PRACTICAL PEDIATRICS811 Ira E. Woods

Grapevine, Texas 76051817-481-3585

AIR BAG SAFETYAn air bag can save your life. However, air bags and young children do not mix. The following information will help keep you and your children safe.

The safest place for all infants and children under 12 years of age to ride is in the back seat.

*Never put an infant under 1 year of age in the front seat of a car with an air bag.

Infants must always ride in rear facing car seats in the back seat until they are at least 20 pounds and 2 year of age.

All children should be properly secured in a car safety seats, booster seats, or shoulder/lap belts correct for their size.

Seat belts must be worn correctly at all times by all passengers to provide the best protection.

What Parents Can Do Eliminate potential risks of air bags to children by buckling them n the back

seat for every ride. Plan ahead so that you do not have to drive with more children than can be

safely restrained in the backseat. For most families, installation of air bag on/off switches is not necessary. Air

bags that are turned off provide no protection to older children, teens, parents, or other adults riding in the front seat.

Air bag on/off switches should only be used if your child has special care needs, your pediatrician recommends constant observation during travel, and no other adult is available to ride in the back seat with your child.

If no other arrangement is possible and an older child must ride in the front seat, move the vehicle seat back as far as it can go, away from the air bag. Be sure the child is properly buckled. Keep in mind that your child may still be at risk for injuries from the air bag. The back seat is the safest place for children to ride.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

CALCIUMAn important part of your child’s diet at every age

Infancy to 1 year of age:

Calcium is vital during the first years of life for good nutrition and is especially important for proper development of teeth and bones. During the first months of life, your baby’s need for calcium is best met through breast milk or formula. When you’re health care provider recommends adding dairy food in your baby’s diet (usually at 6 months to a year), they can serve as an excellent source of calcium.

Children under 2 years of age should get whole milk and whole milk products, rather than low-fat or skim milk products. During this period, your baby needs the fat and calories of whole milk to satisfy the special nutritional and energy needs of this very important time.

Childhood, 1 – 10 years:

By teaching your children good eating habits now, you can help them enjoy a lifetime of better health. This is especially true when it comes to getting enough calcium. Not only is calcium needed today for growing bones and teeth, but getting enough calcium now and during adolescence may contribute to better health in adulthood. Luckily, making sure children get the Recommended Dietary Allowance (RDA) of calcium is easy. Just 3 servings of dairy foods a day satisfy the calcium needs of children 1 to 10 years of age.

Adolescence, 11 – 18 years:

Your children are growing fast and so is their need for calcium. During this period of rapid growth, children need more calcium than during anytime in their lives; 50% more than 1 – 10 years of age. Why this dramatic increase? During adolescence, 20% of their adult height is achieved with a good proportion added during an 18 – 24 month “growth spurt”. Boys generally start their growth spurt around 12, with peak growth at around 12 years of age. Some children who do not get enough calcium during this period of rapid bone growth may not grow to their expected adult height.

Getting enough calcium during adolescence is also important because this is when almost half of adult bone mass (density) is formed. During this period, calcium is “stored” in the bones. This “bone bank” of stored calcium may help prevent osteoporosis, a crippling disease of later life. So, make sure your children get enough calcium while they are in this building period. Adolescents can get the recommended amount of calcium for their age from 4 servings of dairy foods a day.

Recommended Dietary Allowances (RDA) of CalciumAge Daily Calcium (RDA) Bone Development

Infants:Birth – 6 months

400mgRapid dimensional growth,

calcium added to cartilage-like bones

Calcium content of body increases faster than at

6 months - 1 year 600mg any other stage of life

Children 1 – 10 years 800mg Dimensional growth continues, rate of calcium

retention slows

Adolescents:11 – 18 years

1200 mgDimensional growth

accelerates, growth spurt occurs, 45 % of bone mass is added, bone density and

thickness increase

If diet does not provide enough daily calcium needed, Tums or Children’s Mylanta, which contain calcium, may be used to supplement diet

Product Name Amt of Calcium per tab Tums (regular) 200 mg Tums E-X 300 mg Tums Ultra 400 mg Children’s Mylanta Tablets 160 mg Children’s Mylanta Liquid 160 mg /tsp Viactiv Chocolate Chews 500 mg L’il Critters Gummy Calcium 200 mg Flintstones Chocolate Chew 500 mg

The Best Sources of Calcium in the 5 Food GroupsMilk Group Portion Mg of Calcium

Yogurt, plain (low fat) 1 cup 415

Yogurt, fruit flavored (low fat)

1 cup 345

Cheese, parmesan (grated) ¼ cup 338

Cheese, ricotta (part skim) ½ cup 337

Milk, skim 1 cup 302

Milk, 1% - 2% 1 cup 300

Milk, whole 1 cup 291

Buttermilk 1 cup 285

Milk, chocolate (low fat) 1 cup 284

Milk, nonfat (dry, instant) 1/3 cup 280

Cheese, Swiss 1 oz 272

Cheese, Monterey Jack 1 oz 212

Cheese, mozzarella(low moisture, part skim)

1 oz 207

Cheese, cheddar 1 oz 204

Cheese, American 1 oz 174

Cheese, cream (nonfat) 1 oz 100

Ice Cream ½ cup 88

Cottage cheese, creamed ½ cup 63

Fruit Group Portion

Mg of Calcium

Orange 1 med 60

Dates, chopped ¼ cup 26

Raisins ¼ cup 22

Orange juice (calcium fortified)

1 cup 300

Vegetable Group Portion

Mg of Calcium

Turnip green, cooked

½ cup 98

Bok choy, cooked ½ cup 79

Kale, cooked ½ cup 47

Broccoli, cooked ½ cup 36

Carrot, raw 1 med 27

Meat Group Portion Mg of Calcium

Sardines (canned, w/bones) 3 oz 372

Salmon, pink 3 oz 165

Tofu (processed w/calcium 4 oz 145

Almonds, shelled 1 oz 66

Soybeans, cooked ½ cup 66

Dried beans, cooked(lima, navy, kidney)

½ cup 35 – 48

Egg 1 large 27

Peanut Butter 2 tbsp 18

Grain Group Portion

Mg of Calcium

Farina, enriched (instant, cooked)

1 cup 189

Tortilla, corn 1 med 60

Bread, whole wheat 1 slice 25

Some foods are fortified with calcium.Check the label for amount.

Adapted from Nutrition Education Services, Oregon Dairy Council

1/04/10Fun in the Sun:

Keep Your Baby Safe!

Warm, sunny days are wonderful.  The sun feels good on your skin.  But what feels good can be very bad for you, your family, and especially your baby.  Before you take your baby to the park, beach, or even out into the backyard please read this.  It will help you learn how to protect your entire family and develop safe sun habits that can last a lifetime.

Skin cancer and the sunThe sun provides energy to all living things on earth.  But it can also harm us.  Its ultraviolet (UV) rays can cause sunburn and skin cancer.  The sun is the main cause of skin cancer, the most common form of cancer in the United States.  There will be a million new cases of skin cancer this year.  Skin cancer can and does occur in children and young adults, but most of the people who get skin cancer are older.  Older people get skin cancer because they have already received too much of the sun's damaging rays.  Your skin remembers each sunburn and each suntan year after year.

The sun and your baby's skinYour baby's skin is very delicate and it's up to you to protect it.  Sunburns hurt. Sunburns can also cause dehydration and fever.  Too many sunburns and too much sun exposure over the years can cause not only skin cancer, but also wrinkles and cataracts of the eyes. Most of our sun exposure---between 60% and 80% ---- happens before we turn 18 years of age.  That's because children spend more time outdoors than most adults, especially in the summer.

The dangers of sunburnsResearch has shown that two or more blisters sunburns as a child or teen increases the risk of developing skin cancer later in life.  It is very important, therefore, to protect babies and children from sunburn.

A baby's sensitive skin is thinner than adult skin and a baby will sunburn more easily than an adult.  Even babies with naturally darker skin need protection.

It's up to you to protect your baby.  A baby can't tell you when he/she is too hot or beginning to sunburn.  Your baby can't move out of the sun and into the shade without your help.

Protecting your babyFollow these simple rules to protect your baby from sunburns now and from skin cancer later in life: *Babies under 6 months of age should be kept out of direct sunlight.  Move your baby to the shade or under a tree, umbrella, or the stroller canopy*Dress your baby in clothing that covers the body, such as comfortable lightweight long pants, long-sleeved shirts, and hats with brims that shade the face and cover the ears.*Select clothes make of tightly woven fabrics.  Clothes that have a tighter weave---the way a fabric is constructed---generally protect better than clothes with a broader weave.  If you're not sure about how tight a fabric's weave is, hold the clothing up to a lamp or window and see how much light shines through.  The less light the better.  Clothing made of cotton is both cool and protective.*When using a cap with a bill, make sure the bill is facing forward to shield the baby's face.  Child-sized sunglasses with UV protection are also good ideas for protecting your child's eyes.

Remember...............*The sun's rays are the strongest between 10:00 a.m. and 4:00 p.m.  Try to keep your baby out of the sun during these hours.*The sun's damaging UV rays can bounce back from sand, snow, or concrete; so be particularly careful in these areas.*Most of the sun's rays can come through the clouds on an overcast day; so use sun protection even on cloudy days

Sunscreen for your baby Choose a sunscreen made for children.  For babies under 6 months of age sunscreen may be used on small areas of the body such as the face the backs of hands if adequate clothing and shade are not available.  For babies over 6 months of age, test the sunscreen on your baby's back for a reaction before applying it all over.  Apply carefully around the eyes, avoiding the eyelids.  If your baby rubs sunscreen irritates her eyes, try a different brand or try a sunscreen stick or sun block with titanium dioxide or zinc oxide.  If a rash develops, talk to your pediatrician.

When choosing a sunscreen, look for the words "broad-spectrum" on the label ----- it means that the sunscreen will screen out both ultraviolet B (UVB) and ultraviolet A (UVA) rays.  A sunscreen with a sun protection factor (SPF) of 15 should be adequate in most cases.Use enough sunscreen and rub it in well, making sure to cover all exposed areas, especially your baby's face, nose, ears, feet, and hands and even the back of the knees.  Put it on 30 minutes before going outdoors.  The sunscreen needs time to work on the skin.   Reapply the sunscreen frequently, especially if your baby in the water. Zinc oxide, a very effective sun block, can be used as extra protection on the nose, cheeks, tops of the ears, and the shoulders.

Remember...........Sunscreens should be used for sun protection and not as a reason to stay in the sun longer.

Sunburn can be dangerousIf your baby gets sunburn and is under 1 year of age, contact your pediatrician at once ---- severe sunburn is an emergency.  For babies over the age of 1 year, tell your pediatrician if there is blistering, pain, or fever.

Remember............

*Avoid sunburns ---- they can be very dangerous to a baby.*If your baby gets sunburn, give juice or water to your baby to replace lost fluids.*Cool water soaks may help your baby's skin feel better.*Do not use any medicated lotions on your baby's skin unless your pediatrician recommends it.*Keep your baby completely out of the sun until the sunburn is totally healed.

Set a good exampleMake sun protection a regular family event. Your baby needs you for protection from the sun and form sunburns. Since babies learn by imitation, you can be the best teacher by practicing sun protection yourself. Teach all members of your family how to protect their skin. Sun MythsMyth: A suntan is good for your baby.Fact: A tan is a sign of skin damage.

Myth: Babies can't get sunburned on a cloudy day.Fact: Most of the sun's rays can come through clouds and cause sunburns. Myth: Baby oil is good sun lotion.Fact: Baby oil causes the skin to burn faster and offers no protection at all.

Myth: Your baby needs the vitamins that the sun provides.Fact: A proper well-balanced diet and minimum sunlight will give your baby all the necessary vitamins.

* This information is not a substitute for professional medical care.  Diagnosis and treatment should be done only by your health care provider. For more information contact your local health department or physician

SLEEP PROBLEMS IN CHILDREN

Common Sleep ProblemsFor a young child, many things can interrupt a good night’s sleep. As a parent you may be able to prevent some of them.

NightmaresNightmares are scary dreams that usually happen during the second half of the night, when dreaming is most intense. This may occur more than once a night. After the nightmare is over, your child may wake up and can tell you what occurred. Children may be crying or fearful after a night mare but will be aware of your presence. They may have trouble falling back to sleep because they can remember the details of the dream.

How to handle nightmares:*Go to the child as quickly as possible.*Assure her/him that you are there and will not let anything harm her/him. Allow the child to have the bedroom light on for a short period to reassure her/him.*If your child is fearful, comfort and calm her/him.*Keep in mind that a nightmare is real to a young child. Listen to her and encourage her to tell you what happened in the dream.*Once the child is calm, encourage her to go back to sleep.

Night TerrorsNight terrors are more sever or frightening than nightmares, but not as common. They occur most often in toddlers and preschoolers. Night terrors come of the deepest stages of sleep, usually within an hour or so after a child falls asleep. During a night terror, children usually cannot be awakened or comforted. Night terrors may also cause the following:*Uncontrollable crying*Sweating, shaking, and fast breathing*A terrified, confused, and glassy-eyed appearance*Thrashing around, screaming, kicking or staring*Child may not realize anyone is with her/him*Child may not appear to recognize you*Child may try to push you away, especially when you try to restrain her/him

Night terrors may last as long as 45 minutes, but are usually much shorter. Children seem to fall right back to sleep after a night terror, but they actually have not been awake. Like nightmares, night terrors may occur more often in times of stress or may relate to difficult feelings of ears. However, unlike a nightmare a child will not remember a night terror.

How to handle night terrors:*Remain calm, night terrors are usually more frightening for the parent than for the child.*Do not try to wake your child.*Make sure the child does not injure herself/himself. If the child tries to get out of bed, gently restrain her/him.*Remember, after a short time, your child will probably relax and sleep quietly again.*If your child has night terrors, be sure to explain to your baby-sitters what they are and what to do.

Keep in mind that night terrors do not always indicate serious problems. Your child will be more likely to have night terrors when he is overly tired and during periods of stress. Your child can become overly tired when he gives up a daytime nap, wakes up too early, or this nighttime sleep is interrupted. Try to keep your child on a regular sleep schedule or increase the amount of sleep she/he gets to prevent night terrors. Night terrors usually disappear by the time a child reaches grade school. If they do persist, talk to your pediatrician.

Sleepwalking and sleep talkingLike night terrors, sleepwalking and sleep talking happen when a child is in deep sleep. While sleepwalking, your child may have a blank, staring face. She may not respond to others and be very difficult to awaken. When your child does wake up, she will probably not remember the episode. Sleepwalking children will often return to bed by themselves, and will not even remember that they have gotten out of bed. Sleepwalking can be common, and tends to run in families. It can even occur several times in one night among older children and teenagers. If you have concerns or the condition persists, talk to your child’s pediatrician.

How to handle sleepwalking and sleep talking:*make sure your child doesn’t hurt herself/himself while sleepwalking. Clear the bedroom area of potential hazards that you child could trip over or fall on.*Lock outside doors so you child cannot leave the house.*Block stairways so your child cannot go up or down.*There is no need to try to wake your child when she/he is sleepwalking or sleep talking. Gently lead her/him back to bed and she/he will probably settle down on her/his own.

Sleepwalking and sleep talking are more likely to occur when your child is overly tired or under stress. Keeping your child’s sleep schedule regular may help prevent sleepwalking and sleep talking.

Bed-Wetting (also called enuresis)Nighttime bed-wetting is normal and very common among preschoolers. It affects about 40% or 3 year olds and may run in families. The most common reasons your child may wet the bed include the following:*A bladder that has not yet developed enough to hold urine for a full night.*Your child may not yet be able to recognize a full bladder and wake up to us the toilet.*Stress. Changes in the home, such as a new baby, moving or a divorce can lead to a sudden case of bed-wetting for a child who has been dry at night in the past.

How to handle bed-wetting:*Do not blame or punish the child for bed-wetting.*Have your child use the toilet and avoid drinking large amounts of fluid just before bedtime.*Until your child can stay dry during the night, put a rubber or plastic cover over the mattress to protect against wetness and odors. Keep the bedding clean.*I your child is old enough, involve her/him in handling the problem. Encourage him to help change the wet sheets and covers. This will help teach responsibility and avoid the embarrassment of having other family members know about the problem every time it happens. Do not, however, use this as punishment for the child.*Talk to your pediatrician about other approaches to bed-wetting, such as rewards for younger children or alarm devices for the older children.

Most importantly, don’t pressure your child. Bed-wetting is beyond a child’s control and he may only become sad or frustrated if he cannot stop. Set a “no-teasing” rule in the family. Make sure your child understands that bed-wetting is not his fault and it will get better in time.

Teeth GrindingIt is also common for children to grind their teeth during the night. Though it produces and unpleasant sound, it is usually not harmful to your young child’s teeth. It may be related to tension and anxiety and usually disappears in a short while. However, it may reappear with the next stressful episode.

Give it TimeHandling your child’s sleep problems may be a challenge and it is normal to become upset at times when a child keeps you awake at night. Try to be understanding. A negative response by a parent can sometimes make a sleep problem worse, especially f it is associated with a stressful situation like divorce, a new sibling, a tragedy in the family, problems at school, or some other recent change in your child’s life.

If the problem persists, there may be a physical or emotional reason that your child cannot sleep. If you fell you need additional help, start a sleep diary and discuss the problem with your pediatrician. Keep in mind that most sleep problems are very common, and with time and your pediatrician’s help, you and your child will overcome them.

Keeping a Sleep DiaryIt may be helpful for you in preparation for discussing a sleep problem with your pediatrician to keep a sleep diary for your child. Chart the following:*Where your child sleeps*How much sleep she normally gets at night*What time she was put to bed*What the child needs to fall asleep (favorite toy, blanket, etc.)*The time it takes for her/him to fall asleep* The time that you went to bed* The time awakened during the night*How long it took to fall back to sleep*What you did to comfort and console the child

*The time the child woke up in the morning*The time and length of naps* Any changes or stresses in the home.

Keep in mind that every child is different and no two children may have the same sleep patterns or problems.

YOUR GROWING CHILDFrom 9 to 12 Months

Your baby is moving around now and the pace of life has quickened somewhat.  This may suit you if you found the tiny baby stage restrictive.  He/she will be 'talking' and making recognizable sounds, and he/she will really love you talking to him/her and repeating single words clearly.

He/she may be clingy and wary of strangers but he/she is forming special relationships with family members and his/her personality will be becoming clear to you.Social and emotional developmentIt is usually in these three months that your baby begins to understand his very special relationship with you, and with friends and relatives. He/she starts to know that when you go away, you will come back again, and that you are still there even when he cannot see you. No wonder 'peek-a-boo' and 'hiding' are favorite games because they play out in a simple way the comings and goings of people that your baby has come to recognize and depend upon. He/she also has some understanding that you see him and that he can hide from you, although he/she still thinks that if he/she can't see you, you can't see him. He/she starts to understand that he/she is a person, and he/she can recognize himself in the mirror.

He/she will have developed some definite ideas about what he/she likes and does not like. He/she may kick and resist nappy change time or other restrictions on his freedom.He/she will smile and babble and try to engage you in a conversation and copy simple hand games like 'clap hands' or 'bye bye'. In other words he/she is becoming aware of himself as a social creature. He/she understands the meaning of "no", although he/she is going to spend the next eighteen months checking its meaning exactly!The down side of all this is that he/she is frightened when you leave him and will cling and cry, and [very sensibly] be wary of strangers.Moving around

The big breakthrough in motor development is that he/she will move all on his/her own. He/she might pull himself/herself along with his/her arms, roll around or crawl on all fours. During this time he/she will start to pull himself/herself to standing and support his/her weight while holding on to you or to furniture. Some babies will start to walk by themselves during these months, although many won't walk for a few months yet.

It's a big thing to see your baby 'standing on his/her own two feet', probably holding on and not walking quite yet, but vertical nevertheless. If you have loved the tiny baby stage you may have some sadness when your baby starts to look like a child or else you may be relieved to see the promise of some independence to come.

Safety is a big issue when babies start to move around by themselves. You need to baby-proof your house and make sure all poisons and dangerous items are locked away up high. Put things that he/she might break well out of reach too. He/she can't stop himself/herself from touching anything that looks interesting. His/her fine motor skills are improving quickly too. He/she can pick up an object with his/her thumb and fingers rather than grabbing with the palm of his/her hand. He/she pokes and points with his/her finger and transfers objects from one hand to another. He/she cannot however control putting things down and he/she has to drop to release objects from her grasp. He/she will still put anything he/she holds into his/her mouth and now that he/she can pick up small things this can be a risk time for swallowing dangerous objects or choking. He/she will be able to sit on his/her own for quite long times and will enjoy exploring objects and the sounds he/she can make with them while sitting on the floor.

He/she will be feeding himself/herself in her high chair although he/she may often be more interested in squishing and feeling than the actual eating bit. He/she is also able to drink out of a cup with a spout without help.TalkingHe/she has got the idea of conversations now and even though he/she may not have any recognizable words he/she will 'chat' away with the right inflexion in his/her voice. He/she may be saying simple sounds like 'mumum' and 'daddad'. He/she recognizes several words and may shake his/her head for "no''.

He/she is not making the huge variety of sounds that he/she was in earlier months because his/her sounds are more specific to his/her native language. He/she begins to drop [for instance] those European sounds deep in the back of his throat for more English, front of mouth sounds, (if English is his native tongue).

He/she begins to love music and rhymes and he/she will bounce and sway to the rhythm and he/she will love the repetition of songs that help him to learn that language in itself is a musical thing. Babies can be very interested in books now.Activities for the 9-12 months oldMake a kitchen cupboard of his/her own to open and shut the door Give hi m/her pots and spoons to bang. Sing songs and repeat phrases. Bounce him/her and sing. Look at simple books with clear pictures in them. Play 'hiding' behind the couch or curtains. Talk to him/her a lot. Sit him/her on the floor with his/her toys. Encourage him/her to push a trolley with bricks in it. Cuddle and roll on the floor.Children of this age still like being with people best of all, but they are starting to have some interest in toys that do something, like move or make a noise.What to watch out forSeek help from your health professional if your baby by 12 months is not:Pulling himself/herself up to stand Moving around somehow Changing objects from one hand to another Looking up when you call his name Copying simple sounds like "mummum" Showing signs of being especially attached to his parent Smiling, laughing and trying to attract your attentionSummary Social emotional A baby usually:Is well aware of strangers and familiar people and withdraws from strangers May not even go to familiar people for a while - demanding the person who looks after him/her most Gives cuddles by 10 months Enjoys peek-a-boo games

There may be a problem if a baby:Does not show pleasure when he/she sees familiar people Does not show anxiety when separated from his/her main caregiverMotor skills A baby usually:Can move around by crawling or bottom shuffling by 10 months Can lean over while sitting without falling over Can pull up to standing by 10 to 11 months Walks with hands held by 10 to 12 months

There may be a problem if a baby:Is not sitting by 9-10 months Is not starting to move around by any meansUnderstanding A baby usually:Is interested in small objects and reaches out for them Starts to look at and feel objects before taking them to his mouth Looks in the correct direction for things that have fallen downThere may be a problem if a baby:Is not interested in new objectsSpeech and language A baby usually:

Is putting strings of babble sounds together Shakes head for 'no' by about 10 months Recognizes several words including own name (eg looks for daddy if 'daddy' is said) Imitates sounds made by other people

There may be a problem if:Babbling has not become more complex and baby does not babble in 'conversation' with others.

YOUR CHILD’S EYESThis handout describes the normal function and development of an infant’s eye and vision. It gives an overview of warning signs and other problems that should be evaluated by your pediatrician or ophthalmologist. Regular eye exams at proper age intervals are the key to maintaining your child’s healthy vision. The earlier the visual problems are detected, the better the outcome.Visual DevelopmentAt birth, babies have not yet attained normal adult vision, but they can see. Newborns can make out large shapes and faces but are unable to distinguish fine details. Faces have strong visual appeal. Because the visual system is immature, your baby probably cannot distinguish between pastel colors or subtle variations in shading, but can see bright, strong colors in contrasting patterns of light and dark.

Your baby’s visual development is very dramatic during the first year of life. Vision usually develops rapidly so that by the age of 3 to 4 months, most infants can see small objects. Some babies can distinguish between various colors (especially red and green) by this time.

They can focus clearly on close and distant objects and can distinguish a real human face from one that is drawn.

By 4 months, the baby’s eyes should be well aligned (work together) to give the perception of depth or binocular vision. By 12 months, a child’s vision reaches normal adult levels. Vision does not develop exactly on the same schedule in all infants, but the overall pattern of development is the same. Because visual development is so rapid during the first year, early detection of visual problems is critical so that permanent visual impairment does not occur.Warning Signs that may Indicate a Problem (Infants up to 1 year of age)If your baby can’t make steady eye contact by 2 or 3 months of age, or seems unable to see, you should consult your pediatrician. A constant crossing of the eyes or one eye that turns out is usually abnormal; however, most babies do occasionally cross their eyes during their first 6 months of life. Babies older than 3 months of age can usually follow or “track” an object with their eyes as it moves across their field of vision. You can test this by holding a colored object, like a toy or a ball, in front of your baby until he or she can see it. Then, slowly move the object and watch as you baby’s eyes follow. Be careful to avoid clues aided by voices or other sounds.Warning Signs for your Preschool Child

The presence of any of the following requires immediate consultation with your pediatrician or ophthalmologist. If the eyes become misaligned (strabismus) the child should be evaluated immediately. This may be a situation that is easily corrected with glasses or it may represent a more serious eye disorder. The presence of a white pupil suggests a number of eye disorders ranging from a cataract to a tumor of the eye. Immediate evaluation is indicated. The sudden development of pain and redness in one eye or both eyes can represent a number of different conditions ranging from simple pink eye to blinding eye problems. If this occurs, a simple visit to your pediatrician will generally result in the correct diagnosis and proper treatment.Warning Signs at Any AgeNo matter how old your child is, if you spot any one of the following, consult your pediatrician:

Your child’s eyes flutter quickly from side to side or up and down (nystagmus). The eyes are always watery. The eyes are always sensitive to light. Any change in the eyes from their usual appearance. You see white, grayish-white, or yellow colored material in the pupil. There is redness in either eye that doesn’t go away in several days. There is continued pus or crust in either eye. The eyes look crossed, turn out, or don’t focus together (strabismus). Your child often rubs the eye(s). Your child often squints. Your child often tilts (or turns) his/her head. The eyelid(s) appear to droop. The eye(s) appears to bulge.

Vision Screening InformationVision screening is a very important factor in identifying vision threatening conditions. The American Academy of Ophthalmology and the American Academy of Pediatrics recommend that children be screened in four stages:

1. In the newborn nursery: Pediatricians and ophthalmic practitioners should examine all infants prior to their discharge from the nursery to check for infections and structural defects, cataracts, or glaucoma. All children with multiple medical problems or with a history of prematurity and/or oxygen exposure should be examined by an ophthalmologist.

2. By the age of 6 months: Pediatricians should screen infants at the time of their well baby visits to check for alignment (eyes working together).

3. At the age of 3 to 4 years: all children should be examined by a pediatrician. At this age, the visual acuity is checked and the eyes are examined for any other abnormality that may cause a problem with the child’s educational development. Any abnormality requires referral to an ophthalmologist.

4. At the age of 5 years and older: Pediatricians should screen children annually if this is not provided by school personnel or volunteer organizations. Visual acuity is tested as well as evaluation of other ocular functions.

Specific Problems that Require Further Evaluation Falsely Misaligned Eyes (pseudostrabismus) - Sometimes infants appear to have crossed

eyes, yet the eyes are truly straight. The cause for pseudostrabismus is presence of a wide nasal bridge or extra folds of skin between the nose and the inside of the eye that make the child have a cross-eyed appearance. Most children outgrow this problem, but you should contact your doctor for an examination. Your pediatrician can tell whether a child has misaligned eyes or just pseudostrabismus, but in some instances, a visit to an ophthalmologist is necessary for further tests.

Misaligned Eyes (strabismus) – With strabismus, the eyes are not aligned. Strabismus is quite common and occurs in about 4% of children. One eye may gaze straight ahead while the other eye turns inward, upward, downward, or outward. When an eye turns inward, the

child has “crossed” eyes (esotropia). There are two common causes for esotropia. Some children are born with crossed (or develop it shortly after birth), and in this situation the muscles are too tight. Treatment for this most commonly involves surgery on the eye muscles, generally performed prior to the age of 2.

The second most common cause for esotropia is excessive farsightedness. This problem can be present at birth, but most commonly occurs between the age of 2 and 6 years. This type of esotropia is corrected with glasses.

When an eye turns outward, the child has exotropia. Exotropia may be present from birth, but most commonly is seen in children2 to 7 years of age. Generally the eyes turn out on rare occasions at first but with time more frequent outward turning of the eyes is noted. Children with exotropia occasionally squint one eye when exposed to bright sunlight. The treatment for large amounts of exotropia is usually eye muscle surgery.

Children with misaligned eyes will generally turn off the vision in the turned eye so that they are not plagued with double vision. Children with strabismus should have a careful examination by an ophthalmologist because untreated strabismus may lead to a lazy eye (amblyopia) or loss of depth perception. Rarely, strabismus may indicate a more serious condition such as cataract or eye tumor (retinoblastoma).

Lazy Eye (amblyopia) – Lazy eye is reduced vision from lack of use in an otherwise normal eye. It usually happens only in one eye. Any condition that prevents a clear image can interfere with the development of vision and result in amblyopia.

Amblyopia is common, affecting about 2% of children. Some causes of amblyopia include strabismus, droopy eyelids (ptosis), cataracts, or refractive errors. Because early treatment offers the best results, your pediatrician will refer you to an ophthalmologist.

Cataract (cloudy lens) - A cataract is a clouding of the eye’s normally clear lens. The lens is located behind the pupil and helps focus images on the back of the eye (retina). Cataracts may be present at birth or may appear later in life. Injury may also cause this condition. Early detection and treatment are crucial in infants and children so that normal visual development can occur. For this reason, most cataracts should be surgically removed soon after they are discovered. It should be noted that cataracts in infants and children are uncommon and not related to cataracts that occur in adults.

Glaucoma (elevated eye pressure) – Glaucoma is a condition in which the pressure inside the eye is too high. If left untreated, glaucoma will eventually lead to total blindness. Warning symptoms are extreme sensitivity to light, tearing, and persistent pain. Signs include an enlarged eye, cloudy cornea, and lid spasm. If any of these are present, your pediatrician will refer you to an ophthalmologist immediately. Glaucoma in childhood usually requires surgery to prevent blindness.

Tearing – The tear duct system, which allows the tears to drain from the eyes into the nose, usually opens in the first few months of life. In some infants however, the system remains blocked, resulting in the eyes overflowing with tears and collecting mucus. Tearing may result from other ocular conditions, the most serious of which is glaucoma. If you child suffers from continued tearing or watering from the eyes, please consult your pediatrician. Gentle massage of the tear duct can occasionally assist in relieving the blockage. If massage and observation are unsuccessful, a tear duct probe or more involved surgery is occasionally required.

Ptosis (droopy eyelids) - Ptosis refers to a situation in which the eyelids are not as open as they should be. This situation is caused by a weakness of a muscle that opens the upper eyelid. When ptosis is mild, it is just a cosmetic problem. However, ptosis can interfere with

vision if it is severe enough to block the vision in the eye. In infancy, it is important that ptosis be eliminated so that vision will develop normally. Correction of ptosis usually requires surgery on the eyelid(s).

Blepharitis (swollen eyelids) – Blepharitis refers to an inflammation in the oily glands of the eyelid. This usually results in swollen eyelids and excessive crusting of the eyelashes, most evident in the morning. Tenderness of the eyelids and a foreign body sensation in the eye may occur as well. Blepharitis can be treated with warm compresses and eyelid scrubs using baby shampoo. If an infection is present, antibiotics may be necessary. If any of these findings are present, please consult your pediatrician.

“Pink Eye” (conjunctivitis) – Pink eye appears as a reddening of the white part of the eye. It is usually associated with excessive tearing, a discharge, and a foreign body sensation in the eyes. Conjunctivitis has many causes and can occur at any age. In infants and children, pink eye is usually caused by a viral or bacterial infection. In older children, it may also be caused by allergy. Depending on the cause of conjunctivitis, eye drops or ointment may be indicated. If you child has conjunctivitis, regular hand washing will help prevent the spread of the infection to other family members. If conjunctivitis occurs, call your pediatrician’s office.

Corneal Abrasion (scratched cornea) – A corneal abrasion refers to a scratch of the front clear surface of the eye (cornea). These abrasions are very painful and usually associated with light sensitivity and tearing. Treatment consists of antibiotics to prevent infection and a patch to allow for the healing of the scrape. This may be monitored by your pediatrician although more serious injuries often need follow up by an ophthalmologist.

Nearsightedness (myopia) - Children who are “nearsighted” see objects that are close to them clearly, but objects that are far away are unclear. Nearsightedness is very rare in infants and toddlers, but becomes more common in school-aged children. Eyeglasses will help clear the vision but will not “cure” the problem. Despite using glasses, nearsightedness will generally increase in amount until the mid-teenage years so that periodic follow up examinations by an ophthalmologist are indicated.

Farsightedness (hyperopia) – A small degree of farsightedness is normal in infants and children. It does not interfere with vision and requires no correction. It is only when the farsightedness becomes excessive, or causes the eyes to cross, that glasses are required.

Astigmatism - Astigmatism is the result of an eye that has an irregular corneal shape. Astigmatism may result in blurred vision. Children with astigmatism may need lasses if the amount of astigmatism is large.

Learning DisabilitiesLearning disabilities are quite common in childhood years and have many causes. The eyes are often suspected but are almost never the cause of learning problems. Your pediatrician may refer you for an evaluation by an educational specialist to pinpoint the exact cause.When Should your Child’s Eyes be Checked?Pediatricians check the eyes shortly after birth as part of the newborn examination. Your baby’s eyes also will be examined later during health supervision visits. The doctor looks for eye disease and checks to see if the eyes are functioning properly. Children with a family history of serious vision problems are more likely to have eye problems.

Fortunately, most babies have normal, healthy eyes. When problems occur, early detection and treatment make it more likely that the child’s vision will develop normally. If your pediatrician detects problems, he/she may refer your child to an ophthalmologist for further evaluation and care.

Vision care is an important part of preventive health care for children. The American Academy of Pediatrics is dedicated to working for a better future for your children. Join us by making sure your children receive regular eye examinations.GlossaryAmblyopia - reduced vision in an otherwise normal eye; causes include strabismus, droopy eyelids, cataract, and refractive errors

Astigmatism – an irregular or uneven corneal curvature that causes distortion or blurring of vision for objects at any distance

Blepharitis – swelling of the eyelids caused by an inflammation of the oily glands of the eyelids

Cataract – clouding of the normally clear lens within the eye that may cause reduced vision

Choroid – pigmented vascular layer between the retina and sclera

Ciliary Body – the structure that focuses the lens and produces the fluid inside the front of the eye

Conjunctiva - a thin, transparent tissue with tiny blood vessels covering the white portion of the eye or sclera; when an eye is irritated, the vessels in the conjunctiva can swell and cause the eye to appear bloodshot or pink

Conjunctivitis – redness of the conjunctiva; usually associated with excessive tearing, discharge, and foreign body sensation in the eye.

Cornea – crystal clear membrane which is in front of the colored part (iris) of the eye

Corneal Abrasion – a scratch of the front surface of the eye that may cause pain, light sensitivity, and tearing

Esotropia – inward crossing of the eyes

Exotropia – outward turning or misalignment of the eyes

Glaucoma – elevation of the pressure within the eye that may cause damage to the optic nerve and loss of vision

Hyperopia – the medical term for farsightedness; the eyeball is usually shorter than normal, which may make it difficult for the child to focus on objects that are nearby

Iris – the colored part of the eye that opens and closes the pupil, regulating the amount of light entering the eye Learning Disabilities – a number of conditions that include dyslexia, problems understanding math, spelling difficulties, and reading disabilities; not caused by the eyes but by the brain’s inability to quickly interpret images seen by the eyes

Lens – the powerful focusing portion of the eye that acts like the lens in a camera

Myopia – the medical term for nearsightedness; the eyeball is usually longer than normal, which may make it difficult for the child to clearly see objects far away

Optic Nerve – a bundle of nerve fibers that is similar to a telephone cable that is made up of many wires; the optic nerve carries the many nerves of sight from the retina to the brain

Pseudostrabismus (false strabismus) – the false appearance of eyes crossing caused by widening of the nasal bridge and extra folds of skin between the nose and the eye

Ptosis – droopiness of the lid or lids, usually present from birth, which is related to a weakness in the muscle that raises the eyelid

Pupil – black appearing circle in the center of the iris; changes in size control the amount of light that reaches the retina

Retina - back portion of the eye that registers visual images for transmission to the brain

Sclera – the white portion of the eye, a thick outer coating of the eye

Strabismus – a condition in which the eyes are not aligned; one eye will appear straight while the other eye turns inward, outward, upward, or downward

Vitreous – the clear jelly that fills the back of the eye behind the lensThe information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.