Figure 103-14 Dermoid cyst removed in total. The terms proptosis, exophthalmos, and exorbitism are often used interchangeably to describe forwardly displaced eyes. Absence of the Moro reflex in an infant is abnormal. Found inside – Page 246NURSING ALERT Always record and report absence of the red reflex. It may indicate the presence of glaucoma, retinal abnormality, retinoblastoma, cataracts, or a systemic disease (American Academy of Pediatrics, 2008d). Care Advice for Newborn Reflexes and Behavior. Found inside – Page 497... for a newborn and infant? 3. What factors should you use when deciding which chart is most appropriate for testing vision in a child? 4. What is the red reflex test? a white opacity in the pupil or by an abnormal red reflex test ... If neither pupil constricts on direct illumination to one eye, the first eye may be severely deficient in vision. Intrauterine infectious disease such as rubella, toxoplasmosis, or cytomegalovirus necessitates a thorough eye evaluation. The orbital rims should be sharply outlined. A comprehensive newborn examination involves a systematic inspection. Plastic molds of the conjunctival sac of gradually enlarging sizes are used to stretch the lids and sac sufficiently to hold an ocular prosthesis. The visual system is not completely developed at birth but progressively matures during the neonatal period.27 The neonatologist must recognize normal ocular findings during different stages of the infant’s growth to understand what is abnormal. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Maintenance of the eyes on an object is called fixation. The diagnosis of proptosis can be confirmed if the examiner observes the infant’s eyes and lids from above, over the prominence of the eyebrows. By varying the size of the stripes, the examiner can grade the visual acuity equivalent. This ocular reflex may be a form of optokinetic nystagmus and is reduced in infants with major defects of the vestibular system, lower motor pathways to the extraocular muscles, visual system, or central nervous system.19 Stephen Ludwig, MD is Chairman of the Graduate Medical Education Committee and Continuing Medical Education Committee and an attending physician in general pediatrics at The Children's Hospital of Philadelphia; and Emeritus Professor of ... Vascularization of the retina begins with the ophthalmic artery entering the eye through the posterior edge of the eye’s embryonic fissure at 4 months of gestation. The swinging flashlight test is used to check for a relative afferent pupillary defect. Complex microphthalmia describes small eyes with internal disorganization, such as anterior segment dysgenesis, cataract, coloboma, or persistent fetal vasculature. Figure 103-9 Congenital ptosis of the left upper lid. A more anterior protrusion of the orbital content is observed in comparison with the opposite side. Although the usual cause of epiphora is a blockage of the nasolacrimal ducts (dacryostenosis), the possibility of congenital glaucoma is the most important consideration in the differential diagnosis. Found inside – Page 501Refer infants with an abnormal red reflex or history of retinoblastoma in a parent or sibling. 6 to 42 mo Ocular history Vision assessment External inspection of the eyes and lids Ocular motility assessment Pupil examination Red reflex ... The swinging flashlight test is used to check for a relative afferent pupillary defect. In the neonate, the orbital rims form a circular outline at the anterior base of the cone. Dermoid cyst removed in total. Found inside – Page 405All infants with an abnormal or absent reflex should be referred immediately to an ophthalmologist. 6. Do the eyes need to be dilated to perform the red reflex test? In general, no. An adequate examination can usually be performed ... Epiphora (excess tearing) usually does not occur until after the first 3 weeks of life, when the major portion of the lacrimal gland has become functional. Cross extension reflex - Elicited with the infant supine by holding one leg extended with the knee pressed down and stimulating the bottom of that foot. The cause is unknown, but it has been suggested to result from hypoplasia of the lacrimal gland or an absence of innervation of the lacrimal gland structures. For infants less than 4 to 6 weeks of age, visual function is assessed by withdrawal or blinking to light, or pupil constriction to light.24. In unilateral situations, orbital reconstruction using tissue expanders can dramatically improve the overall facial appearance. A direct ophthalmoscope, set to a lens power of “0,” is projected onto both eyes from a distance of 18 inches. D Correct. The screening eye examination should include an evaluation of visual function, preferably one eye at a time. Hyperthyroid exophthalmos, a rare neonatal sequela of hyperthyroidism, can occur as the result of maternal Graves disease during the last trimester of pregnancy. Inspecting a childs red reflex with an ophthalmoscope and finding black spots or opacities, the nurse knows thes findings are abnormal and may indicate a cataract. Enophthalmos refers to eyes that look sunken into the orbit. Observation for change in size, shape, depth, or pigmentation is recommended (Figure 103-12). Common other ocular abnormalities include exotropia, dacryostenosis, epibulbar dermoids, palpebral fissure changes, and optic atrophy.95 A phenotypically similar, but probably distinct clinical entity within the frontonasal dysplasia spectrum, has been reported with the features of facial midline defects, basal encephalocele, callosal agenesis, endocrine dwarfism, and morning glory disc anomaly.93, Colobomas of the lids are partial-thickness or complete defects that can range from a small notching of the lid borders to involvement of the entire length of the lid. Complex microphthalmia describes small eyes with internal disorganization, such as anterior segment dysgenesis, cataract, coloboma, or persistent fetal vasculature.121 Colobomatous microphthalmia occurs when the embryonic cleft of the optic vesicle fails to close. The condition could be idiopathic or inherited, unilateral or bilateral, congenital or acquired. Importance of red reflex examination at the 6 week check. Medial canthus to lateral canthus Nevi Found inside – Page 225A much better course would be to add the possible presence of strabismus to the infant's problem list and re-examine the situation during the first and second postnatal visit, unless leukocoria or absent red reflex is noted on initial ... Found inside... and American Academy of Ophthalmology recommends that all newborn infants be examined in the nursery for structural abnormalities and have a red reflex test performed to check for abnormalities in the back of the eye (posterior ... Familial dysautonomia results from a mutation in the IKBKAP gene encoding elongation protein 1, resulting in defective splicing.84. A screening eye examination should be performed during the newborn physical examination and during routine well-baby checkups.3 The screening examination should include the assessments24 listed in Box 103-1. It occurs as a developmental failure of the optic vesicle. Epiphora can occur as the result of corneal abrasion, corneal foreign body, or nasal and facial lesions that irritate the fifth cranial nerve. For example, early detection and treatment of congenital cataracts and congenital glaucoma are critical for visual rehabilitation. Differentiation of fovea completed Epiblepharon is an extra fold of skin along the lower lid that can cause lashes to turn inward. Care Advice for Newborn Reflexes and Behavior. Early surgical correction is often required when the coloboma is greater than one third of the eyelid margin.100 A direct ophthalmoscope, set to a lens power of “0,” is projected onto both eyes from a distance of 18 inches. In unilateral situations, orbital reconstruction using tissue expanders can dramatically improve the overall facial appearance. Nevus of Ota. Although these modalities are still valid, they are not free of side effects. Persistent adhesion between the upper and lower lid. Although the usual cause of epiphora is a blockage of the nasolacrimal ducts (dacryostenosis), the possibility of congenital glaucoma is the most important consideration in the differential diagnosis. Treatment of mild nasolacrimal infection consists of topical antibiotic drops or ointment. Hypotelorism Term Neonate Any amount of a white reflection is abnormal and could indicate an abnormality within the lens, vitreous, or retina. Eyelash Abnormalities The red reflex (RR) test, also known as the Bruckner test, is vital for the early detection of potential eye health and vision problems in neonates, infants and children. • Cerebral gigantism When a hemangioma involves the eyelids, amblyopia can develop. If the infant’s visual function is less than the ability to distinguish the stripes from the gray target, the infant will look randomly right or left. The bulbar and palpebral conjunctivae are normally moist and pinkish. This can be a warning sign for the presence of a serious eye condition. The cause is unknown, but it has been suggested to result from hypoplasia of the lacrimal gland or an absence of innervation of the lacrimal gland structures. The red reflex refers to the reddish-orange reflection of light from the back of the eye, or fundus, observed when using an ophthalmoscope or retinoscope. Hemangioma 24th ed. Anticipated Structure: • Introduction – brief mechanism, describe abnormal finding, and most common pathology. Two forms of myasthenia gravis can produce ptosis in the neonatal period. Found inside – Page 391Abnormal. Red. Reflex. An uncommon but urgent finding in newborns ... The most common cause of absent or diminished red reflex in newborn infants is congenital cataract. Cataracts can occur unilaterally or bilaterally. The upper and the lower lids may be fused at birth or through an inflammatory process (Figure 103-11). Orbital Abnormalities Although normally incomplete for the first 6 months of life, pigmentation of both irides develops simultaneously. Red reflex testing is a mainstay of efforts to screen infants for ocular pathology and eye doctors worldwide rely on it. A patient with a microphthalmic right eye also has significant choroidal coloboma in the same eye. Epicanthus is the most commonly encountered lid abnormality. The ocular motor system is evaluated with a motility examination. The test can alert us to large lesions in the retina. Marked enlargement of the eye, as in congenital glaucoma or high myopia, makes the eye appear proptotic because of the increased size of the globe. Because the conjunctival sac is absent or small, attempts to separate the lids from the ocular structures are usually unsuccessful, and surgical correction is not advisable in most circumstances. Excessive hair on the lids and forehead can occur as a dominant characteristic in male infants and, on occasion, may be extreme. Cataracts. Figure 103-4 Rotational nystagmus. If a second row of lashes is present in the area of the meibomian glands (metaplasia), the condition is referred as distichiasis. Red reflex testing is a mainstay of efforts to screen infants for ocular pathology and eye doctors worldwide rely on it. R29.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Normal values in the neonate fall within a very wide range. The red reflex test is a critical tool to screen for vision problems in children. This result indicates decreased vision in the eye that inappropriately dilated. Reflex tearing from ocular irritation or psychogenic (emotional) tearing may not develop for weeks to months after birth. Enlarged corneas suggest the diagnosis of congenital glaucoma. Duplication for commercial use must be authorized in writing by ADAM Health Solutions. Some ocular and visual milestones are shown in Table 103-1. The knee jerk is an example of the simplest type of reflex. They may virtually occur in any body location, including the upper or lower lids and orbit. Reflex tearing to irritants is evident shortly after birth. Normal horizontal measurement of the lid fissures in the newborn can range from 17 to 27 mm (Table 103-2). In more darkly pigmented children, the reflex may be more gray than red; Children who have an abnormal red reflex (eg, dark spots, markedly diminished reflex, white reflex, asymmetry) should be referred to an ophthalmologist Fundus Examination. Hypertrichosis lanuginosa is transmitted as an autosomal dominant condition. Blepharophimosis can occur in isolation, as a feature of BPES (blepharophimosis, ptosis, and epicanthus inversus syndrome), or in multiple systemic syndromes such as fetal alcohol syndrome, Saethre-Chotzen syndrome, and van den Ende-Gupta syndrome. These ocular changes and constriction of the pupil by instillation of 0.125% pilocarpine should establish the diagnosis. However, if abnormalities are suspected because of the history, presence of systemic anomalies, or abnormal result of the screening examination, a more detailed ocular evaluation is mandatory, preferably by a pediatric ophthalmologist.34 Inspecting a childs red reflex with an ophthalmoscope and finding black spots or opacities, the nurse knows th findings do not suggest the child has experienced trauma. Oral propranolol or topical timolol are effective ways of treating these tumors.22,67 In the past, treatment involved systemic, injectable, or topical corticosteroids with potential side effects over months of treatment. The lid margins should be inspected for regularity of contour, apposition to the globe, and the presence of lacrimal puncta. Those located within the cone of extraocular muscles produce a symmetric anterior displacement, whereas tumors located outside the cone of extraocular muscles displace the eye outward and away from the area of origin of the tumor. The adventurous neonatologist or primary care physician can attempt direct viewing of the infant’s retina with a direct ophthalmoscope or a panoptic (Figure 103-8). 7 years • Globes The American Academy of Pediatrics currently recommends red reflex assessment as a component of the eye evaluation in the neonatal period and … For preterm infants, ophthalmologic consultation is necessary to exclude ROP. Characteristic findings of frontonasal dysplasia are medial cleft nose, lip, and palate, widow’s peak, and cranium bifidum occultum. Clinicians should develop the ability to recognize the signs and symptoms of serious eye diseases or complications of diseases early in their course to prevent visual loss and, in some cases, to preserve life. Blepharophimosis, ptosis, and epicanthus inversus syndrome is divided into type 1 and type 2, with and without premature ovarian failure, respectively.11. Premature birth suggests potential retinopathy of prematurity (ROP), and difficult delivery with obstetric forceps can result in direct ocular trauma. Ankyloblepharon At first, the eyes pursue a moving visual stimulus with short saccades. Anophthalmia is a rare sporadic phenomenon in which there is total absence or a minute rudiment of the globe, and it can present either unilaterally or bilaterally (Figure 103-18). Excessive eyelash growth can result as a side effect from multiple medications, including topical prostaglandin analogues and epidermal growth factor receptor inhibitors. Treatment of mild nasolacrimal infection consists of topical antibiotic drops or ointment. Because the lashes are soft when the child is younger, lashes rubbing against the cornea tend not to produce symptoms. Once cord clamped: PVR very low and systemic vascular resistance will increase. The irides are usually similar in appearance. Causes in infants include orbital asymmetry, microphthalmos, trauma resulting in an orbital blow-out fracture, congenital fibrosis of the extraocular muscles, and congenital Horner syndrome. Any opacity or translucency is abnormal after the first few days of life, and referral to an ophthalmologist is indicated. The infant’s eyes will then tonically rotate in the direction of the spin, with short, quick movements (saccades) in the direction opposite the spin. Area Normal Abnormal Head • Molding Repeated massage of the lacrimal sac at the medial canthal area serves to flush out the stagnant tears, decrease the risk for infection, and “pop” open the nasolacrimal obstruction. Birth With an optokinetic drum, which consists of black and white stripes on a spinning cylinder, if the examiner can elicit optokinetic nystagmus in the infant, this establishes that the child has enough visual function to discern the stripes. Information about maternal diseases (e.g., rubella), injuries, medications, or use of drugs or alcohol during the prenatal period should be obtained. Both are noninvasive, inexpensive, and quick. The eyes appear stationary as the head turns. 2. It is often accompanied by other congenital anomalies, such as central nervous system defects and mental retardation, and has been observed in isolation, in genetic defects (e.g., SOX2, STRA6, PAX6 genes), and in chromosomal syndromes (e.g., trisomy 13).119 Because lid formation does not depend on ocular formation, the lids are fully formed. Brief stiffening of the body, straightening of arms and opening of hands. 's editorial policy editorial process and privacy policy. A cephalic bruit is often heard in the infant but is not pathognomonic of a carotid-cavernous sinus fistula. Panoptic, indirect, and direct ophthalmoscope. The eyelids are examined grossly and are compared for symmetry of horizontal and vertical placement. Hemangiomata are quite common and occur in up to 10% of newborns. Found inside – Page 478Cataract may first be discovered by the presence of a white opacity in the pupil or by an abnormal red reflex test conducted by the primary care physician. Glaucoma in newborns and infants is often characterized by an enlarged hazy ... Watery Eye Optokinetic nystagmus can be evident in term newborns.73 (2) Another quantitative technique to measure a visual acuity equivalent in the infant older than 3 months is forced preferential looking.108 An infant prefers to look at black and white stripes instead of a uniformly gray target. "This is a marvelous book, which provides comprehensive coverage of the field. 4,111 Examination starts with a “0” diopter setting in the direct ophthalmoscope, and the child is examined at arm’s length, with both pupils illuminated (Figure 103-7). Surgical treatment with a nasolacrimal probing should be considered within the next 2 to 4 days (Figure 103-17). As the reflex ends, the infant draws its arms back to the body, elbows flexed, and then relaxes. Until recently, treatment was oral use or intralesional injections of steroids, subcutaneous interferon, or excision of the lesion. Aims To evaluate the red reflex of newborns, percentage of ocular diseases resulting in red reflex abnormality, and their relation with consanguinity in … Convergence spasms are a normal transient phenomenon of infancy. Any opacity or translucency is abnormal after the first few days of life, and referral to an ophthalmologist is indicated. They include alacrima and corneal anesthesia. Parents should talk to their child's provider if: The provider will perform a physical exam and ask about the child's medical history. They include alacrima and corneal anesthesia. A rapid up-and-down movement of the lid during nursing indicates a jaw-winking phenomenon (Figure 103-2).61. Similar lesions found higher than the medial canthus should be suspected to be encephalocele. Congenital trichiasis patients should be examined for Down syndrome or signs of ectodermal dysplasia. Turning the baby's face in the other direction reverses the position. A reflex is built into the nervous system and does not need the intervention of conscious thought to take effect. By 3 months of age, the infant can fixate and follow in both vertical and horizontal directions. Although a globe is present, only rarely is vision obtainable. By varying the size of the stripes, the examiner can grade the visual acuity equivalent. The infant will turn toward the side that was stroked and begin to make sucking motions. The distended lacrimal sac is filled with clear fluid, feels firm or fluctuant to palpation, and does not pulsate like a frontal encephalocele.125 Initiating oral antibiotics is recommended as soon as a dacryocystocele is identified to prevent infection of the dacryocystocele, which can occur in up to two thirds of these patients. Congenital Blepharophimosis The red reflex of each eye should be clearly distinct, with no shadows or alterations. The growth of the eye, which parallels that of the brain, continues at a rapid rate for the first 3 years of life, especially during the first year. Objectives: To review the literature on the diagnostic accuracy of the red reflex test in infant screening for ocular pathologies and to perform meta-analyses to provide summary estimates. Clearly visualize the optic disk, blood vessels, and more laterally the macula. Hypertrichosis lanuginosa is transmitted as an autosomal dominant condition. 12-16 They have worries about their child's development. They notice that baby reflexes continue in their child after they should have stopped. Any amount of a white reflection is abnormal and could indicate an abnormality within the lens, vitreous, or retina. Measurement (mm) A patient with Goldenhar syndrome, with maldeveloped right side of the face and anophthalmia. Intrauterine infectious disease such as rubella, toxoplasmosis, or cytomegalovirus necessitates a thorough eye evaluation. This reflex occurs in slightly older infants when the child is held upright and the baby's body is rotated quickly to face forward (as in falling). The hand will close around the finger. Found inside – Page 281TABLE 18-1 Pediatric Vision Screening Recommendations of the American Academy of Ophthalmology Age Examination Referral Newborn Corneal light reflex test Abnormal red reflexes Red reflexes Any other ocular abnormality By age 6 mo ... Facial abnormalities that produce shallow orbits, as in Crouzon disease, simulate proptosis because the normal amount of orbital structure appears to protrude in an abnormally shallow orbit. It is particularly noticeable in fetal alcohol syndrome and Waardenburg syndrome. To determine whether the red reflex is normal, comparison with the red reflex of a parent of the child may be helpful. Importance of red reflex examination at the 6 week check. The baby will extend his arms forward as if to break a fall, even though this reflex appears long before the baby walks. Red reflex examination is recommended for all infants. • Infants/Neonates abnormal exam • Children abnormal exam (1) Optokinetic nystagmus describes a reflex ocular response to a moving target. Amblyopia may be secondary to the hemangioma’s obstruction of the visual axis, or from pressure on the cornea that subsequently induces astigmatism and anisometropic amblyopia (Figure 103-15). This condition usually results in contact of the lashes with the cornea, producing corneal irritation and abrasions. Section on Ophthalmology. 6 months Dermoid cysts are tumors that appear at the suture lines, most commonly at the superotemporal brow or in the superior medial central area of the brow (Figure 103-13). is among the first to achieve this important distinction for online health information and services. These syndromes might not become apparent until the end of the neonatal period or even later in life when the iris is fully pigmented. A red image, symmetrical from both eyes, should be visible. Common other ocular abnormalities include exotropia, dacryostenosis, epibulbar dermoids, palpebral fissure changes, and optic atrophy.95 A phenotypically similar, but probably distinct clinical entity within the frontonasal dysplasia spectrum, has been reported with the features of facial midline defects, basal encephalocele, callosal agenesis, endocrine dwarfism, and morning glory disc anomaly.93 Fortunately, the screening examination identifies most problems such as glaucoma, cataract, infection, or tumor. The result of the red reflex examination is to be rated as normal when the reflections of the 2 eyes viewed both individually and simultaneously are equivalent in color, intensity, and clarity and there are no opacities or white spots (leukokoria) within the area of either or both red reflexes. Epicanthus The visual system is not completely developed at birth but progressively matures during the neonatal period. Plastic molds of the conjunctival sac of gradually enlarging sizes are used to stretch the lids and sac sufficiently to hold an ocular prosthesis. Color vision present Newborn infants have strong grasps and can almost be lifted up if both hands are grasping your fingers. Neonatal Eye Examination If persistent, treatment is then offered, but requires general anesthesia because these children are too large to swaddle for an office probing. The visual system is not completely developed at birth but progressively matures during the neonatal period.27 The neonatologist must recognize normal ocular findings during different stages of the infant’s growth to understand what is abnormal. Sensitivity of pencil light examination was 71.4%. Print+CourseSmart If a view of the retina is required, such as for retinopathy of prematurity screening, the consulting ophthalmologist should dilate the infant’s eyes and use more sophisticated examination instrumentation such as an indirect ophthalmoscope. The screening eye examination should include an evaluation of visual function, preferably one eye at a time. At first, the eyes pursue a moving visual stimulus with short saccades. Currently, the American Academy of Pediatrics policy recommends eye examinations for neonates and children from birth to 2 years of age at specific intervals during the newborn examination and well-child visits. Those located within the cone of extraocular muscles produce a symmetric anterior displacement, whereas tumors located outside the cone of extraocular muscles displace the eye outward and away from the area of origin of the tumor. Although both upper and lower eyelids may be ptotic, the terms blepharoptosis or ptosis generally refer to the upper lids unless otherwise specified (Figure 103-9). This is a normal reflex present in newborn infants. Various types of eyelid specula to keep the eyelids open, scleral depressor to gently move the eye around, cyclomydril eye drops for dilation (1.25% phenylephrine [ophthalmic], 0.25% cyclopentolate [ophthalmic]), and a 20- or 28-diopter magnifying lens. ICD-9-CM 796.1 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, 796.1 should only be used for claims with a date of service on or before September 30, 2015. To keep latex sensitivitiy from becoming a problem, … Familial dysautonomia results from a mutation in the IKBKAP gene encoding elongation protein 1, resulting in defective splicing.84 The red reflex test is an essential part of the infant screening eye examination. *Neonates weighing 1000 to 1300 g. Stereoacuity at adult level If persistent, treatment is then offered, but requires general anesthesia because these children are too large to swaddle for an office probing. Note any facial dysmorphism that could affect ocular health, or be part of an ocular syndrome, such as clefts or abnormal head shape. A study recently reported that an abnormal red reflex finding most likely reflects an underlying ocular pathology; however, a normal red reflex … Fortunately, the screening examination identifies most problems such as glaucoma, cataract, infection, or tumor. The onset of major systemic symptoms occurs when the child is about 2 years old. Clinically, an encephalocele is suggested by the presence of a pulsating, fluctuant cyst that can be reduced somewhat with digital pressure or that increases with coughing or crying. Pseudoleukocoria. Ptosis is asymmetry in upper lid height or symmetrical lowering of both upper lids. Left upper lid ptosis seen in the first picture, whereas the left lid raises up while the patient sucks from the bottle. Iris stromal pigmentation well developed The orbits should be proportional and symmetric compared with the overall craniofacial configuration. The integrity of the cornea requires monitoring and will determine the treatment. When threatening the sight via amblyopiogenic properties, treatment is warranted. • Smith-Lemli-Opitz syndrome Anteroposterior diameter of eye at birth At 28 weeks of gestation, the globe is only 10 to 14 mm in diameter. Spontaneous opening and closing of the lids should be observed. The punctum, the proximal opening into the nasolacrimal drainage system, is a minute hole in each lid margin a short distance from the inner corner of the eye. Any child with strabismus and an abnormal red reflex should be referred immediately. Mild, unilateral ptosis should prompt a comparison of pupil size to evaluate for Horner syndrome. If the patient does not appear to move the eyes well enough into the periphery, either spontaneously or by following an object, these movements can be driven by the doll’s head maneuver vestibulo-ocular reflex (VOR). Oral propranolol or topical timolol are effective ways of treating these tumors. You may also needFluid, Electrolytes, and Acid-Base HomeostasisPulmonary Vascular DevelopmentDisorders of Digestion in the NeonateThe Skin of the NeonateLegal Issues in Neonatal-Perinatal MedicineGastroesophageal Reflux and Gastroesophageal Reflux Disease in the NeonateCardiac EmbryologyCongenital Defects of the Cardiovascular System A reflex that is still present after the age when it would normally disappear can be a sign of brain or nervous system damage.
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