TORCH, Toxoplasmosis, other (congenital syphilis), rubella, cytomegalovirus, and herpes simplex virus. *Some health problems fit in several categories (e.g., lead intoxication may be involved in several areas).
†This also may be considered as an acquired childhood disease.
Children with mild to moderate visual impairment usually have an uncorrected refractive error. The most common presentation is myopia or nearsightedness. Other causes are hyperopia (farsightedness) and astigmatism (alteration in the shape of the cornea leading to visual distortion). In children younger than 6 years, high refractive errors in one or both eyes also may cause amblyopia, aggravating visual impairment.
The diagnosis of severe visual impairment commonly is madewhen an infant is 4 to 8 months of age. Clinical suspicion is based on parental concerns aroused by unusual behavior, such as lackof smiling in response to appropriate stimuli, the presence of nystagmus, other wandering eye movements, or motor delaysin beginning to reach for objects. Fixation and visual trackingbehavior can be seen in most infants by 6 weeks of age. Thisbehavior can be assessed by moving a brightly colored object(or the examiner’s face) across the visual field of a quiet but alertinfant at a distance of 1 ft. The eyes also should be examined forred reflexes and pupillary reactions to light. Optical alignment(binocular vision with both eyes consistently focusing on thesame spot) should not be expected until the infant is beyondthe newborn period. Persistent nystagmus is abnormal at anyage. If ocular abnormalities are identified, referral to a pediatricophthalmologist is indicated.
During the newborn period, vision may be assessed by physical examination and by visual evoked response. This test evaluates the conduction of electrical impulses from the optic nerve to the occipital cortex of the brain. The eye is stimulated by a bright flash of light or with an alternating checkerboard of black-and-white squares, and the resulting electrical response is recorded from electrodes strategically placed on the scalp, similar to an electroencephalogram.
There are many developmental implications of visual impairment. Perception of body image is abnormal, and imitative behavior, such as smiling, is delayed. Delays in mobility may occur in children who are visually impaired from birth, although their postural milestones (ability to sit) usually are achieved appropriately. Social bonding with the parents also is often affected.
Visually impaired children can be helped in various ways. Classroom settings may be augmented with resource-room assistance to present material in a nonvisual format. Fine motor activity development, listening skills, and Braille reading and writing are intrinsic to successful educational intervention for a child with severe visual impairment.
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The clinical significance of hearing loss varies with its type (conductive versus sensorineural), its frequency, and its severity as measured in the number of decibels heard or the number of decibels of hearing lost. The most common cause of mild to moderate hearing loss in children is a conduction abnormality caused by acquired middle ear disease (acute and chronic otitis media). This abnormality may have a significant effect on the development of speech and language development, particularly if there is chronic fluctuating middle ear fluid. If hearing impairment is more severe, sensorineural hearing loss is more common. Causes of sensorineural deafness include congenital infections (e.g., rubella and cytomegalovirus), meningitis, birth asphyxia, kernicterus, ototoxic drugs (especially aminoglycoside antibiotics), and tumors and their treatments. Genetic deafness may be either dominant or recessive in inheritance; this is the main cause of hearing impairment in schools for the deaf. In Down syndrome, there is a predisposition to conductive loss caused by middle ear infection
Moderate 40–65 Chronic otitis media/ Conversation must be dB (ASA) middle ear effusions loud to be understood.