

Language: mama, dada and possibly one or two other words

Personal/ social: wave bye bye, simple self feeding, games

What is the skill acquisition of a 12 month old?

Gross motor: crawls, stands alone momentarily

Fine motor: Neat pincer grasp

Adaptive: serial play; 2 block tower

Language: gives on request, 1 or 2 more words

Personal/social: cooperates in care

What is the skill acquisition of a 15 month old?

gross motor: toddles independently, stands alone for short periods

Fine motor: puts small object in bottle

Adaptive: looks at objects in line of sight

Language: few more words. Pats picture

Personal/social: thanks, shows wants

What is the skill acquisition of an 18 month old?

gross motor: walks, seats self in chair, throws when standing

Fine motor: turns pages

Adaptive: 4 tower block, scribbling

Language: 10 words. identifies picture, 2 direction commands

Personal/social: pulls toy, carries doll, helps feed

What is the skill acquisition of a 2 year old?

Gross motor: runs, climbs stairs, kicks large ball

Adaptive: 7 blocks, copies hand movements

Language: pronouns, 3 word sentences, 4 direction commands

Personal/Social: toilet trained

What is the skill acquisition of a 3 year old?

Gross motor: jumps off step, pedals trike

Fine motor: holds crayon in fingers

Adaptive: 10 blocks, simple bridge, copies simple drawings

Language: uses plurals, verbs, understands prepositions

Personal/social: feeds well, dresses, sings

What is the skill acquisition of a 4 year old?

Gross motor: alternating foot descent

Fine motor: Draws 2 part people, copies cross

Adaptive: counts 3 objects with correct pointing

Language: names colours

Personal/ social: self hygiene, runs errands

What is the skill acquisition of a 5 year old?

Gross motor: skips, stands on one leg for more than 3 seconds

Adaptive: counts 10 objects, copies triangle, unmistakable people

Language: Knows red/ green/ bluee; describes pictures

Personal/ social: asks meaning of words, starts to write letters

What is the skill acquisition of a 6 year old?

Gross motor: Stands on either foot with eyes closed

Fine motor: 3 step structures with blocks

Adaptive: copies diamond

Personal: ties shoelaces, knows L and R. am and pm. counts the 30

Why examine children?

•Visual sensory deprivation in the early years of life can lead to irreversible loss of visual function

•The early detection, diagnosis and treatment of vision problems is critical to success

who to examine paediatric

All children?

- May need specialised expertise?

- May need specialised equipment for full diagnosis?

- May require more specialised techniques for proper evaluation of visual

function in infants (e.g., VEP, preferential looking techniques, ERG)

• Preschool children ( 3 to 5 years of age)

• School aged children and beyond

what factors affect ability to conduct eye test on child

- developmental status

- cognitive ability

- attention span

- effect of the consulting room environment

- rapport with you

What are the different problems a child can have which may affect the examination?

•Developmental problems

•Strabismus and amblyopia

•Motor development

•Learning problems

Paediatric diseases

children vs adults

• Children are not just small adults

• Children can have different problems

• Children present differently

• Age is an important factor in the paediatric

examination

child presenting with issues in practice

Frequently presented by parents or other relatives

• Difficulty in child knowing if they have a problem

• Children's vocabulary and experiences are different

• Child's views may not coincide with parents

• Child may not want to be there

how to adjust the paediatric practice to adress concerns well

Provide a child-orientated environment

• Spend time building rapport with child

- but don't neglect the parents

• Structure the exam to suit the child?

- When they are alert?

• Can be especially important with babies

- Often see children after school (when they are tired)

What are some common complaints from parents about their child?

-eye turns when tired

-sits too close to the TV

-blinks a lot

-rubs eyes a lot

school difficulties

Which other relevant infomation would you need besides main concern ?

•Explore complaint

•Child's neonatal history

•Development

- milestones and abilities

•Family history

What neonatal history do you need to gather?

•Neonatal: Normal birth? Caesarean? Trauma?

•APGAR Score: Assessed 1 minute after birth, better later

-Score 8 or over is good

-Score of 4 signals a weak baby with possible problems later

What are the risk factors for development of refractive erroe?

Prematurity and low birth weight infants

Increased prevalence of myopia and astigmatism

Maternal disease

Diabetes

Fetal alcohol syndrome

Rubella

Genetic predisposition

40% chance of myopia when both parents myopic

apgar chart point system

step 2 - forming hypothesis

What are the most likely causes of the complaint?

• Are any of these the province of the optometrist?

• If yes, what tests will tend to confirm or deny the

hypotheses?

• If no, counsel and refer.

epidemiology of ocular disorders

Refractive error

• Amblyopia

• Strabismus

• Ocular disease

• Other conditions

- Colour vision problems

- Visual perceptual problems

- Reading difficulties associated with vision

refractive error in children

Significant refractive error is the most common cause of decreased

vision in children (and adults)

• Infants are generally born hypermetropic (+2.00D ± 2.7). The

refractive error reduces (emmetropisation) over the first 18 months

of life to emmetropia. The variance in the refractive error

distribution also reduces

mechanism of emmetropiasiton in children

is currently unknown.

There is some suggestion that the eye senses the sign and

magnitude of the refractive error and then adjusts its rate of growth

through an active feedback process to reduce the refractive error

refractive error distribution in children

The distribution of

refractive errors in infants

is relatively broad and

achieves the more typical

leptokurtic appearance

over the first 18 months

to 2 years

refractive error stats in children

• Over 80% of children 1-7 years are between +0.50 and +3.00 D

• Less than 5% of all 5-7-year-olds are over +5.00D

• Less than 3% are myopic

myopia prevelence in children

The prevalence of myopia increases with age after about 8 years

and may be as high as 15-30% (early onset myopia) at 15 (while

hypermetropia remains at around 6%)

astigmatism in infants

Reports vary but anywhere between 17-63% of infants have

astigmatism > 1.00DC (most report against the rule)

– Astigmatism appears to be transient, and the prevalence

decreases in the first year or two of life

amblyopia in children

Single most prevalent cause of vision

loss in children (and adults up to

about 45 years of age!)

• Prevalence of amblyopia estimated

at 2-3% in the general population

risk factors of amblyopia in children

Strabismus

• Anisometropia

• High refractive error

• Form deprivation - rare (e.g.

cataract)

strabismus prevalence in children

Prevalence less well

established but estimated

to be around 3-5%

(horizontal deviations)

• Prevalence for vertical

deviations not well known

but probably much less

ouclar disease in children

- However - MUST always be aware of the possibility of the

presence of underlying ocular pathology

- Especially important in the assessment of strabismus in

children

• Note that the cause of vision loss in children with some

ocular conditions may be amblyopia e.g., congenital

cataracts

other conditions of children that may affect vision

Non-strabismic binocular vision anomalies

– Convergence insufficiency

– Accommodative insufficiency

• Learning difficulties

– Association with vision?

• Colour vision defects

– Congenital defects - may have an impact on learning

• Developmental defects

– e.g., Down Syndrome, Cerebral Palsy

– Usually associated with significant visual defects

3 main causes of vision changes in children

- Refractive error

- Amblyopia

- Strabismus

What is sometimes not agreed is how/when to

treat the above

• however Ocular disease in children, when it occurs,

should be treated