Health Awareness blog

Squint is common in early childhood. Up to 1 in every 15 children found to have squints when they start schooling. In special population like child with brain damage or learning disability, the incidence of squint is even higher.

All fixed squints and any squint that persists after 5-6 months of age require careful evaluation. Most cases of squint in children are non paralytic. There is normal range of external ocular movements. In this type of squint, the angle of squint between bilateral eyes is constant in every directions of gaze. Paralytic squint is cause by paralysis of one of the ocular muscle. This is rare in children. Most cases occur due to failure of development of binocular coordination of unknown etiology. However, some may be caused by cataract, glaucoma, retinal disease or retinoblastoma. Latent squint is difficult to diagnose. In this case, there is imbalance of extra ocular muscle. However, the eyes do not deviate the entire time make it not visible on inspection. Decrease visual acuity of one eye may lead to latent squint. It means that the visual acuity or the eyesight should be tested in all children with squint.

Classification of squint:

The diagnosis is mainly made from clinical examination. Symmetrical corneal reflection or occlusion testing may assist diagnosis in less obvious cases. Epichontic folds, low nasal bridge and hypertelorism (wide-spaced eyes) such in the Down Syndrome children may give rise to false appearance of squint.  This is called pseudo-squint which is not significant

Early recognition and management of squint ensure better prognosis. If not detected early, it will lead to suppression of vision from the squinting eye in order to prevent blurry of vision or double vision. When unused, this deviated eye may end up with amblyopia or diminished acuity of the central vision. The lesion may be permanent and lead to condition of “lazy eye”. The child will have problem in later life. If left alone without treatment, the vision in the squinting eye may be lost permanently, denying the child binocular vision for life. Early treatment before the school age may prevent this problem.

Refractive errors are very common in children with squint. Correction of refractive error and occlusion of the non squinting eye are mandatory. Many cases can be cured with early use of spectacles. Rarely, occlusion of the non squinting eye is done. The occlusion of the eye means to force the child to use the squint eye. This treatment may be need for several months and is unpopular among children. Surgery is sometimes indicated in selected cases.

Reference:

1. Simon J Newell et al. Lecture Notes Paediatrics. 8^th edition. 2008. Blackwell Publishing.
2. Paediatrics Colour handbook. 1999. Mosby Elsevier.

Child development means progressive, orderly, acquisition of skills and abilities of a child as he/she grows. This developmental activity is influence by a lot of things including genetic, neurological, physical, environmental and emotional factors. Developmental assessment is very important for a child especially from the day he/she was born until 5 years old. If there is any sign of developmental delay, prompt management should be sought. Observe your child at home, if there is anything that worries you, do not hesitate to ask your physician opinion about it.

During developmental assessment, it is important to make sure that the child is cooperates, not fretful, too tired or hungry. He/she should be in a good health. This simple measure may look simple but it can affect their assessment tremendously. If the child is a premature baby, full allowance should be given till he/she is up to 2 years old. The parents are almost always right that is why their opinion is important. If the parents claim that the child has squint, there is high possibility that the child has squint.

Normal developmental progress is highly dependent on the integrity of child’s hearing and vision. That is one big reason why hearing and vision assessment has become 2 important aspects in assessing a child. This means that a normal pattern of speech and language development is essential for a normal social, intellectual and emotional development. Important to note that if the child has advanced motor development, it does not mean that he/she has mental superiority like some people think might be possible. However, manipulative skills can be used and can be a more reliable guide. Assessment of social, gross and fine motor skills are also important.

Developmental retardation may be global and affect all areas equally. Sometimes it can be normal except in one specific area for example in speech. If this occurs, deafness should be excluded. In global retardation, hypothyroidism should be ruled out in all cases. Below is a list of warning signs of the developmental progress. It can be used as a guide when to refer to pediatrician or when to take actions about the developmental delay.

General warning signs

• The head size is out of proportion with length or crossing the centile lines (in other words, it is either too large or too small).
• The child has abnormal rates of growth in weight and height.
• There is obvious congenital abnormalities, odd facies, symmetrical defects of hands and feet.
• The baby has unusual hairs or hairline.
• Persistence of primitive reflexes after 6 months of age (e.g.: Moro’s reflex; glabellar tap).
• The baby has fisting or adducted thumb after the second month of age.

Warning signs for gross motor

• The baby do not role over by 5 months old
• The baby do not sit unsupported by 8 months old
• The baby do not stand while holding up by 10 months old
• The infant still unable to walk by himself by 18 months old
• The infant still unable to climb up or down the stairs by 2 years old
• The infant still unable to jump with both feet by 2 ½ years old
• The child still unable to stand on one foot by 3 years old
• Do not hop by 4 years old
• The child still unable to walk a straight line back and forth or balances on one foot by 5 years old

Warning signs for fine motor

• The baby still unable to hold a rattle by 5 months old
• The baby still unable to hold and object in each hand by 7 months old
• Absence of pincer grasp by 12 months old
• Do not scribble by 2 years old
• The infant can’t turn a single page of a book by 2 ½ years old
• Unable to draw a straight line by 3 years old
• Unable to copy a circle by 4 years old
• Unable to copy a cross by 5 years old

Warning signs for language functions

• Do not babbling by 6 months old
• The baby do not say “da” or “ba” by 9 months old
• The baby do not say “dada” or “baba” by 11 months old
• The infant do not has at least 3 words with meaning by 18 months old
• The infant do not has two-word phrases by 2 years old
• The infant has speech unintelligible even to parents by 2 ½ years old
• Speech unintelligible to strangers by 3 years old. Gestures used instead of speech.
• The child do not has any question of “what” or “why” by 4 years old. The child cannot tell a simple story and has poor social play. The child may have poor word or sentence structures.
• The child still gets words, sentences and ideas jumbled up by 5 years old. Articulation problem by this age also is considered abnormal.

Warning signs for psychosocial functions

• The baby do not have any social smile by 3 months old
• The baby do not response or not laughing in playful situation by 6 to 8 months old
• By 1 year old, the infant is hard to console or stiffens when approached
• The infant do not point fingers or do not indicate wants by 18 months old
• Take seriously when the child still kicks, bites and scream easily even without any provocation or the child has no eye contact and still rocks back and forth by 2 years old.
• By 3 to 5 years old the child is in constant motion. Resist to discipline and do not socialize and play with other kids.

Warning signs for cognitive functions

• Do not alert to mother by 3 months old
• No interest to play “peek-a-boo” by 9 months old
• The baby does not search for hidden object by 12 months old
• The infant do not have any interest in “cause-and-effect” games by 18 months old
• Does not know categories by 2 years old
• Does not know his/her full name by 3 years old
• The child cannot pick shorter or longer of 2 lines by 4 years old.
• The child cannot count sequentially by 4 ½ years old
• The child does not know any colors or letters by 5 years old

Reference:

Paediatrics Protocols For Malaysian Hospital. Hussain Imam et al. Second edition. 2008.