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Later problems of premature babies (Part 2)

Eye and Vision Problems

What are some of the more common eye problems of former preemies?
The most common eye problems to appear after discharge are:

  • Poor vision (either near sighted or far sighted)
  • Strabismus (inward or outward turning of one or both eyes)
  • Amblyopia (lazy eye due to unequal vision)
  • Nystagmus (constant or frequent jerking movements of the eye)
  • Decreased color vision (some colors look alike, for example purple, blue, green)
  • Smaller field of vision

Although the above listed problems are more common in infants who have had Retinopathy of Prematurity, they can occur in other preemies as well.

  • Hemangiomas are small networks of tiny blood vessels. They can appear anywhere on the skin and grow rapidly for several months. If they are on the eyelid or skin surrounding the eye, they may interfere with vision. Hemangiomas are more common in premature infants.
  • Former preemies can have eye problems common in all children, these include:
    • Conjunctivitis – inflammation or infection of the surface of the eye
    • Blocked tear duct

How will I know if my child has an eye problem?
If your child develops any of the following, bring these to the attention of your child’s doctor. Your infant may need to see an ophthalmologist (eye doctor) very soon; s/he might have a serious vision problem.

  • Infant frequently pokes at his/her eye
  • Lazy eye, slow to move
  • Constant movement of eyes, even when trying to look at something
  • Frequent crossing of eyes, beyond three months of age correcting for prematurity
  • One eye that stays out or in most of the time
  • Frequent or constant jerking of eyes especially when looking straight ahead. A few jerks when looking to the far left or far right is normal.
  • The infant fails to blink to a camera flash just in front of the face
  • The surface of the eye or the pupil (black circle in the center of the eye) appears cloudy or white
  • In a photo, the center of one eye appears red while the other eye does not
  • Abnormal head turn or head tilt
  • The infant (beyond 6 weeks of age correcting for the weeks of prematurity) cannot fix his/her eyes on an object or a face, or follow it as it moves
  • The infant’s eyelid droops so much that it completely covers the pupil (black center) of the eye when he/she is awake
  • Normal lighting seems to hurt the baby’s eyes and make him/her cry or turn away

Common problems can often be handled by your baby’s regular doctor.

These include:

  • Frequent tearing (blocked tear duct)
  • Redness to the eyes with cloudy or yellow drainage (may indicate a conjunctivitis or infection on the surface of the eye)

If you have a question about your baby’s sight or think your child may not see well, call your baby’s physician or an eye doctor.

It is important to keep any eye appointment that was arranged at your baby’s discharge, even if you do not think there is an eye problem.

How are eye problems treated?
Infants who have poor vision can be fitted with glasses. If the correction of vision would require very heavy or thick lens, soft contact lens may be prescribed. Other conditions, such as wondering eye and crossed eye, are treated with patching of one eye to encourage the use of the other eye. Early treatment is important for best visual outcome later on.

Why is early treatment so important?
When infants see much better out of one eye, or if using both eyes causes double vision, they will gradually stop using (seeing out of) the weaker eye. Visual pathways are still being established in the first few months and years of life. Making and keeping these connections requires regular use of the eye. If a child “blocks out” vision in one eye during this critical period in eye development, these connections are not established and cannot be made at a later age. Sight from two eyes is necessary for determining what is close and far away (depth perception). Poor vision may slow mental development and physical progress in many areas such as recognition of objects, learning symbols such as letters or pictures, and motor activities such as walking or climbing.

Hearing Problems

How common are hearing problems in preemies?
At birth, moderate to severe hearing impairment occurs in about three per 1000 infants born on time, but in about three per 100 (3%) of high risk infants.

High risk factors include:

  • Birth weight under 1500 grams (3lb 5oz), especially those with IVH or PVL
  • Family history of childhood hearing loss
  • Viral infection present at birth
  • Any abnormality in the formation of the face or the ear
  • Very high bilirubin levels necessitating exchange transfusion
  • Infection of the fluid surrounding the brain, called meningitis
  • Severe lack of oxygen near the time of birth

Children can also develop hearing loss after birth during childhood.

How will I know if my baby has a hearing problem?
Many nurseries screen babies for hearing. Commonly used hearing tests are:

  • Auditory Brainstem Response (example, ALGO) – Three electrodes are placed on the baby’s head and a click sound is delivered to the baby’s ear by a small headphone. The baby’s brainwave response to the sound is recorded and compared to a normal baby pattern.
  • Otoacustic Emissions – A small rubber probe is placed in the ear canal. It delivers a sound which travels to the inner ear. The inner ear sends back an echo which is picked up by a microphone in the probe.
  • The Crib-o-gram – A loud sound is presented to the infant during light sleep. If the baby responds by arousing from sleep or startling, s/he passes. This test only detects severe hearing loss.

If my baby does not pass the screening test, is s/he deaf?
Hearing tests are designed to not miss a possible hearing problem. There are many “false positives” or abnormal tests in babies who eventually turn out to have normal hearing.

Things that cause false positive tests include:

Ear wax or other substance blocking the canal

  • Narrow ear canal
  • Testing in a noisy setting
  • Ear infection
  • Restless, fussy baby
  • Certain medications

Some medical problems of preemies cause changes in hearing which go away when the problem resolves. For that reason, babies are usually tested near the time of discharge, not when they are the sickest.

Any abnormal screening test must be verified by another test at later point in time.
After discharge how will I know if my child has a hearing problem?

The following is a check list for hearing. All ages listed are based on the child’s age from his/her due date, not the date of birth.

Due Date

  • Does your baby awaken, startle or cry to a loud sound?
  • Does your baby seem to listen to speech part of the time?

At 3 Months

  • Does your baby seem to recognize mother’s voice?
  • Does your baby appear to listen to sounds or speech?
  • Does your baby smile when spoken to?
  • Does your baby turn toward the person speaking?

At 6 months

  • Does your baby distinguish friendly sounds from angry or warning sounds, such as NO!?
  • Does your baby notice and look around for the source of new sound?
  • Does your baby turn toward the side a sound is coming from?
  • Does your baby enjoy vocal play?
  • Does your baby coo in more than one tone?

At 9 months

  • Does your child turn or look when you call?
  • Does your child look for the source of a new sound?
  • Does your child listen to sounds or people talking?

At 12 months

  • Has your child begun to respond to requests, such as Where is…..?
  • Does your child babble?
  • Does your child have 3 words?

At 18 months

  • Does your child understand and respond to requests?
  • Does your child have at least 8 words?
  • Does your child have a way of indicating no, either verbal or gesture?
  • Does your child respond to rhythm music?

After 24 months hearing loss may be suspected if:

  • The child’s speech sounds like s/he has a cold even when s/he does not
  • The child’s speech is difficult to understand
  • The child has fewer words than other children his/her age
  • The child does not pay attention when someone is speaking
  • The child cannot follow simple directions

Hearing is often decreased during a cold or ear infection. When children are young, their speech and communication may be noticeably poorer during a cold or ear infection, but should return to the previous level after the illness.

What should I do if I suspect my child has a hearing problem?
Notify your child’s doctor of your concern and make arrangements to have his/her hearing tested. This testing should be done at your earliest convenience and when your child does not have a cold or ear infection. Do not delay several months; early detection of hearing loss is very important!

Why is early detection of hearing loss so important?
Hearing is essential for speech and language development. The sooner a hearing loss is detected, the sooner the child can be treated and the better language and speech s/he will develop.

How is hearing loss treated?
If there is some hearing, sounds can be amplified (increased) by a hearing aids. If the loss is severe, children may also be taught other forms of communication such as sign language or lip reading. Speech and hearing therapists can teach you how to best communicate with your child. Specialists must determine the location of the hearing problem (outer, middle or inner ear) before deciding on the best treatment.

Dental Problems

What are common dental problems of former preemies?
The most common dental problems are:

  • Abnormal formation of enamel (white outer covering of the tooth)
  • Slow teething, especially of the first baby teeth. As the child gets older, there is catch up to the normal teething pattern.
  • High arch or groove to the palate (roof of the mouth)
  • Abnormal bite called cross-bite

Why do preemies have more dental problems than term babies?
We do not know all of the reasons for these problems, but some common factors are:

  • Stress and severe illness delay and alter normal tooth formation.
  • Normally during the second half of pregnancy the teeth are forming enamel from calcium and phosphorus. It is not possible to deliver as much calcium and phosphorus to the preemie as s/he would get if s/he were in the womb.
  • This is true even though formulas, breast milk and nutritional fluids by vein are fortified with added calcium and phosphorus.
  • If a baby needs to be on the breathing machine, the breathing tube that is in the mouth rubs or presses against the roof of the mouth and the gums. Over time this may make the palate high and more arched than normal. The pressure of the tube or an instrument on the gums may also change the development of the teeth under the gum.

How will I know if my child’s teeth have enamel problems?
Often small abnormalities in enamel formation are not visible. More severe abnormalities are:

  • The teeth may not appear as white as other children’s. They may have a gray or brownish color.
  • The teeth may have an uneven surface.
  • The teeth may have an abnormal shape.

What problems should I expect if my child’s teeth have poor emamel?
When the enamel of the tooth is poorly formed, it is much easier for the tooth to develop cavities.

What can I do to prevent tooth decay?
It is very important to do the following:

  • Develop good toothbrushing habits as soon as the teeth break through the gums. The teeth should be cleaned two times a day, morning and before bedtime.
  • Avoid the habit of letting your child sleep at night or nap with a bottle. It can cause decay so severe that it destroys the teeth. Dentists refer to this as Nursing Bottle Tooth Decay.

Which teeth are most likely to be abnormal?
The baby teeth are most often affected with enamel probems. Sometimes the first permanent teeth to come in are affected also, but usually to a lesser degree. These include the front teeth (incisors) and the first permanent molars (six-year molars).

What can be done for my baby’s abnormal teeth?
Often problems look worse than they actually are. Good dental care and regular toothbrushing may be all that is needed. Cavities can be filled just as for any child with a dental cavity.

What can be done for my baby’s high arched palate?
The shape of the palate can effect many things, including speech and bite. As your child gets older, the shape of the palate, along with other factors, determine if your child needs braces or other orthodontics. Most children seem to adapt to the shape of their palate and will compensate if their palate is higher than normal.

Will my child need braces later on?
The need for braces is determined by many factors including the shape of the palate and the presence of a cross-bite. The chances that your preemie will need braces are probably a little higher than average.

When should my premmie first see a dentist?
Pediatric dentists prefer to see children at a very young age. The current recommendation of the American Academy of Pediatric Dentistry is for any child to see the dentist by his/ her first birthday. Since preemies are known to have more dental problems, this early exam is often beneficial.

At this visit your dentist may:

  • Show you how to care for your child’s teeth; give tips on brushing
  • Address diet concerns that relate to teeth
  • Find any problems that need attention

No matter what the age, if you notice any questionable areas in your child’s teeth, make a dental appointment.

(Copyright University of Wisconsin Medical School, Pediatrics Department)

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