Pediatric Eye and Ear Problems

Authors/Editors: Nettina, Sandra M.; Mills, Elizabeth Jacqueline Title: Lippincott Manual o Nursin! "ractice, #th Edition $op%ri!ht &'(() Lippincott *illia+s , *il-ins CONDITIONS OF THE EYE INFECTIOUS PROCESSES .n ectious processes o the e%e include con/uncti0itis, orbital or periorbital cellulitis, and hordeolu+. The% are characterized b% in la++ation and tissue da+a!e caused b% +icrobes, such as bacteria, 0iruses, or $hla+%dia tracho+atis. $on/uncti0itis is a co++on proble+, a ectin! al+ost all children at so+e ti+e or another. Pathophysiolo y and Etiolo y Microbes are usuall% introduced into the e%e or surroundin! tissues b% direct contact 1ith in ected ob/ects. "eriorbital cellulitis is usuall% associated 1ith in ection in nearb% tissues, such as sinusitis or dental abscess. This initiates an in la++ator% response that includes dilation o blood 0essels, s1ellin!, antibod% production, and destruction o the o endin! a!ent b% 1hite blood cells. $o++on bacterial a!ents include Staph%lococcus, Streptococcus pneu+oniae, and 2ae+ophilus in luenzae. Adeno0irus and, less co++onl%, herpes 0irus +a% occur. 3ecause the in ectin! a!ents are easil% spread ro+ person to person, con/uncti0itis +a% occur in outbrea-s in 1hich se0eral children in the sa+e a+il%, classroo+, or co++unit% are a ected. Clinical !ani"estations These depend on the part o the e%e that is in ected. 4edness is characteristic, and +ust be di erentiated ro+ the red e%e o nonin ectious processes Common Causes of Eye Redness in Children C#USE #SSOCI#TED SY!PTO!S !#N#$E!ENT

Con%&ncti'itis 5iral $o++onl% associated 1ith other 2%!iene, rest s%+pto+s o !eneralized 0iral illness 3acterial 6ello1, !reen, or 1hite dischar!e, Antibiotic e%edrops or oint+ent, photophobia h%!iene $hla+%dial $ou!h, histor% o +aternal S%ste+ic antibiotic in ection 2erpetic "ain, photophobia, s-in lesions E0aluation b% specialist, anti0iral a!ents Aller!ic .tchin!, seasonal onset o Topical +ast cell stabilizer e%edrops,

$he+ical

s%+pto+s, other aller!ic s%+pto+s, 1ater% dischar!e *ater% dischar!e, onset o s%+pto+s 1hen e9posed to ci!arettes or other irritants

hista+ine78 anta!onist e%edrops, a0oidance o aller!ens A0oidance o irritatin! substances

Tra&ma Con enital la&coma

"ain, photophobia, increased tear E%e patch, re erral to specialist production .ncreased tear production, cloudiness o cornea 4e erral to specialist

Con%&ncti'itis 4edness o the e%e caused b% dilation o the blood 0essels o the con/uncti0a. E9cessi0e tearin! or e9udate. "hotophobia. 5ision +a% be cloud% because o e9udate, but is not i+paired. Orbital or Periorbital Cell&litis S1ellin! and in la++ation o so t tissues surroundin! the e%e. Tenderness, pain. .ncreased te+perature o a ected areas. 5ision not i+paired. Hordeol&m (Stye) "ustule in area o e%elash ollicle. Tenderness, pain. Localized s1ellin! and er%the+a. Dia nostic E'al&ation $ulture o e9udate or bacteria or 0irus or anti!en testin! or Neisseria !onorrhoeae or $. tracho+atis. :i erent +edia are required or cultures o each, but one s1ab +a% be sent or anti!en testin!. The +ost li-el% a!ents are tested, based on the histor% and ph%sical indin!s. Screenin! 0ision e9a+ +a% be done; a thorou!h 0isual and ocular e9a+ +a% be done i 0ision is i+paired or i internal in0ol0e+ent is suspected. A dendritic ulcer caused b% herpes 0irus can be 0isualized b% instillin! luorescein d%e and e9a+inin! the cornea 1ith a cobalt7 iltered blue li!ht. NURSIN$ #*ERT

A child 1ho has a pain ul red e%e should be re erred i++ediatel% or +edical e0aluation because this +a% indicate herpetic in ection or da+a!e to the cornea. !ana ement Antibiotic e%edrops or oint+ent, such as er%thro+%cin, tri+ethopri+ sul ate and pol%+%9in 3, sul aceta+ide, cipro lo9acin, or tobra+%cin, 1ill shorten the course o bacterial con/uncti0itis and 1ill +a-e the child +ore co+ ortable. S%ste+ic antibiotic treat+ent is indicated or orbital cellulitis. These children +a% be ad+itted to the hospital or close obser0ation and a!!ressi0e +ana!e+ent. A hordeolu+ 1ill usuall% resol0e 1ithout antibiotic treat+ent. *ar+ co+presses are reco++ended, and incision and draina!e +a% be necessar%. Complications "er+anent scarrin! o the cornea and 0isual i+pair+ent 1ith herpetic in ection. Spread o orbital cellulitis to the central ner0ous s%ste+. N&rsin #ssessment Assess nature and e9tent o s%+pto+s and their e ect on child;s acti0ities. Assess 0isual acuit%. :eter+ine resources a0ailable to a+il% or treat+ent. N&rsin Dia noses 4is- or .n ection <trans+ission= related to hand7to7hand or hand7to7ob/ect contact Acute "ain related to tissue s1ellin!, in la++ation, and li!ht sensiti0it% N&rsin Inter'entions Preventing Infection Per"orm or teach proper cleansin o" draina e+ o >se 1ar+ 1ater or saline and a disposable applicator, such as cotton balls or !auze. o >se a separate applicator or each e%e. o *ipe ro+ inner to outer canthus to a0oid conta+ination. Teach sel",care meas&res to pre'ent spread to others+ o ?bser0e !ood hand71ashin! practices. o *ipe e%es and nose 1ith tissues and dispose pro+ptl%. o A0oid rubbin! e%es to pre0ent spread to other e%e. Ad+inister and teach proper instillation o e%edrops or oint+ent <see pa!e @)A=. Ad+inister oral or ..5. antibiotics as indicated. Minimizing Pain Appl% 1ar+ co+presses to a ected area. Su!!est dar-ened roo+ and sun!lasses or patients 1ith photophobia. Ad+inister an anal!esic as indicated. Family Ed&cation and Health !aintenance #d'ise o" -ays to pre'ent transmission to others+

:o not share 1ashcloths or to1els. A0oid s1i++in! until in ection is resol0ed. The child can return to school a ter ha0in! recei0ed antibiotic treat+ent or 'B hours. o :ispose o conta+inated ite+s in proper receptacles. #d'ise parents o" indications "or ree'al&ation by health care pro'ider+ o Lac- o response to antibiotic treat+ent. o .ncrease in s1ellin! and tenderness. o E%e pain. o *orsenin! o 0isual acuit%. o :e0elop+ent o additional s%+pto+s such as e0er. Encoura!e routine ollo17up 0isits.
o o o

E'al&ation. E/pected O&tcomes "arents per or+ treat+ent correctl%; h%!iene procedures ollo1ed "atient 0erbalizes less pain; tolerates bri!ht li!ht

CON$ENIT#* PRO0*E!S $on!enital proble+s o the e%e include structural de ects present at birth or de0elopin! soon therea ter. These are usuall% !eneticall% trans+itted. The% include cataract, dacr%ostenosis, !lauco+a, ptosis, and strabis+us.

Con enital Eye Problems

CONDITION #ND DESCRIPTION Con enital Cataract ?pacit% o the lens. "ossible causes include abnor+al e+br%onic de0elop+ent, in ection durin! pre!nanc%, disturbance o carboh%drate +etabolis+, +etabolic disorders, retinopath% o pre+aturit%. .ncidence is 8 in '@( neonates. Dacryostenosis 4elati0el% co++on C*INIC#* !#NIFEST#TIONS

!#N#$E!ENT

Absence o red re le9 5isible cloudin! o lens 5ar%in! i+pair+ent o 0ision, dependin! on size, location, and densit% o cataract Ma% result in a+bl%opia E9cessi0e tearin!

Sur!ical re+o0al 1ith lens i+plantation 1ithin irst A +onths to correct 0ision. "ostoperati0e care: sedation or irst 'B hours to pre0ent cr%in!, 0o+itin!, and increased intraocular pressure <.?"=; antibiotic and steroid oint+ents to pre0ent in ection; e%e patch and shield or se0eral da%s. 4esol0es spontaneousl% in

obstruction o the nasolacri+al duct caused b% inco+plete duct de0elop+ent and persistence o +e+brane at lo1er end o duct. Tears cannot e9it 0ia the duct into the nasal ca0it% and continuousl% spill o0er onto the chee-. Ma% be unilateral or bilateral.

and spillin! onto chee$rusted e%elashes and lids E9coriated cheeNor+al7appearin! e%e structures and 0ision "ossible episodes o secondar% con/uncti0itis and lacri+al duct in ection 2aziness o the cornea "hotophobia E9cessi0e tearin! :ecreased 0isual acuit% <s%+pto+s present in A@D at birth= "er+anent loss o 0ision and a+bl%opia +a% result 1ithout treat+ent :roopin! is 0isible on inspection 5ision +a% be i+paired i e%elid co0ers the pupil Ma% be unilateral or bilateral . unilateral, a+bl%opia +a% result 1ithout treat+ent As%++etric pupillar% li!ht re le9es

C(D o in ants in irst %ear o li e. So+e reco++end !entle +assa!e o lacri+al duct, but e ecti0eness has not been docu+ented. Topical antibiotics or secondar% in ection. Sur!ical probin! o duct i persists be%ond a!e 8' +onths; +ore co+ple9 sur!er% i probin! unsuccess ul. Tono+etr% is done to deter+ine .?". Sur!ical inter0ention is usuall% necessar% to nor+alize .?". "ostoperati0el%, a patch and shield +a% be 1orn or se0eral da%s to protect sutures.

$la&coma 4are con!enital or acquired abnor+alit% in 1hich the balance bet1een aqueous luid production and out lo1 is disrupted. .ncreased pressure o luid in anterior cha+ber causes da+a!e to the retina, cornea, and other structures.

Ptosis :roopin! o the e%elid caused b% 1ea-ness o le0ator palpebrae or, less requentl%, MEller;s +uscle. Ma% be con!enital or acquired; a ectin! either the +uscle or the ner0e that inner0ates it.

Sur!ical correction to raise the e%elid and increase 0isual ield. "atchin! not necessar% postoperati0el%.

Strabism&s Malali!n+ent o the e%es caused b% +uscle i+balance or b% paral%sis,

"atchin! o the stron!er e%e or a prescribed period each da% +a% correct latent

1hich pre0ents both e%es ro+ ocusin! correctl% on the sa+e i+a!e. ?ccurs in AD o the population.

As%++etric e9traocular +o0e+ents :iplopia, i+paired depth Tendenc% to close one e%e or tilt head durin! 0ision testin! A+bl%opia +a% result 1ithout treat+ent

strabis+us b% e9ercisin! the +uscles o the 1ea-er e%e. Sur!ical repositionin! o the e9traocular +uscles or se0ere or i9ed cases. "ostoperati0el%: antibiotic oint+ent, no e%e patch.

N&rsin #ssessment Assess or red li!ht re le9, especiall% in neonates. Absence or as%++etr% o the red li!ht re le9 +a% indicate con!enital cataract or an intraocular tu+or. .nspect the e%es or redness o con/uncti0a, cloudiness o the cornea, e9cessi0e tearin!, e%elids that partiall% occlude the pupil, or ob0ious +isali!n+ent, 1hich pro0ide clues to con!enital e%e proble+s. Assess 0isual acuit% routinel% in in ants and children. $han!es in acuit% +a% be the irst +ani estation o a proble+ or indication o e ecti0eness o treat+ent. "er or+ 2irschber!;s test or s%++etr% o the pupillar% li!ht re le9es to help detect strabis+us. Nor+all%, the li!ht re le9es are in the sa+e position in each pupil 1hen a li!ht is shone on the brid!e o the nose, but as%++etrical re lection 1ill occur 1ith strabis+us <positi0e 2irschber!;s test=. "er or+ the cross co0er test to detect latent strabis+us caused b% 1ea- e%e +uscles. *hen the patient is i9ated on an ob/ect appro9i+atel% 8' inches <A(.@ c+= a1a% and one e%e is co0ered, obser0e the unco0ered e%e. . +o0e+ent occurs, this e%e +ost li-el% has strabis+us. *hen the e%e 1ith strabis+us is co0ered, it dri ts out o position and can be seen snappin! bac- quic-l% 1hen unco0ered. N&rsin Dia noses :isturbed Sensor% "erception <5isual=, related to reduction in 0isual acuit% :isturbed 3od% .+a!e related to the need or patch or !lasses 4is- or .n/ur% related to reduced 0isual acuit% and +odi ied depth perception :ela%ed Fro1th and :e0elop+ent related to altered 0isual sti+ulation and possible o0erprotecti0e beha0ior o parents N&rsin Inter'entions Minimizing Effects of Vision Loss Participate in 'is&al ac&ity problem identi"ication and enco&ra e prompt treatment to minimi1e "&nctional impairment+ o Neonates should be e9a+ined in the nurser% to detect con!enital e%e proble+s.

All children should be screened or 0isual acuit% and strabis+us. .n %oun! children, this is acco+plished b% ph%sical e9a+ination and assess+ent o de0elop+ental +ilestones <ie, loo-s at +other;s ace, s+iles responsi0el%, reaches or ob/ects=. 3% a!es A to @, +ost children can cooperate or per or+ance o accurate 0isual acuit% screenin! tests. Encoura!e and assist parents in obtainin! correcti0e lenses or child. Enco&ra e and assist parents in pro'idin normal e/periences "or child to achie'e ma/im&m potential. o Assist parents in locatin! and accessin! resources, such as inancial assistance, special education in 3raille, or parent support !roups. o Ad0ise parents o their child;s ri!ht to a public education.
o

Minimizing Body Image Disturbance Encoura!e parents to ocus on nor+alization rather than on o0erprotection. This +eans ha0in! e9pectations based on the child;s abilities rather than disabilities, pro0idin! opportunities or interaction 1ith peers, and +a-in! the child;s li e as nor+al as possible. Encoura!e acceptance o appearance and e+phasize the positi0e aspects o treat+ent. Preventing In ury Enco&ra e the "amily to be a-are o" sa"ety in the home2 school2 and comm&nity+ o Su!!est the use o i+pact7resistant e%e!lasses and de0ices to -eep e%e!lasses ro+ allin! o . o Ad0ise the a+il% to +aintain a consistent and uncluttered urniture arran!e+ent; noti % child o planned chan!es. o .nstruct child in the use o a cane or other assisti0e de0ice. o Teach tra ic sa et% and personal securit% +easures. Orient 'is&ally impaired children in the hospital to the placement o" "&rnit&re and other ob%ects in their room+ o ?rient child to ood place+ent on +eal tra%s. o Assist child 1ith a+bulation and use side rails on bed or crib to pre0ent alls. Promoting !ormal "ro#th and Develo$ment Encoura!e parents to pro0ide +an% sensor% opportunities, such as +anipulatin! ob/ects, hearin! 0arious sounds, notin! the s+ells in the en0iron+ent, and tastin! an assort+ent o substances. Allo1 child to per or+ acti0ities o dail% li0in! <A:Ls= as independentl% as possible. Family Ed&cation and Health !aintenance Posto$erative %eaching Teach about instillation o +edications and use o e%e shield to pre0ent in/ur% to e%e a ter sur!er%.

Teach about acti0it% restrictions a ter !lauco+a sur!er%. o 3ed rest +a% be required i++ediatel% postoperati0el%. o ?lder children should not en!a!e in strenuous acti0it% or contact sports or ' 1ee-s. Ad0ise that acti0it% is not usuall% restricted or sur!er% or strabis+us or ptosis. A ter cataract sur!er%, encoura!e beha0iors to reduce the ris- o da+a!e to sutures ro+ increased intraocular pressure <.?"=: o A0oid o0er eedin! to pre0ent 0o+itin!. o Mini+ize cr%in!. Encoura!e parents to re+o0e e%e dischar!e or crusts on lashes re!ularl% b% 1ashin! the e%es 1ith 1ar+ 1ater. Separate 1ashcloths should be used or each child. Moist cotton balls +a% be used to clean the a ected child;s e%es. A separate one should be used or each e%e.

&ther Concerns Ad0ise o indications or ree0aluation b% health care pro0ider. o *orsenin! o 0isual acuit%. o E0idence o in ection, such as pain, redness, s1ellin!, draina!e, and increased te+perature. 4e er a+il% to "re0ent 3lindness A+erica, http://111.pre0entblindness.or!, or in or+ation on e%e disease and sa et% +easures. E'al&ation. E/pected O&tcomes $hild 1ears !lasses as prescribed; 0ision i+pro0ed "arents and child report in0ol0e+ent in acti0ities, satis actor% school per or+ance, and positi0e peer interactions No in/uries reported Achie0es a!e7appropriate de0elop+ental +ilestones EYE TR#U!# E%e trau+a causes structural da+a!e to the e%e and is produced b% +echanical orce or contact 1ith a corrosi0e che+ical. So+e co++on t%pes o e%e trau+a are corneal abrasions, blunt trau+a, per oratin! in/uries, and che+ical in/uries. E%e in/uries are co++on a+on! children and are usuall% related to their in0ol0e+ent in 0i!orous pla% acti0ities. Pathophysiolo y and Etiolo y Corneal 'brasion "roduced 1hen an area o the cornea is scratched. This +a% happen 1hen a orei!n ob/ect beco+es lod!ed in the e%e, a contact lens rubs a!ainst the e%e because o inadequate tear production, or a in!ernail or other sharp ob/ect enters the e%e and scrapes the cornea.

Blunt %rauma This occurs 1hen the e%e or surroundin! tissues are struc- b% a blunt ob/ect such as a ball. The resultin! in/ur% includes tissue s1ellin! and seepa!e o blood into the surroundin! tissues. The bon% structures surroundin! the e%e +a% be ractured. The lens +a% beco+e dislod!ed or the retina +a% separate ro+ the bac- o the e%e. Perforating In ury *hen an ob/ect penetrates the e%eball, there +a% be loss o 0itreous +aterial and/or da+a!e to the internal structures o the e%e. 3acteria +a% also be introduced into the interior o the e%e, causin! in ection. Chemical In uries $orrosi0e che+icals burn the delicate tissues o the cornea and +a% penetrate into deeper la%ers o the e%e. 2ealin! +a% occur 1ith scarrin!. Clinical !ani"estations "ainGbecause the delicate tissues o the e%e contain +an% ner0e endin!s. .ncreased tear productionGone o the e%e;s de enses a!ainst in/ur% or irritation. .n/ection o the blood 0essels o the corneaGincrease o blood lo1 to the cornea is another protecti0e +echanis+; +ost li-el% to be seen 1ith orei!n bodies, abrasions, or che+ical burns that a ect the cornea. Impaired 'is&al ac&ity ca&sed by+ o S1ellin! o the cornea, reducin! its clarit%. o S1ellin! o the so t tissues surroundin! the e%e, causin! the e%e to partiall% or co+pletel% close. o E9cessi0e tear production, i+pairin! 0ision. o :a+a!e to internal structures o the e%e, alterin! or obstructin! 0isual path1a%s. 5isible si!ns o in/ur%Gbruisin!, s1ellin!, or a orei!n ob/ect 0isible in the e%e. NURSIN$ #*ERT At ti+es, pain +a% be use ul in distin!uishin! a serious e%e proble+ ro+ a sel 7li+itin! condition. Dia nostic E'al&ation Thorou!h inspection o the e%e, includin! e0ersion o the upper lid to inspect or a orei!n ob/ect. Hunduscopic e9a+ination +a% detect abnor+alities, such as a dislod!ed lens, retinal he+orrha!e, retinal detach+ent, or papillede+a 1ith increased .?". Stainin! 1ith luorescein d%e 1ill re0eal lesions o the cornea such as abrasions. Assess+ent o e%e unction, includin! near and ar acuit%, e9traocular +o0e+ents, and 0isual ield testin!.

!ana ement Most childhood in/uries are not se0ere and 1ill resol0e spontaneousl% 1ith no ad0erse lon!7ter+ consequences. .t is i+portant, ho1e0er, to identi % and obtain pro+pt treat+ent or si!ni icant in/uries. Corneal 'brasion . the abrasion 1as caused b% a contact lens or orei!n bod%, re+o0al o the o endin! bod% is indicated. "atchin! o the a ected e%e, usuall% or 'B hours, 1ill control pain. Antibiotic e%edrops or oint+ent pre0ent in ection. Blunt %rauma Application o cold co+presses +a% help control pain and s1ellin!. The head should be ele0ated A( de!rees to a0oid increased .?". Sur!er% +a% be required because o da+a!e to underl%in! bones or e%e structures. Perforating In ury Sur!er% is usuall% necessar% to re+o0e the ob/ect and reconstruct da+a!ed tissues. NURSIN$ #*ERT Ne0er re+o0e a penetratin! ob/ect ro+ the e%e. .t should be stabilized and the e%e should be shielded 1ith no pressure applied. The other e%e should be patched and the patient transported b% stretcher. The head should be ele0ated A( de!rees to a0oid increased .?", and the child should be -ept on nothin!7b%7+outh orders in preparation or sur!er%. Chemical In uries Fentle lushin! o the a ected e%es 1ith 1ater 1ill help re+o0e the o endin! che+ical. This should be done ro+ the inner aspect o e%e to the outer to pre0ent conta+inated 1ater ro+ lo1in! into the other e%e. Antibiotics +a% be prescribed to pre0ent in ection. Hurther +ana!e+ent depends on the nature and e9tent o the in/ur%. Complications .n ection. E9tensi0e tissue da+a!e +a% result in per+anent 0ision i+pair+ent. :is i!ure+ent +a% result ro+ se0ere or e9tensi0e tissue da+a!e. N&rsin #ssessment ?btain histor% o in/ur%, includin! the child;s account o ho1 the in/ur% occurred, and a description o s%+pto+s e9perienced. .nspect or location and e9tent o s1ellin! and bruisin!, as%++etr%, or abnor+alit% in appearance o an% part o the e%e.

Assess 0isual acuit% and co+pare 1ith baseline. This should include near and ar acuit% in each e%e. . the patient cannot see 1ell enou!h to read a Snellen chart, assess abilit% to count in!ers or percei0e li!ht.

N&rsin Dia noses Acute "ain related to in la++ation, photophobia, or trau+a to e%e tissue 4is- or .n/ur% related to i+paired 0ision and ad0erse e ects o pain +edications Heedin!, :ressin!, and Froo+in! Sel 7$are :e icit related to i+paired 0ision and ad0erse e ects o pain +edications N&rsin Inter'entions Minimizing Pain Appl% cold co+presses to the a ected area to help reduce s1ellin! and disco+ ort. Ieep the child;s roo+ as dar- as possible to help reduce pain or photophobic patients. Ad+inister or teach parents to ad+inister anal!esics as prescribed. Preventing In ury En"orce sa"ety meas&res+ o >se o bed side rails. o Assistance 1ith a+bulation. o $lose obser0ation. Maintaining 'DLs "ro0ide assistance 1ith eatin!, bathin!, toiletin!, and other A:Ls, as needed. Teach child location o sel 7care ite+s and positionin! o ood on tra% to pro+ote independence. Encoura!e child to atte+pt sel 7care, and o er praise e0en i unsuccess ul. Family Ed&cation and Health !aintenance Teach indications "or ree'al&ation by health care pro'ider+ o .ncrease in s1ellin!, tenderness, discoloration, or pain. o *orsenin! o 0isual acuit%. o :e0elop+ent o additional s%+pto+s, such as e0er, alteration in sensoriu+, or other indications o neurolo!ic in/ur%. "ro0ide sa et% education to all a+ilies to pre0ent co++on causes o in/ur%. .n particular, encoura!e a+ilies to use protecti0e e%e1ear 1hen participatin! in sports acti0ities. "ro0ide a+ilies 1ith in or+ation and support as the% cope 1ith ha0in! a 0isuall% i+paired child in the ho+e. The A+erican Acade+% o ?phthal+olo!% has patient in or+ation and a list o help ul resources at its *eb site, http://111.aao.or!/aao/ne1s/e%enet/. E'al&ation. E/pected O&tcomes :e+onstrates decreased pain

No in/uries reported :ressin! and eedin! sel 1ith +ini+al assistance

H>N$T.?NAL "4?3LEMS Hunctional proble+s o the e%e in0ol0e i+pair+ent o the 0ision because o re racti0e errors or disuse o 0isual path1a%s. Such proble+s requentl% result in a+bl%opiaG i+paired 0ision in one or both e%es due to poor 0isual sti+ulation rather than an or!anic proble+. Abnor+al 0ision screenin! 1ith re erral occurs in 8.'D o @7%ear7old patients and increases to C.8D b% the ti+e the child reaches a!e 8A. A+bl%opia a ects 8D to AD o the population. Pathophysiolo y and Etiolo y Refractive errors are usually caused by a genetic $redis$osition to shortened or elongated eyeballs or by individual variations in gro#th( o .n an elon!ated or shortened e%eball, the 0isual i+a!e is ocused either in ront o or behind the retina, resultin! in unclear i+a!es. o The nearsi!hted <+%opic= child can see near ob/ects, such as print in schoolboo-s, but cannot ocus clearl% on ar ob/ects such as 1ritin! on the blac-board. o The arsi!hted <h%peropic= child can see ar ob/ects clearl% but has di icult% seein! near ob/ects. o The proble+ +a% be unilateral or bilateral. 'mblyo$ia may result from any condition that causes the t#o retinas to receive different images( Etiology may include( o :iplopia caused b% strabis+us. o Si!ni icant di erence in acuit% o the t1o e%es. o $ataract. o >nilateral ptosis. )hen a discre$ancy e*ists bet#een images received on the t#o retinas+ the more unclear image is su$$ressed( o ?0er ti+e, a %oun! child 1ill beco+e per+anentl% unable to use the 0isual path1a%s o the suppressed e%e. o Althou!h the 0isual path1a%s are structurall% nor+al, the child is 0isuall% i+paired in that e%e due to poor 0isual sti+ulation. Clinical !ani"estations Children &s&ally do not complain that they cannot see -ell2 b&t may e/hibit other si ns o" 'ision problems2 incl&din . "oor acade+ic per or+ance or beha0ioral proble+s in school. :isli-e or readin!. 2ead tiltin!. Squintin!. Sittin! close to the tele0ision or holdin! readin! +aterials close to the ace. 4e usal or resistance to co0erin! one e%e durin! 0ision screenin!. Dia nostic E'al&ation

Standardi1ed 'ision screenin tests2 s&ch as the Snellen chart2 the Titm&s machine2 or the H.O.T.3 matchin symbol test2 may be &sed "or distance ac&ity screenin + o Tests can be ad+inistered to children as %oun! as a!e A. o Each e%e should be tested separatel%. Near 0ision +a% be tested b% ha0in! the child read or b% standardized 0ision screenin! tests such as the Tit+us +achine. Each e%e should be tested separatel%. Muscle balance can be tested usin! the cross co0er test and the Tit+us +achine.

!ana ement Most 0isual acuit% proble+s can be treated b% the use o correcti0e lenses or re racti0e sur!er%. #mblyopia mana ement "oc&ses on pre'ention thro& h early identi"ication and treatment o" conditions that ca&se it+ o Strabis+us is treated 1ith !lasses and patchin! o the stron!er e%e. .n so+e cases, ho1e0er, sur!er% +a% be required. o A ne1 phar+acolo!ic treat+ent, puri ied botulis+ to9in, is beco+in! a0ailable or strabis+us but is not in 1idespread use. 3otulis+ to9in 1or-s b% bloc-in! acet%lcholine release ro+ ner0e endin!s in the +uscle that is contractin! e9cessi0el%. o Sur!er% +a% also be required to correct ptosis. o Acuit% proble+s due to re racti0e error are usuall% +ana!ed 1ith the use o correcti0e lenses. ?pti+al outco+e is acco+plished 1hen treat+ent is be!un earl% in li e, 1hile 0isual path1a%s are still de0elopin!. 2o1e0er, so+e 0isual unction +a% be reco0ered e0en i the proble+ is treated in adolescence or adulthood. .deall%, the proble+ can be pre0ented b% earl% identi ication and treat+ent o actors that +a% cause it. Complications .n/uries caused b% 0isual i+pair+ent. N&rsin #ssessment 3e!in 0isual acuit% screenin! earl%, in the preschool %ears, and 1hene0er a child displa%s beha0iors su!!esti0e o acuit% proble+s. Assess 2irschber!;s test or s%++etr% o the pupillar% li!ht re le9es routinel%, be!innin! at birth. "er or+ the cross co0er test as part o routine e%e assess+ent as soon as the child can cooperate <as %oun! as a!e A=. Assess the e ect o the unctional de icit on the child;s o0erall unction, includin! acade+ic pro!ress, sel 7estee+, and sa et%. N&rsin Dia noses :isturbed Sensor% "erception <5isual= related to reduced acuit% or inabilit% to use one e%e 4is- or .n/ur% related to i+paired 0isual acuit% or lac- o depth perception

$hronic Lo1 Sel 7Estee+ related to lo1ered per or+ance caused b% poor 0ision

N&rsin Inter'entions Minimizing Effects of ,ensory Deficits Encoura!e the consistent use o correcti0e lenses as prescribed. Teach the parents -ays to help de'elop the child4s s5ills in interpretin in"ormation thro& h the senses o" hearin 2 smell2 and to&ch+ o Ha+iliarize the child 1ith co++on sounds and s+ells in the en0iron+ent. Also, orient the child to tra ic sounds and sounds associated 1ith dan!er, such as ani+als and speedin! 0ehicles, and instruct the child ho1 to respond. o >se 0oice or touch, rather than acial e9pressions or !estures, to e9press e+otion. o Spea- to the child be ore touchin! to reduce startlin!. o Allo1 the child to touch and handle un a+iliar ob/ects to learn about the+. o 2a0e the child practice such thin!s as retellin! stories and !i0in! the ho+e telephone nu+ber and address. o E9plain un a+iliar sounds and s+ells to the hospitalized child. Preventing In ury 4eco++end the use o shatterproo e%e!lasses 1ith le9ible ra+es. 4eco++end the use o e%e protection on a routine basis because e%e trau+a can occur une9pectedl%. This is especiall% i+portant or children 1ho rel% on onl% one e%e. Su!!est e9tra protection, such as shatterproo !o!!les or shields, 1hen participatin! in contact or ball sports and acti0ities. Maintain a stable arran!e+ent o urniture in the ho+e, adequate li!htin!, and an uncluttered en0iron+ent to +ini+ize alls. ?rient hospitalized children to the hospital roo+ and o er assistance 1hen 1al-in!. Promoting a Positive ,ense of ,elf-Esteem "ro0ide opportunities or +aster% o de0elop+entall% appropriate acti0ities. Encoura!e interactions 1ith si!hted children to decrease eelin!s o isolation. Also, su!!est interactions 1ith children 1ith si+ilar alterations in 0ision. Encoura!e the child to discuss eelin!s and strate!ies or copin! 1ith ne!ati0e peer reactions such as teasin!. Encoura!e independence in sel 7care acti0ities to pro+ote autono+%, such as dressin!, eedin!, and use o bathroo+. Assist the patient and a+il% 1ith e ecti0e copin! +echanis+s to pro+ote a+il% stabilit% Comm&nity and Home Care Considerations

"er or+ a sa et% inspection o the ho+e en0iron+ent and +a-e chan!es as necessar% to help pre0ent alls and other in/uries. Assist a+il% access to inancial and social resources as needed. Ma-e sure that the child is recei0in! specialized educational resources as needed.

Family Ed&cation and Health !aintenance Teach the i+portance o 1earin! correcti0e lenses as prescribed, and their proper care. 4e er a+ilies o blind children to co++unit% resources that can help their child learn special s-ills, such as readin! 3raille, usin! a cane, or de0elopin! sel 7care s-ills. .n or+ation can be obtained ro+ a!encies such as the A+erican Houndation or the 3lind, http://111.a b.or!. E'al&ation. E/pected O&tcomes .denti ies co++on sounds No in/ur% reported; 1ears protecti0e e%e!lasses 4eports !ood school per or+ance and participation in e9tracurricular acti0ities; can eat and dress independentl% CONDITIONS OF THE E#R EUST#CHI#N TU0E DYSFUNCTION Eustachian tube d%s unction <ET:= co+prises disorders that arise ro+ closure o the eustachian tube, 1hich 0entilates the +iddle ear to equalize pressure on both sides o the t%+panic +e+brane. ET: leads to +iddle ear e usion. ET: +a% present as otitis +edia 1ith e usion <?ME=, also -no1n as serous otitis; acute otitis +edia <A?M=; and recurrent otitis +edia. Appro9i+atel% C8D o children e9perience one or +ore episodes o +iddle ear e usion b% the ti+e the% are a!e ' %ears. Pathophysiolo y and Etiolo y S-ellin o" the e&stachian t&be linin is ca&sed by an ac&te &pper respiratory in"ection or an aller ic response+ o .n ected secretions +a% pass throu!h the tube ro+ the nasal area into the +iddle ear. o *hen s1ellin! causes the eustachian tube to close, the passa!e o air into and out o the +iddle ear is pre0ented. o The air in the +iddle ear is absorbed into the +iddle ear linin! and a 0acuu+ is created. o The 0acuu+ is illed b% serous luid that seeps out o the +iddle ear linin!. o The 1ar+, +oist en0iron+ent o the +iddle ear and nutrients in the serous luid are conduci0e to the !ro1th o 0iruses or bacteria that +a% be present in the +iddle ear ca0it%. Children bet-een a es 6 and 78 months are predisposed to the de'elopment o" #O! beca&se their short2 relati'ely strai ht e&stachian t&bes more easily

allo- the passa e o" in"ected nasal secretions into the middle ear ca'ity+ Ris5 "actors incl&de+ o More requent episodes o upper respirator% in ections in %oun!er children. o Nasal aller!ies. o FeneticsGin so+e a+ilies, children;s eustachian tubes tend to be lopp% and to close easil%. o Nati0e A+erican or Es-i+o herita!e. o $ranio acial abnor+alities. o :o1n s%ndro+e. o Lo1er socioecono+ic status. o E9posure to ci!arette s+o-e. !ost common bacterial a ents incl&de+ o S. pneu+oniae. o 2ae+ophilus in luenzae. o Mora9ella catarrhalis. 3arotrau+a, caused b% rapid chan!es in at+ospheric pressure, +a% also lead to closure o the eustachian tube and to de0elop+ent o serous otitis. This is less li-el% to in0ol0e introduction o +icroor!anis+s throu!h in ected nasal secretions; de0elop+ent o A?M is less co++on.

Clinical !ani"estations :ecreased hearin!Gte+porar% conducti0e hearin! loss; usuall% resol0es 1hen t%+panic +e+brane +obilit% is restored. Sensation o ullness in the a ected ears. "oppin! sensations in the a ected ears +a% be e9perienced as the eustachian tube be!ins to open and ad+it air into the +iddle ear ca0it%. Ear pain. Si!ns o in ectionG e0er, irritabilit%, or decreased appetite. Dia nostic E'al&ation Otoscopic e/amination+ o ?MEG%ello1ish e usion, pro+inent bon% land+ar-s, a di use li!ht re le9, and decreased +obilit% o t%+panic +e+brane. o A?MGin la+ed t%+panic +e+brane 1ith decreased or absent +obilit%; bul!in! o the t%+panic +e+brane +a% obscure the bon% land+ar-s and li!ht re le9. T%+pano+etr%Gquic- and si+ple 1a% to assess t%+panic +e+brane +obilit% <see Hi!ure BJ78, pa!e 8@'B=.

(A) Type A tympanogram: This is the normal pattern showing mobility of the tympanic membrane with a peak mobility at the 0 point (the point at which there is neither positive nor negative pressure in the external ear canal). (B) Type B tympanogram: This pattern shows a low level of mobility with no peak. t is characteristic of impaire! mobility !ue to the presence of flui! in the mi!!le ear. (") Type " tympanogram: This pattern shows a !istinct peak in the mobility level of the tympanic membrane# but the peak occurs when there is negative pressure in the external ear canal. This in!icates eustachian tube !ysfunction causing negative pressure in the mi!!le ear cavity. $egative pressure in the external ear canal e%uali&es pressure on both si!es of the tympanic membrane an! allows for maximum mobility. o A probe occludes the ear canal 1hile pressure is 0aried and a test sound is e+itted. The test produces a !raphic displa% that sho1s the +obilit% o the t%+panic +e+brane at 0arious air pressures. o A nor+al readin! has a distinct pea- in the +iddle o the !raph <see Hi!ure BJ78A, pa!e 8@'B=. o A lat t%+pano!ra+ <no pea-= indicates lac- o +obilit% o the t%+panic +e+brane, usuall% caused b% serous otitis or A?M o A pea- to the le t o the center indicates ne!ati0e pressure in the +iddle ear <see Hi!ure BJ78$=. #co&stic re"lectometry9&se"&l in in"ants older than a e : months+

o o

A probe held at the openin! o the ear canal +easures re lected sound 1a0es ro+ the +iddle ear. 4eduction in re lected sound is an indication o +iddle ear e usion.

!ana ement &titis Media #ith Effusion >suall% resol0es spontaneousl%. Treat+ent o underl%in! predisposin! actors <e!, aller!ies=, +a% pro0ide so+e relie . "lace+ent o 0entilatin! tubes +a% be considered or e usions that persist or A or +ore +onths 1ith bilateral hearin! loss o '( or +ore decibels. Adenoidecto+% +a% bene it so+e children. 'cute &titis Media ?nl% s%+pto+atic cases should be treated. S%ste+ic antibiotic treat+entGusuall% an oral preparation is ta-en or @ to 8( da%s. #mo/icillin remains the dr& o" choice2 altho& h hi her doses are no- i'en (;< to =< m >5 ) beca&se o" ro-in pre'alence o" resistant bacteria (S+ pne&moniae)+ o Those at ris- or resistance are children %oun!er than a!e ', those treated 1ith antibiotics 1ithin the past ' +onths, and those 1ho attend da% care. Alternati0e antibiotics or treat+ent ailures include a+o9icillin7cla0ulanate <Au!+entin= or one o the cephalosporins. "lace+ent o 0entilatin! tubes b% +%rin!oto+% <incision into the t%+panic +e+brane= +a% be considered or children 1ho e9perience three or +ore episodes in ) +onths or our or +ore episodes per %ear <see Hi!ure BJ7'=.

' ventilating .myringotomy/ tube $rovides air to the middle ear to $revent otitis

media( Recurrent &titis Media "lace+ent o 0entilatin! tubes in the t%+panic +e+brane allo1s luid to drain throu!h the ear canal rather than to beco+e trapped in the +iddle ear. Antibiotic proph%la9is is no lon!er reco++ended because it +a% contribute to the proble+ o antibiotic7resistant bacteria. Complications "er+anent hearin! loss, per orations o the t%+panic +e+brane, scarrin! because o healed per orations, or da+a!e to the ossicles o the +iddle ear. :ela%ed speech and lan!ua!e de0elop+ent. Mastoiditis, +enin!itis, lateral sinus thro+bosis, or intracranial abscess; spread o bacterial in ection. N&rsin #ssessment Assess or etiolo!ic actors that contribute to eustachian tube d%s unction. Assess or s%+pto+s o serous otitis and A?M to identi % and to docu+ent the nature and se0erit% o the illness. Assess hearin! a ter the +iddle ear e usion is resol0ed. "ro+ptl% identi % an% hearin! loss that +a% ha0e social and educational consequences. Assess speech and lan!ua!e de0elop+ent in children 1ho e9perience recurrent or prolon!ed in ections to deter+ine de icits. Assess or e ects o illness on a+il%, such as sleep depri0ation o parents caused b% sta%in! up 1ith child at ni!ht or decreased attendance at 1or- caused b% -eepin! child out o school. NURSIN$ #*ERT "ro+pt identi ication o speech and lan!ua!e dela%s is i+portant in %oun! children because speech and lan!ua!e de0elop+ent is quite rapid at this ti+e. 6oun! children +a% de+onstrate rapid re!ression or ailure o pro!ression. N&rsin Dia noses Acute "ain related to increased pressure in the +iddle ear :isturbed Sensor% "erception <Auditor%=, related to reduced sound 1a0e conduction .+paired 5erbal $o++unication caused b% conducti0e hearin! loss N&rsin Inter'entions Minimizing Discomfort #dminister and teach parents to administer antibiotics+ Pro'ide instr&ction in+ o Measure+ent o correct dosa!e. o Ti+e o doses. o .+portance o ad+inisterin! all doses. o "roper stora!e and disposal o unused +edication.

Ad0erse e ects. Ad+inister aceta+inophen as directed or pain or e0er. Appl% 1ar+ co+presses to the e9ternal ear. Ad+inister anal!esic otic drops, i prescribed; usuall% indicated 1hen no per oration o the t%+panic +e+brane e9ists. Ad0ise ele0ation o head to acilitate draina!e o luid ro+ the +iddle ear into the phar%n9. Teach older children to sti+ulate openin! o their eustachian tubes b% %a1nin! or per or+in! 5alsal0a;s +aneu0er.
o

Minimizing 0earing Loss Teach parents to reco!nize earl% si!ns o otitis and to see- pro+pt treat+ent. "ro0ide preoperati0e and postoperati0e teachin! i 0entilation tubes are indicated <see pa!e @C(=. Stress the i+portance o the ollo17up 0isit to +a-e sure that otitis has resol0ed. 1acilitating Verbal Communication Assess hearin!, speech, and lan!ua!e de0elop+ent re!ularl%. Alert parents to i++ediatel% report si!ns o hearin! di icult% or dela%ed speech to ensure earl% inter0ention. 4e er to a specialist or e0aluation and treat+ent, i necessar%. Family Ed&cation and Health !aintenance Teach parents that episodes o" otitis may be minimi1ed by+ o 3reast7 eedin!. o "lacin! older, bottle7 ed in ants in a sittin! position durin! eedin!. o >sin! speciall% desi!ned bottles to allo1 upri!ht eedin!. o .denti %in! and eli+inatin! aller!ens, such as particular oods, +olds, and dust. o Not e9posin! the child to ci!arette s+o-e. Teach the i+portance o ta-in! antibiotic at prescribed ti+es or the indicated len!th o therap% to pre0ent partial treat+ent and the de0elop+ent o resistance. Teach all parents the di erence bet1een 0iral and bacterial in ections and that o0eruse o antibiotics or 0iral in ections contributes to the de0elop+ent o resistant bacteria. Encoura!e all parents to consult 1ith health care pro0ider be ore startin! antibiotic therap% or presu+ed in ection. I" 'entilatin t&bes are placed2 instr&ct parents to do the "ollo-in + o "re0ent 1ater or other luids ro+ enterin! the ear canal. Encoura!e use o earplu!s 1hen the child is bathin! or s1i++in!. o :iscoura!e instillation o eardrops or other +edications in the e9ternal ear unless the% ha0e been prescribed b% the health care pro0ider. o Tubes 1ill all out o the ear spontaneousl%, usuall% in ) to 8' +onths. Enco&ra e "amilies to disc&ss herbal therapy -ith health care pro'ider i" interested+ o Echinacea is used b% so+e to enhance i++une unction.

o o

Eardrops 1ith +ullein, St. John;s 1ort, and !arlic are a0ailable to alle0iate pressure in the +iddle ear durin! acute ear in ections. Folden seal is said to ha0e anti+icrobial acti0it%. 2i!h a+ounts +a% cause F. disco+ ort and possibl% ner0ous s%ste+ e ects.

E'al&ation. E/pected O&tcomes :e+onstrates i+pro0ed co+ ort; a+il% states proper treat+ent re!i+en Maintains ollo17up 0isits; e usion resol0ed Speech and lan!ua!e de0elop+ent appropriate or a!e; reports re!ular assess+ent; recei0es therap% ro+ specialist, i indicated E?TERN#* OTITIS E9ternal otitis is in la++ation in the e9ternal ear canal. .t is requentl% unilateral but +a% be bilateral. Pathophysiolo y and Etiolo y Ca&sed by bacteria or "&n i+ Common patho ens incl&de+ o "seudo+onas aeru!inosa. o Enterobacter aero!enes. o "roteus +irabilis. o Staph%lococcus epider+idis. o Hun!i <candida, asper!illus=. Ris5 "actors incl&de+ o Hrequent s1i++in!, especiall% in chlorinated pools; chlorine destro%s the nor+al ear lora. o .nsertion o ob/ects, such as cotton s1abs, into the ear canals. o A?M 1ith per oration o the t%+panic +e+brane. o 5entilation tubes 1ith draina!e. *hen 1ater re+ains in the e9ternal ear canal, a 1ar+, +oist en0iron+ent is created. S-in linin! the canal is irritated, causin! brea-do1n o its protecti0e barrier. 3acteria or un!i o0er!ro1 in the conduci0e en0iron+ent and cause s%+pto+s o in la++ation and in ection in 8 to ' da%s. 3rea-do1n o protecti0e barrier and introduction and proli eration o in ectious or!anis+s can also occur throu!h trau+a to the ear canal, such as cleanin! the ear 1ith an inappropriate ob/ect or usin! an i+proper technique. Clinical !ani"estations Ear pain, itchin!, and 1hite, %ello1, or !reenish draina!e. .n la++ation o the e9ternal ear canal and structures. "ain 1hen the ear pinna is +anipulated. Dia nostic E'al&ation ?toscopic e9a+ination; +a% be di icult because o se0ere pain and s1ellin!; sho1s redness, s1ellin!, and draina!e in canal; t%+panic +e+brane appears nor+al.

$ultures usuall% not necessar%.

!ana ement Acetic acid solution <5KSol= to dr% and +odi % the p2 o the ear canal. Topical antibiotic solution, possibl% co+bined 1ith a steroid to reduce si!ni icant disco+ ort and s1ellin!. Ear canal +a% require irri!ation to re+o0e draina!e. A +edication7soa-ed 1ic- +a% be inserted to acilitate +edication ad+inistration. N&rsin #ssessment Assess se0erit% o s%+pto+s and need or pain relie . Assess ear h%!iene and the need or earplu!s. N&rsin Dia nosis Acute "ain related to in la++ation and irritation o draina!e N&rsin Inter'entions Relieving Pain #dminister eardrops2 or teach parents administration2 as prescribed+ o 2a0e child lie on side 1ith a ected ear up1ard. o .nstill drops, usin! caution not to conta+inate dropper. o 2a0e child +aintain position or @ +inutes to acilitate penetration o +edication into ear canal. o 4epeat on other side, i ordered. Ad+inister anal!esics, such as aceta+inophen <T%lenol=, as directed. Su!!est application o 1ar+ or cold co+presses to outer ear to relie0e disco+ ort. Hrequentl% clean draina!e ro+ area surroundin! openin! o ear canal to relie0e irritation. Family Ed&cation and Health !aintenance Teach proper ear hy iene+ o .nsert nothin! into ear canal or cleanin! or scratchin!. o $lean the outer area 1ith a 1ashcloth onl%. o :rain 1ater pro+ptl% ro+ ear b% leanin! the child o0er and pullin! auricle sli!htl% do1n1ard and out1ard. .nstruct in the use o 1ell7 ittin! earplu!s, i necessar%. .nstruct in the use o routine acetic acid solution instillation a ter 1ater acti0it%, i prescribed. E'al&ation. E/pected O&tcomes 4eports pain relie0ed; uses co+presses and anal!esics, i necessar% FUNCTION#* HE#RIN$ DISORDERS

Hunctional hearin! disorders arise ro+ proble+s in the unction o the ear. .n a quiet en0iron+ent, the health% child can hear tones bet1een ( and '@ decibels. $ate!ories o hearin! i+pair+ent include sli!ht, 8@ to '@ decibels; +ild, '@ to B( decibels; +oderate, B( to )@ decibels; se0ere, )@ to C@ decibels; and pro ound, C@ or +ore decibels. .n the >nited States, appro9i+atel% @,((( in ants are born 1ith +oderate to pro ound bilateral sensorineural hearin! loss each %ear. Hactors that place an in ant at hi!h ris- or hearin! loss include lo1 birth 1ei!ht, a+il% histor% o hereditar% childhood hearin! loss, and certain in ections, such as rubella or bacterial +enin!itis. Pathophysiolo y and Etiolo y 2earin! loss +a% be conducti0e or sensorineural. Cond&cti'e loss occ&rs -hen so&nd transmission thro& h the o&ter and>or middle ear is impaired2 ca&sed by impaction o" cer&men in the e/ternal ear canal2 "l&id in the middle ear ca'ity2 or scarrin o" the tympanic membrane+ o A +echanical obstruction, such as ceru+en or a orei!n ob/ect bloc-in! the e9ternal ear canal, +a% bloc- the passa!e o sound 1a0es to the t%+panic +e+brane. o *ith otitis +edia or ?ME, luid in the +iddle ear ca0it% does not trans+it sound as 1ell as air. o A scarred or per orated t%+panic +e+brane has lost its nor+al +obilit% and does not trans+it sound as 1ell as a nor+al one. o Most cases o conducti0e hearin! loss in children are re0ersible and produce no per+anent e ect. Sensorine&ral hearin loss res&lts "rom dama e to the cochlea or a&ditory ner'e and con enital de"ects o" the cochlea+ E/amples incl&de dama e ca&sed by ototo/ic dr& s2 dama e res&ltin "rom prenatal in"ections2 and dama e ca&sed by prolon ed e/pos&re to lo&d noise+ o :a+a!e to the auditor% ner0e pre0ents trans+ission o sound i+pulses to the brain or interpretation. o :a+a!e to hair cells o the cochlea +a% be caused b% prolon!ed e9posure to loud noise, resultin! in hearin! loss, especiall% pronounced or hi!h7 pitched sounds. o Sensorineural proble+s are usuall% irre0ersible. Clinical !ani"estations .n ants +a% be noted to be unresponsi0e to sound. 4esponse to sound, ho1e0er, is not su icientl% reliable as a screenin! +ethod, especiall% or hi!h7ris- in ants. Children &s&ally do not complain that they cannot hear -ell+ They may e/hibit other si ns o" hearin problems2 incl&din + o "oor acade+ic per or+ance or beha0ior proble+s in school. o Lac- o response to sounds. o :ela%ed lan!ua!e de0elop+ent. o Listenin! to the tele0ision or radio at a loud 0olu+e. o Spea-in! loudl%. Dia nostic E'al&ation

>ni0ersal ne1born hearin! screenin! usin! a t1o7sta!e process is ad0ocated b% the A+erican Acade+% o "ediatrics and the A!enc% or 2ealth $are "olic% 4esearch and is 1idel% accepted as the standard o care or in ants in the >nited States. This is acco+plished b% an initial auto+ated transient e0o-ed otoacoustic e+ission <?AE= be ore dischar!e ro+ the hospital ne1born nurser%. . indicated, an auto+ated auditor% brain response test is used to con ir+ a positi0e ?AE screen. .n ants 1ho ail their initial screenin! need a ollo17up appoint+ent 1ith an audiolo!ist 1ho 1ill per or+ a dia!nostic screenin! e9a+ination. This 0er% i+portant step should occur be ore the child is a!e A +onths. .n ants 1hose initial hearin! screen is nor+al should be routinel% assessed or their response to sound and achie0e+ent o de0elop+ental speech lan!ua!e +ilestones. 4outine audio+etric screenin! should be done be!innin! as soon as the child can cooperate and ollo1 instructions <bet1een a!es A and @=. .t is i+portant that the child be screened and hearin! de icits addressed be ore entr% into school.

!ana ement Treat+ent o the underl%in! proble+, such as i+pacted ceru+en or otitis +edia. 2earin! aids +a% be help ul or both conducti0e and sensorineural hearin! loss. Cochlear implants help some children -ith sensorine&ral hearin loss+ o $onsists o an e9ternal +icrophone and speech processor, 1hich sends radio si!nals to an internal electrode arra% i+planted in the cochlea. o Most e ecti0e in the %oun! child 1ho has had shorter hearin! depri0ation, but requires a lon! period o rehabilitation. . the proble+ cannot be corrected, the ocus o treat+ent is on de0elop+ent o adapti0e s-ills throu!h special education, si!n lan!ua!e or other co++unication alternati0es, and/or technical de0ices or the hearin! i+paired. Complications Speech and lan!ua!e dela%s. .nadequate social de0elop+ent. N&rsin #ssessment "eriodicall% assess hearin! in the child 1ith an identi ied hearin! i+pair+ent, to ollo1 up pro+ptl% on chan!es in abilit% to hear. Assess speech and lan!ua!e de0elop+ent requentl% so that children +a% obtain special assistance, as indicated. Assess social de0elop+ent and acade+ic pro!ress periodicall% so that counselin! and inter0ention can be instituted. N&rsin Dia noses :isturbed Sensor% "erception <Auditor%=, related to li+ited abilit% to hear .+paired 5erbal $o++unication related to inabilit% to hear and i+itate speech sounds 4is- or .n/ur% related to inabilit% to hear 1arnin! sounds o i+pendin! dan!er

$hronic Lo1 Sel 7Estee+ related to social and acade+ic di iculties

N&rsin Inter'entions Minimizing Effects of 0earing Loss Hace the child, use appropriate acial e9pressions, and +a-e sure the child can see %our ace clearl% 1hen co++unicatin!. Approach the child so that %ou can be seen; touch the dea child on the shoulder to !et attention. Assist the child in utilizin! hearin! aid as prescribed. Promoting Effective Communication :eter+ine usual +ethod o co++unication: abilit% to 1rite, usin! 0erbal cues, or readin! lips. :o not depend on !estures to co++unicate 1ith child or 1ith a third part% 1ho does not -no1 si!n lan!ua!e. ?btain an interpreter, 1hen necessar%, or children 1ho co++unicate usin! si!n lan!ua!e. Adequate co++unication is especiall% i+portant 1hen pro0idin! health education or 1hen treatin! children 1ho +a% ha0e been abused. Help the parents o" a yo&n child to stim&late and comm&nicate -ith him or her+ o Teach the+ to use !estures, +i+e, and non0erbal co++unication. o Teach the+ to help the in ant to de0elop 1atchin! beha0ior b% re1ardin! hi+ 1ith pleasure and praise. o Teach the+ to tal- to the child 1hile loo-in! directl% into his e%es and usin! appropriate acial e9pressions. Preventing In ury Ad0ise parents that ho+e sa et% de0ices, such as s+o-e detectors, +a% require 0isual or tactile alar+s < lashin! li!hts or 0ibration= rather than auditor% alar+s. Encoura!e the use o other senses to co+pensate or inabilit% to hear. Hor e9a+ple, the child should be especiall% care ul to loo- in all directions 1hen crossin! the street. :o not lea0e the child alone in an un a+iliar en0iron+ent 1ithout +eans o co++unication. "ro0ide close sur0eillance and requent 0isual contact or the hospitalized child. Increasing ,elf-Esteem .n or+ a+ilies o the child;s ri!ht to a public education. Encoura!e interaction 1ith hearin! and nonhearin! children to pro+ote inte!ration. Encoura!e +aster% o de0elop+ental +ilestones and s-ills throu!h sel 7care acti0ities and pla%. 2elp parents understand that the child +a% not be able to e9press an9iet% or rustration and +a% act out instead. Teach the+ to be consistent in their use o discipline and to pro0ide alternati0e 1a%s or the child to !ain attention or to relie0e stress. "raise the child or acco+plish+ents and atte+pts at social interaction.

Family Ed&cation and Health !aintenance Encoura!e a+ilies to learn si!n lan!ua!e and alternati0e +ethods o co++unication 1ith the child. Ad0ise on proper hearin! aid cleanin! and +aintenance. Encoura!e attention to health +aintenance needs, such as i++unizations and 1ell7child 0isits. Hor additional support and in or+ation, re er to a!encies such as the A+erican Speech72earin! Association, http://111.asha.or!. E'al&ation. E/pected O&tcomes 4esponds appropriatel% to en0iron+ental sti+uli $o++unicates e ecti0el% throu!h si!n lan!ua!e, interpreter, and 0isual cues 4eports no in/uries 4eports adequate pro!ress in school and participation in e9tracurricular acti0ities ,ELEC%ED RE1ERE!CE, Al1ard, *.L.M. <'((B=. A ne1 an!le on ocular de0elop+ent. Science, 'CC<@)8'=, 8@'J. A+erican Acade+% o Ha+il% "h%sicians, A+erican Acade+% o ?tolar%n!olo!%72ead and Nec- Sur!er%, ,A+erican Acade+% o "ediatrics Subco++ittee on ?titis Media 1ith E usion. <'((B=. ?titis +edia 1ith e usion. "ediatrics, 88A<@=, 8B8'78B'C. A+erican Acade+% o "ediatrics. <8CCJ=. En0iron+ental tobacco s+o-e: A hazard to children. "ediatrics,CC<B=, )AC7)B'. 3ec-, A.:. <'((8=. :ia!nosis and +ana!e+ent o pediatric !lauco+a. ?phthal+olo!% $linics o North A+erica,8B<A=, @(87@8'. 3ehr+an, 4.E., Ilie!+an, 4.M., ,Jenson, 2.3. <'((B=. Nelson te9tboo- o pediatrics <8Jth ed.=. "hiladelphia: *.3. Saunders. $arpenito, L.J. <'((A=. Nursin! dia!nosis: Application to clinical practice <8(th ed.=. "hiladelphia: Lippincott *illia+s ,*il-ins. $o++ittee on "ractice and A+bulator% Medicine, Section on ?phthal+olo!%. A+erican Association o $erti ied ?rthoptists; A+erican Association or "ediatric ?phthal+olo!% and Strabis+us; A+erican Acade+% o ?phthal+olo!%. <'((A=. E%e e9a+ination in in ants, children, and %oun! adults b% pediatricians. "ediatrics,888<B "art 8=, C('7C(J. $unnin!ha+, M., , $o9, E.?. <'((A=. 2earin! assess+ent in in ants and children:4eco++endations be%ond neonatal screenin!. "ediatrics, 888<'=, BA)7BB(. Hu/i-a1a, S., ,6oshina!a7.tano, $. <'(((=. $urrent status o uni0ersal ne1born hearin! screenin!. $urrent ?pinion in ?tolar%n!olo!% and 2ead and Nec- Sur!er%,#<@=, B(B7 B(#. 2e land, M., et al. <'((8=. Ne1born hearin! screenin!: S%ste+atic e0idence re0ie1 nu+ber @. A24L "ublication No. ('7S((8. A0ailable: http://111.ncbi.nl+.nih.!o0/boo-s/b0. c!iMridNhstatA.chapter.8J#J. Leonardi, A., ,Abelson, L.A. <'((A=. :ouble7+as-ed, rando+ized, placebo7controlled clinical stud% o the +ast cell7stabilizin! e ects o treat+ent 1ith olopatadine in the con/uncti0al aller!en challen!e +odel in hu+ans. $linical Therapeutics,'@<8(=, '@AC7 '@@'.

Marc%, F., et al. <'((8=. Mana!e+ent o acute otitis +edia, e0idence report/technolo!% assess+ent nu+ber 8@. A24L "ublication No. (87E(8(. A0ailable: http://111.ncbi.nl+.nih.!o0/boo-s/b0. c!iMridNhstat8.chapter.'8('). Ie+per, A.4., ,:o1ns, S.M. <'(((=. $ost7e ecti0eness anal%sis o ne1born hearin! screenin! strate!ies. Archi0es o "ediatrics and Adolescent Medicine,8@B<@=, B#B7B##. N.:$:. <'((A=. N.:$: 1or-in! !roup: 3etter co++unication needed to reduce in ants Olost to ollo17up.P N.:$: .nside. A0ailable: http://111.nidcd.nih.!o0/health/inside/spr(A/p!8.asp. 4oland, ".S. <'((B=. ?totopical a!ents are superior to s%ste+ic therap% or the treat+ent o acute and chronic otitis +edia. Ear, Nose, , Throat Journal, #A<C Suppl. B=, C78'. Troc+e, S.:., ,Sra, I.I. <'(('=. Spectru+ o ocular aller!%. $urrent ?pinion in Aller!% and $linical .++unolo!%,'<@=, B'A7B'J. 6oshina!a7.tano, $., ,Fro0el, J.S. <'((8=. The e0idence or uni0ersal ne1born hearin! screenin!. A+erican Journal o Audiolo!%, 8(<'=, )'7)B.