Vision in pediatric Patients
Tape
available from AAP
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With children heading back to school, the American Academy of Ophthalmology recommends that school age children have a complete medical eye exam by their fourth birthday, and routine eye exams approximately every two years thereafter. Parents should be aware of signs which may indicate that their child has vision problems, including:
An appointment with an ophthalmologist, pediatrician, or family physician is recommended. Eye exams may also be obtained through school programs, vision testing programs, churches, synagogues, community centers, clubs, or from volunteer organizations such as local Societies to Prevent Blindness. Common childhood eye problems include:Refractive errors. Refractive errors are eye conditions that can cause eye strain or a decrease in vision. They are corrected by wearing glasses or contact lenses. Hyperopia (farsightedness or the inability to focus on objects at close range) can cause children to cross their eyes. Myopia (nearsightedness or the inability to see clearly at a distance] is uncommon before a child reaches fourth grade. Amblyopia. Amblyopia, or "lazy eye," occurs when vision develops abnormally during early childhood. It can result from a number of underlying causes and is often difficult to detect. Glasses or eye-strengthening patches are used for treatment, which is most effective in preventing loss of vision when initiated at a very early age. Strabismus. Strabismus is a misalignment of the eyes, which causes them to point in different directions. Strabismus is a common condition among children and affects about 4% of all children in the U.S. Glasses or an eye patch are also used to treat strabismus, but surgery may be required in some cases. The American Academy of Ophthalmology Answers Your Questions About Learning DisabilitiesQ: How can I tell if my child has a learning disability? A: In the United States, approximately 3.4 million children younger than 13 years old have learning disabilities. Signs that may indicate your child has a learning disability include difficulty, avoidance, or extreme dislike of reading; poor handwriting; slow writing speed; difficulty with math; not being able to put information in order; difficulty understanding abstract concepts; memory problems; trouble following instructions or remembering words. It is not unusual for a child to have multiple learning disabilities. Children with learning disabilities may become frustrated, lose interest in school work, and try to avoid difficult tasks. Personality and behavioral problems may develop due to loss of self-esteem. Watch for signs of withdrawal, anxiety, depression or aggression. Remember that children with learning disabilities need love, understanding, and reassurance that they will do fine in life. Q: Is a learning disability, such as dyslexia, considered an eye problem? A: No. Learning disabilities are not problems of the eye or vision. Dyslexia is a serious reading disability that involves switching around letters and words. The eyes transmit visual signals to the brain. The brain determines what it has seen. Dyslexia is only one of several learning disorders that can involve reading, writing, speaking, concentrating, listening and doing math. Since it has been demonstrated that dyslexia and other specific learning disabilities stem from the central nervous system, treatment can be complex. Q: Who can help my child with his learning disabilities? A: First, the exact learning disability needs to be identified through school testing or a visit to a physician. Teachers, tutors, and physicians can all help identify and treat learning disabilities. Educators play key roles in offering early diagnosis and educational follow-up. Constant communication with your child is vital, to assist him or her in continuing educational growth, to help build self- esteem, and to offer reassurance. Q: I've been told that eye exercises and special prescription glasses are solutions to helping my child overcome his learning disability. Are these treatments recommended by the American Academy of Ophthalmology? A: No, the American Academy of Ophthalmology does not recommend these treatments, because no research proves their effectiveness. Eyes are used for vision, not comprehension. No scientific or medical evidence supports claims that academic abilities of dyslexic or learning disabled children can be improved with special glasses or eye exercises. Q: How much money should a parent spend on vision therapy to correct a child's learning disabilities? A: Absolutely none! It is often difficult for parents to accept the fact that their child might suffer from a learning disability. Often, out of concern for their child's well-being, parents go to great lengths to provide vision therapy for their children, including special diets, vitamins, sugar restriction, eye exercises or vision training. After spending valuable time, and often excessive money, on vision therapies, the learning disability remains. Ophthalmologists are medical doctors who specialize in eye and vision care. In diagnosis and treatment of eye diseases, ophthalmologists provide comprehensive eye exams, prescribe and administer corrective lenses and medicine, and perform surgery. The American Academy of Ophthalmology is the world's largest association of eye physicians and surgeons. For information on children's vision, visit the Academy's Internet site, http//www.eyenet.org CONTACT: Melissa Hurley, Katy Katzenberger, or Michelle Stephens of the American Academy of Ophthalmology, 415-561-8500 |
The earlier a vision or accompanying eye disorder is detected in infants, children, and young adults, the better the outcome of treatment. Life- and sight-threatening conditions can be detected during routine vision screening. It is for this reason that routine and effective vision screening is essential.
Pediatric Vision Screening: An Instructional Guide is based on the vision screening guidelines endorsed by the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology, included in the AAP policy statement, "Eye Examination and Vision Screening in Infants, Children, and Young Adults." Pediatrics, 1996;98(1): 153-157. The goal of this videotape is to provide professional who work with and care for children and parents with vital and practical information and guidance on vision screening.
Pediatric Vision Screening: An Instructional Guide covers
Ø The purpose and importance of vision screening
Ø Typical conditions screeners are likely to encounter
Ø What to check for during an examination
Ø How to screen children of different age properly
Ø When to refer to an ophthalmologist or other physician
Vision screeners are the first line of defense many children have in preventing blindness and serious illness from eye disease. We hope that your experience in viewing this videotape will prove beneficial to those infants, children, adolescents, and young adults you screen.
Pediatric Vision Screening: An Instructional Guide is a production of the American Academy of Pediatrics, an organization of 55,000 primary care pediatricians, pediatric subspecialists, and pediatric surgical specialists dedicated to the health, safety and well being of infants, children, adolescents, and young adults
To order a copy to this videotape, call the American Academy of Pediatrics at 888/227-1770.
30 minutes $45
Another source
Prevent Blindness America www.preventblindness.org
phone 1-800-331-2020
Eye Examination and Vision Screening in Infants, Children, and Young Adults (RE9625)
AMERICAN ACADEMY OF PEDIATRICS
Committee on Practice and Ambulatory Medicine, Section on Ophthalmology
Vision screening and eye examination are vital for the detection of conditions that distort or suppress the normal visual image,
which may lead to inadequate school performance or, at worst, blindness in children. Retinal abnormalities, cataracts,
glaucoma, retinoblastoma, eye muscle imbalances, and systemic disease with ocular manifestations may all be identified by
careful examination. Examination of the eyes can be performed at any age, beginning in the newborn period, and should be
done at all well infant and well child visits. Vision screening should be performed for a child at the earliest age that is practical,
because a small child rarely complains that one eye is not seeing properly. Conditions that interfere with vision are of extreme
importance, because visual stimuli are critical to the development of normal vision. Normal visual development requires the
brain to receive equally clear, focused images from both eyes simultaneously for visual pathways to develop properly.
Vision screening should be carried out as part of the regular plan for continuing care beginning at 3 years of age. Vision
screening guidelines have been endorsed by the American Academy of Pediatrics (AAP), the American Association for
Pediatric Ophthalmology and Strabismus (AAPOS), and the American Academy of Ophthalmology (AAO). To achieve the
most accurate testing possible, the most sophisticated test that the child is capable of performing should be used (see
"Appendix 1").[1]
As with other specialty areas, it is important for the pediatrician to establish contact with an ophthalmologist who is
experienced in treating children's eye problems and who practices in the same geographic area. A close working relationship
with such a specialist will clarify questions about procedures for eye screening as well as indications for referral for specialized
eye examinations.
TIMING OF EXAMINATION AND SCREENING
Children should have age-appropriate assessments for eye problems in the newborn period and at all subsequent health
supervision visits. Infants at risk for eye problems, such as retinopathy of prematurity, or those with family histories of congenital
cataracts, retinoblastoma, and metabolic and genetic diseases should have ophthalmologic examinations in the nursery. All
infants should be examined by 6 months of age to evaluate fixation preference, ocular alignment, and the presence of any eye
disease. These infants should continue to be checked until 3 or 4 years of age, when visual acuity in children can be evaluated
more easily. Formal vision screening evaluations should begin at 3 years of age.
PROCEDURES FOR EYE EVALUATION
Before objective testing, an adequate history should be obtained to elicit evidence of any visual difficulties. Appropriate
questions that might be asked initially would include: "Does your child seem to see well?" "Does your child hold objects
unusually close to his or her face when trying to focus?" "Do the eyes appear straight?" "Do the eyes seem to cross?" It is
important to listen carefully to parents who note that their children may have problems with their eyes or vision, because
parents' observations often prove correct. Relevant family histories regarding eye disorders or early use of glasses always
should be explored.
Eye evaluation in the physician's office should include the following:
1. External inspection of the eyes;
2. Tests for visual acuity on an age-appropriate basis;
3. Tests for ocular muscle motility and eye muscle imbalances; and
4. Ophthalmoscopic examination.
The child should be comfortable and in good health at the time of the examination and, if at all possible, should have some
preparation for the testing situation. Particularly for younger children, parents should demonstrate the anticipated testing
procedures. It is often convenient for the younger child to sit on the parent's lap during the procedures.
Children who have eyeglasses generally should have their vision tested while wearing the eyeglasses. However, eyeglasses
prescribed for use while reading should not be worn when distance acuity is being tested.
Various tests are available to the pediatrician for assessing vision in children at various ages. Different picture tests, such as
the LH test and Allen cards, can be used for children 3 to 4 years of age. Tests for children older than 4 years include wall
charts containing Snellen letters, Snellen numbers, the tumbling E test, and the HOTV test (a letter-matching test involving these
four letters). Consideration must be given to obtaining proper occlusion of the untested eye; cardboard and paddle occluders
have been found to be inadequate for covering the eye. There are commercially available occluder patches that provide positive
occlusion for appropriate testing (see comment 4 in "Appendix 1").[1] The distance for all vision testing except for that in which
Allen cards are used should be 10 ft. Vision testing should be performed in a well-lit area. Pediatricians can achieve equally
acceptable results using different techniques. A recent study of 102 pediatric practices revealed that 53% of them use screening
machines.[2] Because screening machines may be difficult for some children 3 and 4 years of age, pediatricians should have
picture cards and wall charts on hand for testing these patients.
BIRTH TO 2 YEARS OF AGE
An eye evaluation for infants and children from birth to 2 years of age should include:
1. Eyelids and orbits;
2. External examination;
3. Motility;
4. Eye muscle balance;
5. Pupils; and
6. Red reflex.
Examination of the eyelids and orbits consists of evaluating the structures for symmetry and function, such as the ability to
open both eyes. Neonates and young infants generally will open their eyes when held upright or leaned slightly forward. The
orbits may be evaluated by looking for asymmetrical prominence of one eye compared with the other, the presence of masses
such as hemangiomas, or craniofacial abnormalities involving the orbital bones.
External examination of the eyes consists of a penlight evaluation of the conjunctiva, sclera, cornea, and iris. A cloudy or
asymmetrically enlarged cornea, for example, may be a sign of congenital glaucoma. The pupils should be equal, round, and
reactive to light on both sides.
The examination of ocular motility, muscle balance, and visual acuity commonly may be performed together. Although
young infants may not commonly fix on a target, such as a toy, and follow it until they are at least 3 months of age, older infants
should do so readily. A penlight may be used to evaluate the light reflection from the cornea, known as the corneal light reflex.
These light reflections should present symmetrically on both corneas in relation to the anterior segment structures, such as the
pupil. Asymmetry of the appearance of the corneal light reflex may be an indication of an eye muscle imbalance. The unilateral
cover test, as described in "Appendix 2," also may be used for this purpose but may be more difficult to perform in this age
group.[1]
The unilateral cover test is useful only in infants and children who are able to fixate on a target. By using an interesting toy
as a target and moving it up, down, and from side to side, it is possible to determine whether the eyes see together. If possible,
the examiner should cover one eye with his or her hand and continue to move the toy to see if each eye individually is able to fix
on and follow the object. A sign of poor vision in one eye would be the child's objection to the other eye being covered. If the
child will follow an object happily with the right eye covered but strongly objects and moves his or her head away when the
examiner attempts to cover the left eye for the same purpose, poor visual acuity in the right eye may be suspected. Although
very small infants may seem uninterested in looking at a toy, they commonly will follow a human face at close range.
The red reflex test is used to perform a screening evaluation for abnormalities of the back of the eye (posterior segment)
and opacities in the visual axis, such as a cataract or corneal opacity. An ophthalmoscope focused on the pupil is used to view
the eyes 12 to 18 in away. The red reflex should be symmetrical. Dark spots in the red reflex, a blunted red reflex on one side,
the lack of a red reflex, or the presence of a white reflex are all indications for referral.
FROM 2 TO 4 YEARS OF AGE
Children older than 2 years should have the same eye evaluation as described previously for those from birth through 2
years of age; two additional measures also should be included. As children get older, vision testing and ophthalmoscopy
become possible. The very earliest that vision testing is possible with picture cards is at approximately 2 years of age. Vision
testing is recommended for all children starting at 3 years of age. In the event that the child is unable to cooperate with vision
testing at 3 years of age, a second attempt should be made in 4 to 6 months.[3] Children who, after repeated attempts, cannot
be tested should be referred to ophthalmologists experienced in the care of children for eye evaluations. "Appendix 2" provides
a detailed explanation of the techniques for vision testing applicable to this age group.
Ophthalmoscopy may be possible in very cooperative 4-year-olds who are willing to fixate on a toy while the
ophthalmoscope is used to evaluate the optic nerve and retinal vasculature in the posterior pole of the eye.
AT 5 YEARS AND OLDER
Eye evaluation for children 5 years and older should include the previously described components of the eye evaluation for
younger children; virtually all children should be able to undergo vision testing by this time, and most children should be
sufficiently cooperative for ophthalmoscopy. As for eye examinations in the age groups of birth to 2 years of age and 2 through
4 years, the frequency of examinations is in accordance with the AAP " Recommendations for Preventive Pediatric Health
Care."[3] Any child unable to be tested after two attempts or in whom an abnormality is detected should be referred for an
initial eye evaluation by an ophthalmologist experienced in the care of children.
MUSCLE IMBALANCE TESTING
The assessment of ocular alignment in the preschool and early school-aged child is of considerable importance. The
development of ocular muscle imbalance may occur at any age in children and may represent not only simple strabismus but
also serious orbital, intraocular, and intracranial disease. The corneal light reflex test and either the unilateral cover test at near
and at distance or the random-dot-E stereo test for stereoacuity (depth perception) should be carried out. The latter two tests
are more likely to detect lesser degrees of eye muscle imbalance that may have significant consequences for the child's visual
ability. Some children may have prominent lid folds that cover the medial portion of the sclera on both sides, presenting the
impression of crossed eyes (esotropia). Corneal reflex testing, the cover test, and the random-dot-E stereo test are useful in
differentiating true esotropia from pseudoesotropia. Detection of eye muscle imbalances or the inability to differentiate true
strabismus from pseudostrabismus necessitates referral. "Appendix 2" describes how both tests for eye muscle imbalance are
administered and interpreted.
REFRACTIVE ERRORS
Refractive errors requiring the use of eyeglasses exist in nearly 20% of the pediatric population before the late teenage
years. The most common clinically significant refractive error is myopia (nearsightedness), usually seen in school-aged children
and correctable with eyeglasses. Hyperopia (farsightedness) can cause problems in performing close work but usually does not
necessitate correction in children unless it is sufficient to cause crossed eyes or reduced vision. Astigmatism (unequal curvature
of the refractive surfaces of the eye) necessitates corrective eyeglasses if it causes significantly decreased vision or is of such
severity to contribute to the development of amblyopia (lazy eye). In addition, unequal amounts of refractive error in the two
eyes (anisometropia) also may lead to amblyopia and may require a prescription for corrective eyeglasses. The detection of
amblyopia at an early age is an important aspect of the routine eye examination in the pediatric population. Left undetected and
untreated, amblyopia may lead to irreversible visual deficit.
RECOMMENDATIONS
The pediatrician and others in the office should become expert at vision testing of young children. Although this is a difficult
group to test, there can be very serious sequelae when a problem with visual acuity, ocular alignment, or another abnormality of
the eyes is not identified. All newborns should be screened for risk factors involving visual problems, and all children should
have their visual statuses evaluated on a regular and periodic basis.[1] The results of the vision screening and eye evaluation,
along with instructions for follow-up care, should be clearly communicated to parents.[2] All pediatricians and other providers
of care to children should be familiar with the screening guidelines of the AAPOS, AAO, and AAP. Every effort should be
made to ensure that vision screening is performed using appropriate testing conditions, instruments, and techniques.
COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, 1995 TO 1996
Peter D. Rappo, MD, Chairperson
Edward O. Cox, MD
John L. Green, MD
James W. Herbert, MD
E. Susan Hodgson, MD
James Lustig, MD
Thomas C. Olsen, MD
Jack T. Swanson, MD
AAP SECTION LIAISONS
A. D. Jacobson, MD
Provisional Section on Administration and Practice Management
Robert Sayers, MD
Section on Uniformed Services
Julia Richerson Atkins, MD
Resident Section
LIAISON REPRESENTATIVES
Todd Davis, MD
Ambulatory Pediatric Association
Michael O'Neill, MD
Canadian Pediatric Society
SECTION ON OPHTHALMOLOGY EXECUTIVE COMMITTEE, 1995 TO 1996
Walter M. Fierson, MD, Chairperson
Harold P. Koller, MD (Chair-Elect)
Robert D. Gross, MBA, MD, Ex-officio, Immediate Past Chairperson
Susan H. Day, MD
Gary T. Denslow, MD
Allan M. Eisenbaum, MD
Howard L. Freedman, MD
APPENDIX 1
Vision Screening Guidelines
Vision screening represents one of the most sensitive techniques for the detection of eye abnormalities in children.
Pediatricians, family physicians, school nurses, and public health vision-screening personnel have used a variety of criteria in
determining which children require comprehensive eye evaluation by ophthalmologists. The AAP Section on Ophthalmology, in
cooperation with AAPOS and AAO, have developed guidelines for use by all pediatric vision screening professionals to
standardize the process of screening and to detect children with eye abnormalities who might be overlooked by less-stringent or
inconsistent guidelines. These guidelines ( Table) represent a first effort at a national standard for vision screening to be used by
physicians, nurses, educational institutions, public health departments, and other childhood vision evaluation services.
APPENDIX 2
Testing Procedures for Assessing Visual Acuity
When performing screening, test the child's right eye first by covering the left. A child who has corrective eyeglasses
should be screened wearing the eyeglasses. Tell the child to keep both eyes open during testing. If the child fails the practice
line, move up the chart to the next larger line. If the child fails this line, continue up the chart until a line is found that the child can
pass. Then move down the chart again until the child fails to read a line. After the child has correctly identified two symbols on
the 10/25 line, move to the critical line (10/20 or 20/40 equivalent). To pass a line, a child must identify at least four of the six
symbols on the line correctly. Repeat the above procedure covering the right eye.
For children who may be unable to perform vision testing by letters and numbers, the tumbling E or HOTV test may be
used. Literature is available from the AAO (Home Eye Test, AAO, San Francisco, CA) and Prevent Blindness America
(Preschoolers Home Eye Test, Prevent Blindness America, Schaumburg, IL) for home use by parents to prepare children for
the tumbling E test. This literature contains the practice Es, a tumbling E wall chart, and specific instructions for parents.
Another excellent test for children unable to perform the vision testing by letters and numbers is the HOTV test. This test
consists of a wall chart composed only of Hs, Os, Ts, and Vs. The child is provided an 81/2 x 11-in board containing a large
H, O, T, and V. The examiner points to a letter on the wall chart, and the child indicates or matches the correct letter on the
testing board. The tumbling E test and HOTV tests are excellent tests for this age group. Examiners may determine which test is
most useful in their practices and use that test preferentially.
If a child is not able to perform the tumbling E or HOTV test, the LH symbol test or Allen card test may be used. The
Allen card test is the older of the two and is well known for its commonly used figures, consisting of a schematic truck, house,
birthday cake, bear, telephone, horse, and tree. The Allen card test has four flash cards containing the seven figures. It is
important that a child identify either verbally or by matching all seven pictures before actual vision testing. In this case, testing
should be performed with the remaining figures.
Once it is established that the child can identify the figures, perform initial testing with the child having both eyes open;
testing for each eye individually should then be performed. Begin walking backward very slowly, flipping through the cards and
presenting different pictures to the child. Continue to move backward as the child correctly calls out the figures presented.
When the child begins to miss the figures being presented consistently, move forward several feet to confirm that the child is
able to identify the figures at this point. All Allen figures are 20/30 size figures. The farthest distance at which the child is able to
identify the pictures accurately becomes the numerator, and 30 becomes the denominator. Therefore, if the child were able to
identify the pictures accurately at 15 ft, the visual acuity would be recorded as 15/30. This would be equivalent to 20/40 or
10/20. A matching panel of all of the Allen figures may be prepared on a copy machine and used in the same way as for HOTV
testing, if necessary, for testing very young children or for practice at home.
The LH symbol test is slightly different from the Allen card test in that it is made up of flash cards held together by a spiral
binding. The flash cards contain large examples of a house, apple, circle, and square; these should be presented to the child
before vision testing. Unlike the Allen cards, the LH symbol test contains flash cards with more than one figure per card and
with smaller figure sizes, so that testing may be performed at 10 ft. Each card contains the symbol size and visual acuity value
for a 10-ft testing distance. The visual acuity is determined by the smallest symbols the child is able to identify accurately at 10
ft. For example, if the child is able to identify a symbol at 10 ft for which the visual acuity value on the card reads 10/15, the
child's visual acuity is 10/15 or 20/30. If it is not possible to perform all testing at 10 ft, use a similar technique to Allen card
testing and present the pictures to the child one at a time by covering all but one picture on the card and moving backward at
10 ft. At this point, proceed down in size to the smallest figures the child is consistently able to identify correctly. A matching
panel is provided with the LH test and may be helpful in testing very young children. At least three of four figures should be
identified for each size or distance.
Allen cards and wall charts are available from many medical supply houses. When ordering wall charts, be sure to indicate
that a 10-ft testing distance will be used.
Testing Procedures for Assessing Ocular Alignment
The two tests to detect ocular misalignment are the unilateral cover test and the random-dot-E stereo test. Either test
should be performed to determine whether strabismus (ocular misalignment) is present.
To perform the unilateral cover test, have the child look straight ahead at an object 10 ft (3 m) away. An eye chart is
commonly used to test children older than 3 years. For younger children, it is helpful to use a colorful noise-making toy.
A child who has eyeglasses should be screened wearing the eyeglasses. As the child looks at a distant object, cover the
left eye with a occluder, and look for movement of the uncovered right eye. If the right eye does not move, there is no apparent
misalignment of that eye. If the right eye moves outward, the eye is esotropic (crossed). If the right eye moves inward, it is
exotropic (out-turned). Any movement is the criterion for referral to an ophthalmologist.
After testing the right eye, test the left eye for movement. Occlude the right eye and look for movement of the uncovered
left eye. If the left eye does not move, there is no apparent misalignment of that eye. If the left eye moves outward or inward,
this meets the criterion for referral to an ophthalmologist.
To perform the random-dot-E stereo test, the cards should be held 16 in (40 cm) from the child's eyes. Explain the game
to the child. Show the child the gray side of the card that says "model" on it. Hold the model E in the direction at which the child
can read it correctly. Have the child touch the model E to understand better that the picture will stand out. A child may show
which direction the legs are pointing. Let the child know that is correct, but it is more important that the child knows that the
picture will stick out.
Place the stereo glasses on the child. If the child is wearing corrective eyeglasses, place the stereo glasses over the
glasses. Make sure the glasses stay on the child and the child is looking straight ahead. The child should be shown both the
stereo blank card and the raised and recessed E card simultaneously. Hold each card so you can read the back. The blank
card should be held so you can read it. The E card should be held so you can read the word "raised." Both cards must be held
straight. Do not tilt the cards toward the floor or the ceiling--this will cause darkness and glare. Ask the child to look at both
cards and to point to or touch the card with the picture of the E. The E must be presented randomly, switching from side to
side. Use the following order to present the E card to the child: right, left, down, right, up, and left. The child is shown the cards
up to six times. To pass the test, a child must identify the E correctly in four of six attempts.
REFERENCES
1. American Academy of Pediatrics, Section on Ophthalmology. Vision screening guidelines. . 1995;11:25
2. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screening in pediatric practice: a study from the
Pediatric Research in Office Setting (PROS) network. Pediatrics. 1992;89:834-838
3. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for
preventive pediatric health care. Pediatrics. 1995;96:373-374
---------------- The recommendations in this statement do not indicate an exclusive course of treatment or serve as a
standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright (c) 1996 by the American Academy of Pediatrics.
No part of this statement may be reproduced in any form or by any means without prior written permission from the
American Academy of Pediatrics except for one copy for personal use.