Vision and hearing develop through use during critical periods in early childhood. If the brain does not receive clear images or sounds during these periods, the pathways may never develop fully — even if the eye or ear is corrected later. Early detection and early treatment are therefore the central goals.

Visual disorders

Legal blindness is visual acuity of 20/200 or worse in the better eye with correction, or a visual field of 20° or less.

Hearing loss

Vision — warning signs

• Absent, asymmetric, or white red reflex (cataract, retinoblastoma)
• Eyes that cross or drift after about 4 months; head tilt; covering or closing one eye
• Tearing, light sensitivity, and a cloudy or large cornea (glaucoma)
• Infant does not fix and follow faces or objects by about 3 months; roving eye movements (nystagmus)
• Older child: squinting, holding objects close, rubbing eyes, headaches, poor school performance

Screening tests: red reflex from the newborn exam onward; corneal light reflex (Hirschberg) — light should reflect in the same place on both corneas; cover-uncover test — the uncovered eye moves to fixate if strabismus is present; photoscreening or instrument-based screening from about 12 months to 3 years; visual acuity charts with pictures or letters (e.g., LEA symbols, HOTV) from about age 3–4, Snellen when the child knows letters.

Hearing — warning signs

• Newborn: no startle to loud sound
• By about 3–4 months: does not turn toward sound or voice
• Babbling stops or never develops; delayed speech (no words by about 15–16 months)
• Older child: inattention, "selective hearing," speaks loudly, turns up the TV, behavior or school problems, responds better when looking at the speaker
• Risk factors (take a history including maternal illness or infection in pregnancy): family history, NICU stay over 5 days, cCMV, meningitis, craniofacial anomalies, syndromes (including Down syndrome), ototoxic drugs, severe jaundice

Newborn hearing screening

• Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR); AABR is used for NICU infants because it detects auditory neuropathy
• A "refer" result does not diagnose hearing loss — it means rescreening and a full diagnostic audiologic evaluation are needed promptly
• 1-3-6 goals: screening by 1 month, diagnosis by 3 months, early intervention by 6 months; programs already meeting these aim for 1-2-3
• cCMV testing (saliva or urine PCR) within the first 3 weeks of life in infants who fail the screen, where targeted testing is used

Periodic screening: school-age audiometric screening at regular intervals (e.g., Bright Futures: ages 4, 5, 6, 8, 10, then once each at 11–14, 15–17, and 18–21) catches acquired or late-onset loss.

Later hearing tests: behavioral audiometry (visual reinforcement in infants and toddlers, play audiometry in preschoolers), pure-tone audiometry, tympanometry (middle-ear fluid), ABR under sedation when needed.

Vision: comprehensive eye examination with dilation by a pediatric ophthalmologist for any abnormal screen; ROP screening for preterm infants by gestational age and birth weight criteria; imaging for retinoblastoma.

Vision

• Amblyopia: glasses first, then patching the stronger eye for set hours daily or atropine drops in the stronger eye to blur it (penalization). Treatment works best when young
• Strabismus: glasses, amblyopia treatment, eye-muscle surgery
• Congenital cataract: early surgery (dense unilateral cataracts ideally within about the first 6 weeks; bilateral within about 8–10 weeks), followed by contact lens, glasses, or lens implant and amblyopia therapy
• Congenital glaucoma: surgery (goniotomy or trabeculotomy)
• ROP: laser or anti-VEGF injection
• Chemical eye injury: irrigate immediately and copiously (at least 15 minutes, longer for alkali) before anything else

Hearing

• Conductive: treat effusion or infection (watchful waiting or antibiotics for acute otitis media; tympanostomy tubes for persistent effusion with hearing loss); remove foreign bodies (a button battery in the ear or nose is an emergency)
• Hearing aids fitted within about 1 month of diagnosis
• Cochlear implants for severe to profound sensorineural loss when hearing aids do not help (FDA-approved from 9 months of age); implant recipients need pneumococcal vaccination because of meningitis risk
• Symptomatic cCMV: valganciclovir may improve hearing and developmental outcomes — monitor for neutropenia (CBC)
• Ototoxic drug monitoring: aminoglycoside levels; audiology baseline and follow-up with cisplatin and prolonged aminoglycoside therapy; vancomycin is monitored closely, especially when combined with an aminoglycoside

Listed in priority order.

1. Eye emergencies — chemical splash: irrigate immediately; penetrating injury: shield the eye without pressure, do not remove the object, keep the child calm and still, NPO for possible surgery; report sudden vision loss or new leukocoria promptly
2. Safety for the child with visual impairment
   • Orient to the room; keep furniture in fixed positions and pathways clear; tell the child if anything is moved
   • Call bells and personal items within reach; night light for low vision
   • Sighted-guide technique: the child holds the nurse's arm just above the elbow and walks a half step behind
3. Communication with a child who is blind or visually impaired
   • Say the child's name and introduce yourself before touching; then offer a gentle touch on the hand to connect
   • Explain sounds, procedures, and what you are about to do; tell the child when you leave
   • Describe food positions using the clock method; let the child explore equipment by touch
   • Medications: tell or touch-cue the child before the spoon or syringe reaches the lips
4. Communication with a child who is deaf or hard of hearing
   • Get attention first (wave, light touch on the shoulder); face the child in good light, keep hands and objects away from your mouth
   • Speak clearly at a normal pace and volume — do not shout or exaggerate; use gestures, pictures, and written words
   • Use the child's language: qualified sign language interpreter, not family members, for important information
   • Reduce background noise; check that hearing aids or processors are on and working
5. Pain assessment — when a child cannot see the FACES scale or has cognitive impairment, use behavioral tools such as FLACC; verbal numeric scales for older children who can use them
6. Development — infants with visual impairment need extra auditory and tactile stimulation: talk and sing, musical and textured toys, encourage reaching toward sound, floor time; bonding through touch and voice
7. Postoperative care — after cataract or glaucoma surgery: eye shield, prevent rubbing (arm restraints only if needed and per policy), eye drops as ordered; after cochlear implant: keep the dressing dry, monitor for fever, swelling, facial weakness, and dizziness
8. Teach self-care in the child's mode — braille or audio materials and hands-on practice with real equipment (e.g., counting insulin pen dose clicks, feeling the injection site); before surgery, a comfort object or a recording of a parent's voice can reassure a child who relies on hearing
9. Promote independence and self-esteem — let the child make choices and do self-care with adaptations; school-age children learn braille, large print, or assistive technology; adolescents need peer contact and privacy

• Newborn hearing screen "refer": keep the rescreen and diagnostic appointments — do not wait; the result is not a diagnosis
• Amblyopia: patching must be done for the prescribed hours; the child will resist — use rewards, patch during fun close-up activities; atropine drops: blurred vision and light sensitivity are expected; watch for flushing, fever, or fast heartbeat (systemic absorption) and store safely
• Eye drops in children: pull down the lower lid and instill into the pocket, then press gently on the inner corner of the eye to reduce absorption
• Hearing aids: wear during all waking hours; clean and check daily; keep batteries away from children (swallowing is an emergency)
• Cochlear implant: the external processor is fitted and switched on a few weeks after surgery; hearing is not immediately normal — long-term auditory training is needed; avoid head blows; tell providers before MRI; keep vaccines current
• Home safety for visual impairment: secure rugs or remove small loose rugs, pad sharp furniture corners, install stair gates, keep doors fully open or closed, consistent furniture placement
• Preventing hearing loss: treat ear infections, avoid loud noise (safe headphone volume), do not insert objects into ears
• Preventing eye injury: protective eyewear for sports, keep chemicals and fireworks away from children
• Parents' feelings: grief, guilt, and denial are normal responses to the diagnosis — nurses acknowledge feelings, listen, and connect families with early intervention and parent groups

• Critical periods: early detection and treatment prevent permanent vision or language loss
• Absent or white red reflex → urgent referral (cataract, retinoblastoma)
• Tearing + photophobia + cloudy large cornea = congenital glaucoma, not cataract
• Amblyopia: patch the stronger eye or atropine penalization
• Screening tools: Hirschberg corneal light reflex, cover-uncover test, age-appropriate acuity charts
• Visual impairment: announce yourself before touching, fixed furniture, clear paths, clock method
• Newborn hearing "refer" = rescreen and diagnostic testing, not a diagnosis; 1-3-6 goals
• Otitis media with effusion → conductive loss (fluid limits eardrum and ossicle movement); cCMV → sensorineural
• Ototoxic drugs: aminoglycosides, cisplatin, loop diuretics; vancomycin with aminoglycosides
• Deaf or hard-of-hearing child: face the child, good light, normal speech, visual cues, qualified interpreter
• Cochlear implant: hearing is not instantly normal; pneumococcal vaccination
• Nonverbal or visually impaired child in pain: FLACC