Vision Screening In Children

     Medicine usually readily accepts and applies new technological advances. There is, however, one area where this hasn’t been the case and that is visual screening in children. Throughout my entire career when doing a physical exam on a child, we tested vision the same way that it had been done for decades – the wall chart (”E” chart for older kids; picture cards for younger kids). We also looked into the eye with an ophthalmoscope to see that the lens was clear and that there was a red reflection off the retina. Finally, those of us who were thorough would cover one eye while watching the other eye to see if it would “wander”. These tests helped us find cataracts, tumors in the eye, decreased vision and strabismus. Any of these can result in amblyopia – poor vision in an eye that affects 2 – 4% of children and is the most common cause of permanent vision loss in one eye in adults. But visual screening in children is difficult and the results are inconsistent, so, it is often passed over in the physical exam. A study done in 1992 found that vision screening was attempted in only 38% of 3 year-old children and 81% of 5 year-old children. 

     Amblyopia needs to be detected early. The earlier it is discovered, the easier it is to treat. If it is not found until after age five, the treatment is much more difficult and much less effective. But, although young children are the ones who need testing the most, younger children are the most difficult to test and the tests are the least reliable.

     This is where technology offers an advantage over the old methods. There are now many different types of machines called photoscreening devices. By rapidly reflecting a light off the child’s eye or by taking a picture of the eye, these devices can measure the risk factors for amblyopia. They operate much faster than eye charts, are more efficient in finding abnormalities that could lead to amblyopia and they are much more accurate in testing vision.  Many insurance companies are now paying for routine photoscreening because they realize the importance of early and accurate eye exams. The American Academy of Pediatrics has also recommended that photoscreening should be used for pediatric eye exams. There are plans for new photoscreening devices that use laser technology and may be even faster and more efficient.

     Every pediatric caregiver who does routine physical exams should be using photoscreening and every parent coming into a caregiver’s office should insist that their child have this screening.  For more information, parents and caregivers can check the Alaska Blind Child Discovery program that was started by Robert Arnold M.D. in the early 1990’s. The website is: www.abcd-vision.org/

    

Weight Lifting For Children

     Children and adolescents are constantly exposed to seeing the “ripped” bodies of their teen and young-adult idols. The push to “pump-up” comes from movies, magazines and even weight-loss “reality” programs. It is reasonable for parents to be concerned about the safety of this behavior.

     At first, it was thought that weight training (“strength training or “resistance training”) was dangerous for younger children because it would damage muscles and bones. Studies in the last 5 years have shown that proper weight–lifting programs do not cause injury and can improve muscle and bone growth and strength. The American Academy of Pediatrics and The National Strength and Conditioning Association both agree that strength training can be a part of a child’s overall sports training program beginning at 7 to 8 years of age. Proper strength training has been found to improve sports performance and even prevent injuries.

     The weight training should be part of a balanced training program geared toward the sport in which the child participates. Many experts recommend that younger children should not specialize in one specific sport but should change sports with seasons, but, with the pressure to succeed that exists today, children are often involved in only one sport from an early age. If weight training is involved, there needs to be proper supervision of the weight training. If not done correctly, the injuries previously mentioned can occur. They can include muscle strains, sprains and even tears of muscles, tendons and ligaments. There can also be fractures, joint dislocation and, with intense weight lifting, spinal injury. Supervision by an adult who is knowledgeable in proper technique of weight lifting is important. The program should include proper warm-up and cool-down exercises, using the proper amount of weight for the child’s age and level of development. Increases in weight load and repetitions should be gradual.  

     When teenage boys work out together without supervision, the testosterone can take over and the resulting competition can easily lead to injury.  Trying to advance too rapidly, lift too much or just “outdo” each other leads to trouble. It is recommended that serious, competitive weight lifting not begin until after puberty and then only with close adult supervision, a safe environment, reasonable goals and gradual advancement.

    

Fever

     Up to 30% of acute-care visits in pediatrics are related to concerns about fever.  It is important that parents know the facts about fever so that they will not be frightened by fever and they can actually learn to use fever to evaluate their child’s illness.   

      Fever is a normal part of the body’s response to infection or inflammation. It has long been known that fever helps the body combat disease (Hippocrates felt that fever helped to bring the body’s humors back into a normal balance).  But, in recent times, fever has been wrongly viewed as being dangerous. Both practitioners and parents often react to fever as if it is a disease itself that needs to be treated.

     Fever in children is usually caused by infection. The body develops fever as one of the immune system’s many ways of fighting infection. Often, fever is the first thing a parent notices when the child is sick – late in the afternoon, the child begins to feel poorly and the parent notices that the child “feels hot”.  Feeling the child is an inaccurate way of telling how high a fever is (101, 102, etc.) but feeling a child is an accurate way of telling whether he has a fever or not.

     Most fevers are caused by simple viral infections such as colds or gastrointestinal infections. These fevers usually start in the early evening, run up and down for three days - always spiking higher at night. After three days, the daytime fever resolves but the night fever remains for another night or two. When the fever is spiking, the child feels poorly and has no appetite but when the fever comes down a little, the child should feel better. During the first three days of illness, when the fever is up and down, it is fine to give acetaminophen or ibuprofen to make the child feel a little better. These medications do not make the fever go away; they do not prevent fever seizures and the child doesn’t become ”immune“ to them. The best way to give acetaminophen or ibuprofen is on a routine schedule through the day being careful to give the proper dosage and to follow the proper dosage interval. Don’t delay giving the medication until the fever is high and the child is miserable – it works better if given at regular intervals.. Parents should not alternate acetaminophen and ibuprofen or give other “cold” medications that may contain acetaminophen or ibuprofen. There is no need to wake a child at night to give fever medication.

     The concern we all have is whether a fever is caused by a simple virus or by a more dangerous infection. With either one, the fever can decrease with fever medication, but, with a less serious infection, the child usually feels better when the fever drops a little. With a more serious infection, the child still feels poorly even after taking fever medication and continues to act more lethargic and ill. That child needs to be examined by his caregiver. Other situations when a child needs to be examined are: when the daytime fever lasts more than three days; when the fever resolves in three days but the daytime fever returns after a few days of being gone; or anytime the parent is becoming concerned that the child is acting more ill.

  

Bedtime And Behavior Problems

     There is nothing more obvious than a tired child. Even in early infancy, a child who is suddenly crabby, rubbing his eyes and who can’t be comforted clearly needs sleep. When this happens, parents can have a little quiet time with the child reading, rocking or singing but when the eyes are drooping shut, it’s time to go into the crib. The crib doesn’t feel like being held in Mom’s arms, so Junior will wake up a little when he is laid down, but that’s when our job as parents is to let him go to sleep – avoid picking him back up or doing anything other than quiet reassurance and steady withdrawal from the room.

     Newborns and infants set their own schedule for everything – eating, sleeping, and playtime. But, by 6 months, it is good for parents to start setting a bedtime and creating a bedtime ritual. This starts with an announcement – “We’ll be going to bed in a little while”- that can be followed with, “Let’s pick up our toys” or “Time for your bath”.  This is accompanied by decreased activity – no roughhousing for younger kids and no video games or violent/scary movies for older kids for at least an hour before bedtime. Then it’s time to put on pajamas, go into the bedroom, read a book and sing a song and then lights out – all at the same time every night.

     There is a fad now that says you can allow your kids to set their own bedtime. This is unfair to both kids and parents. The kids need routines – life is disordered and uncertain enough as it is. And parents need a certain “off duty” period they can count so that they can remember why they became parents in the first place.

     And now there is another reason to set and maintain routine bedtimes. A study of 10,230 children was published in 2013 in the journal Pediatrics. This study looked at the same children at 3, 5 and 7 years of age. The researchers asked the question: Are bedtime schedules associated with behavioral difficulties? They looked at children who had regular set bedtimes and children who had irregular bedtimes. They asked the parents and the children’s teachers to evaluate how much behavioral difficulty the children were having both at home and in school.

     They found that children who had non-regular bedtimes had more behavioral problems at each age studied. Even more importantly, they found that the children with irregular bedtimes had increasingly more behavior problems as they got older – in other words, the longer they had been exposed to irregular bedtimes, the more they developed behavior problems. They also found that when the children changed from irregular bedtimes to regular bedtimes, their behavior improved significantly and children who changed from regular to irregular bedtimes had a worsening of their behavior scores.

     A good night’s sleep is important for a child’s well-being and a good night’s sleep begins with a regular bedtime.