Hiding in Plain Sight

Engaging a child in the enjoyment of a Reach Out and Read book is a special bonding moment for parents and their child, and allows the pediatrician opportunities for conversation and observation around the activity. However, the major sensory modality required by the child to fully enjoy their gift – their vision – can be readily overlooked. The young child with blurred vision will not complain about it and can appear to have normal sight, leaving parents and caregivers unaware of the vision problem.

Acquiring clear vision is a developmental process in every child, beginning at birth and continuing throughout their first few years of life. There is no child too young to have or develop a vision disorder: 2% of U.S. children ages 6 months to 6 years of age will develop amblyopia (or lazy eye; untreated, the leading cause of young adult blindness), 2 to 4% of U.S. children under the age of 6 years will develop strabismus, and approximately 10% have high refractive error. The consequences of these conditions are preventable and treatable, often simply with eyeglasses, if detected and treated in early childhood. This underlines the importance of vision screening in the medical home, often the only touchpoint for vision, until the child reaches school.

Professionals using Reach Out and Read methods have a unique opportunity to recognize a possible vision problem by observation while the child is receiving and reading their new book.  Childhood vision problems can show in subtle ways in the child’s behavior or development. Infants and toddlers with untreated vision problems may show:

  • impaired parental bonding
  • delay in reaching motor and cognitive milestones
  • reduced social development, including lack of eye contact with parent
  • delayed language
  • slower acquisition of early learning skills

The preschool child may frequently:

  • squint, frown, rub eyes, or blink frequently
  • be easily distractible/unable to focus or maintain attention
  • close one eye or tilt or turn their head to view the page
  • hold the book close to their face
  • fall asleep or tire quickly, while reading
  • have poor letter or word recognition
  • reread, skip lines, or lose their place
  • lose interest quickly or seem cranky when reading

Additionally, a higher prevalence of vision disorders will be found in some populations of young children, including those:

  • of Hispanic, Latino and African American descent
  • with a history of premature birth or low birth weight
  • with a history of maternal smoking, alcohol or drug abuse during pregnancy
  • whose parents had a vision disorder in their own childhood
  • with neurodevelopmental delay or special health care needs
  • from low income families

Childhood vision disorders will not resolve naturally, at any age, and should always be evaluated by a pediatric eye doctor (a pediatric ophthalmologist or optometrist). Regular follow up and adherence to treatment is paramount for success in young children who are diagnosed with a vision disorder.

The window offered to Reach Out and Read providers during the magical moment of giving a book can make the difference in a child with an undetected vision disorder, between a future with poorer health outcomes and struggle in school, and one of a lifelong ability and love of reading and learning.

For more information, including leaflets in other languages, please contact Paulette Tattersall, Director of Prevent Blindness, Northeast region, and Co-chair of Children’s Vision Massachusetts (CVMA): [email protected]. CVMA is a 70-member coalition representing ophthalmology, optometry, nursing, pediatrics, public health, family practice, education, and parents. The coalition’s mission is to create a systematic approach to children’s vision services in Massachusetts to support awareness, access, early detection, diagnosis and treatment of vision problems in children. Visit: