A child’s birth and developmental history can provide insight into their visual development. Delays or disruptions in developmental milestones may impede the visual system and increase the risk of visual function and processing challenges. Therefore, the case history for a pediatric exam should include questions relating to the birth process, medical conditions, infant development milestones, and academic status.
The most efficient way to obtain a pediatric patient’s developmental history is to provide an intake form to the parents before the scheduled eye examination. This allows the optometrist to review the information ahead of time, ask appropriate follow-up questions, and perform the examination promptly before the child becomes distracted or fatigued.
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Pediatric Eye Exam Developmental History Checklist
Use the questions on this checklist to get a thorough developmental history of pediatric patients.
Questions related to birth history
There are a variety of factors during both the pregnancy and birthing process that could impact a child’s ocular health and visual functions. Asking detailed questions about the mother’s health status during pregnancy, including prematurity, delivery methods, and medical treatments provided after birth, can hint at the child’s risk of future ocular health diseases or visual developmental delays.
1) What was the duration of the pregnancy?
Infants born prematurely (before 28 weeks) are at risk of retinopathy of prematurity, strabismus, and myopia.1 There is also a higher risk of breathing/feeding difficulties, hearing issues, and developmental and cognitive delays.
2) Were there any medical complications to the mother or child during pregnancy?
Certain medical conditions, such as gestational diabetes or pre-eclampsia, can lead to premature birth. If the mother had gestational diabetes, the child is at risk of developing type 2 diabetes later in life.
This is important information, as optometrists are one of the primary healthcare professionals who can detect diabetes early through retinal health evaluations.
3) Was there any smoking, alcohol, or toxic drug exposure to the mother or child during pregnancy?
Smoking and drug use could cause premature birth and cognitive delays, ultimately putting the child at risk for visual challenges. Maternal smoking is a significant risk factor for amblyopia and strabismus,2 and is associated with a thinner retinal nerve fiber layer (RNFL) in young adulthood, which puts the child at risk of later developing glaucoma.3 Those with fetal alcohol spectrum disorders commonly show optic nerve hypoplasia and may have other visual perceptual challenges.4
4) What was the delivery method (vaginal or Caesarean section)?
Delivery through the vaginal birth canal activates specific developmental reflex patterns (necessary for newborn survival) that eventually drive sensory motor development and visual-motor integration. It is suggested that a Caesarean section (C-section) delivery could hinder this activation process and put children at risk of retaining reflexes past the first year of life.5
Retained primitive reflexes can lead to poor visual fixation, tracking, eye-hand coordination, fine motor control, and visual memory. It can also lead to clumsiness, laterality and orientation issues, and short attention.5,6
5) Were forceps used during delivery?
The use of forceps during vaginal delivery can result in ocular trauma to the anterior or posterior segment. Some case reports included corneal scarring or lid ptosis (leading to deprivation amblyopia), cranial nerve palsies (leading to strabismus), and hemorrhages in the anterior chamber or retina.7
6) Were there any medical complications during or immediately after the delivery?
Any trauma experienced in the birth canal can lead to the risk of retaining developmental reflexes past the first year of life. One study also suggested that neonatal jaundice negatively impacts the infant’s visual contrast and grating sensitivity in the first 5 months of life.8
7) Was oxygen provided to your child after delivery?
Oxygen delivered to premature babies can increase their risk of retinopathy of prematurity.9
8) Did your child pass the newborn hearing test?
A hearing delay or impairment could hinder cognitive development and speech and language skills. A failed newborn hearing test may indicate a need for further investigation into the child’s vestibular system, which can impact motor and visual-motor development.
Questions related to medical history
The eyes are connected to the vascular and nervous systems; therefore, having certain medical or neurological conditions could impact not just ocular health but also visual processing skills.
Pediatric patients with neurological conditions or behavioral disorders are at a high risk of visual processing delays, which include issues with eye tracking, spatial planning or laterality (reversals), visual memory, visual figure-ground, and so much more.
Vision is also intertwined with other senses. Awareness of any hearing impairments or motor issues can help rule out any visual challenges related to these sensory delays.
1) Any history of ear infections? If so, which side and how often?
Auditory deprivation in early development secondary to frequent ear infections can impact speech and language, as well as delayed visual information processing skills related to reading and learning.10
Ear infections may signal an issue with primitive reflex development as well.6 If chronic ear infections disrupt the vestibular system, the child could be at risk for visual-vestibular challenges.
2) Any neurological conditions (cerebral palsy, epilepsy, seizures, etc.)?
The visual system is extensively intertwined with different areas of the brain; thus, damage to the neurological system can lead to a broad range of visual and ocular dysfunctions.
Children with cerebral palsy, seizure disorders, hydrocephalus, central nervous system infections, head trauma, or hypoxic-ischemic encephalopathy are at risk of cerebral visual impairment.11 Not only can visual acuity or visual fields be impaired, but many visual processing skills can also be delayed.
3) Any systemic or autoimmune conditions? Any current medications?
Rule out various ocular diseases that their medical conditions could cause. If the child takes any medications, check for ocular side effects.
4) Any allergies?
For all patients, it is important to note any allergies to medications before releasing a new prescription for medication. It is helpful to note food or scent allergies to avoid those triggers in the exam room and the office space.
5) Any suspected or diagnosed behavioral conditions (ASD, ADHD, etc.)?
Behavioral conditions such as Autism Spectrum Disorder (ASD) or Attention Deficit Hyperactivity Disorder (ADHD) can be associated with binocular or accommodative dysfunction and visual processing challenges. Knowing the child’s specific behaviors gives insight into their level of visual function and helps to address the child’s visual needs for maximizing their learning potential at school and home.
6) Any history of head or sports injuries?
If so, the optometrist can ask follow-up questions about whether the child experiences visual symptoms of traumatic brain injury.
7) Any previous or current therapy programs (physical, speech and language, occupational, etc.)?
Asking this question is key to holistically understanding the child’s health. The senses are all related; therefore, if the child has auditory or motor delays, this prompts further investigation to rule out associated visual processing delays.
8) Any history of eye conditions and/or treatments (glasses, eye drops, surgeries, etc.)?
Of course, as optometrists, we cannot forget to ask about the child’s ocular history. Ask the same questions you would ask an adult patient regarding their ocular health, including a history of wearing glasses or contact lenses and any previous ocular surgeries or laser procedures.
9) Any family history of eye conditions?
Family ocular history, such as myopia, strabismus, or glaucoma, could also put the child at risk of developing those conditions, so be sure to pay attention to similar abnormalities during the exam.
Questions related to infant developmental milestones
The following questions are crucial for understanding the child’s developmental process. The Centers for Disease Control and Prevention (CDC) has a guide for stages of development, but it is important to note that development does not necessarily have to follow a strict age timeline.12 Completely skipping a stage, however, can disrupt future stages of sensory development.
Within the first few months of life, infants' motor development expands as they explore the world around them through tummy time, sitting, crawling, and walking. While it was recently removed from the CDC stages of development in 2022, crawling should still be encouraged to promote bilateral coordination and visual-motor skills.
These developmental milestones play an important role in integrating reflex patterns.5,6,13 If these reflexes are retained, children can experience challenges with visual-motor skills, oculomotor skills, binocularity, reading, and athletic performance.
Any delay or skipping of these developmental stages can negatively impact visual development, putting the child at risk for refractive or strabismic amblyopia, oculomotor dysfunction, and visual processing challenges. Remember that experiencing each developmental stage is more important than the age at which each stage was experienced.
Table 1 compares pediatric developmental stages to their corresponding expected ages.
| Developmental Stage | Expected Age |
|---|---|
| Rolling over/tummy time | 2 to 4 months old |
| Crawling | 6 to 11 months old |
| Walking | 12 to 18 months old |
| Speaking simple words (other than mama/dada) | 15 months old |
| Speaking 50 words or more | 30 months old |
Table 1, Courtesy of Amrit Bilkhu, OD, FAOO
Questions related to academic history (if applicable)
Answers to the following questions give optometrists more detailed information on what visual challenges could interfere with the patient's academic performance.
If the child is reading below the expected grade level, having trouble keeping attention in class, avoiding completing homework, or struggling with handwriting, there is a good chance the visual system may be contributing to these challenges.
1) What grade is your child currently in or soon entering?
Be sure to know what reading level is expected in early grades to provide appropriate reading targets during the exam.
2) Has the patient repeated a grade level?
If so, ask further questions as to why the grade level was repeated.
3) What is your child’s current reading level: below, within, or above grade average?
Schools use different grading scales for reading skills using numbers or letters, so be sure to understand where the child falls in their school’s specific grading scale.
4) What are the patient's favorite subjects?
When a child expresses that their favorite subject is gym or story time (where the teacher reads aloud), that could be a sign of avoiding near tasks due to visual discomfort.
5) What are your child’s least favorite subjects or subjects they struggle with?
Subjects that require more reading and handwriting (e.g., science, math, English, and social studies) are often the least favorite for children who experience visual discomfort.
6) Does the patient have any known learning-related challenges?
7) Is your child receiving any tutoring services or additional reading programs?
8) Is there an individualized educational plan or any school accommodations?
If there is an individualized educational plan (IEP) in place, ask if any visual accommodations are added to the plan. Optometrists can recommend additional accommodations based on any visual challenges discovered during the exam.
Make sure to download the Pediatric Eye Exam Developmental History Checklist
Closing thoughts
Keep in mind that parents and caretakers may be sensitive to answering some of the questions listed above. Give them the opportunity to provide answers by completing the form privately at home or offer a telehealth visit before the day of the child’s appointment. If questions are asked in the exam room, allow the parent to decide whether to answer in front of the child or in a separate room.
Using the information provided from a comprehensive medical and developmental history will guide the assessment for associated ocular diseases or visual perceptual challenges. Consideration of any developmental delays or disruptions will also help support a diagnosis of visual challenges and recommendations for interventional therapy programs.
