WHO includes universal newborn eye screening in their first ever postnatal care guidelines

On the 30th of March 2022, the World Health Organization launched its first ever global guidelines to support women and newborns in the postnatal period (the first six weeks after birth).(1) Within these guidelines is a really significant milestone for child eye health – universal newborn eye screening (NES) was included. This means national governments will have to consider how universal NES can be delivered within their routine maternal and child health services.

What is newborn eye screening?

Newborn eye screening is the examination of the eyes of newborns with the purpose of determining if there are any ocular abnormalities which may require referral to an ophthalmic specialist for further examination.The standard test includes using a torch light to examine the front of the eye and, traditionally, a direct ophthalmoscope to test the red reflex of the eyes to check for potentially blinding eye conditions such as cataract, corneal opacities, glaucoma or retinoblastoma.

Why is including newborn eye screening in the WHO Postnatal Care Guidelines an important milestone?

In high-income countries, universal NES is considered standard of care. However, in low- resource settings, NES is more often not included in child health policies or practiced routinely. This leads to children presenting late to health services with serious eye problems. The early development period (newborn to 5/7 years old) of a child is critically important for eye conditions as a child’s vision is still developing, and any condition which stops the child seeing will also stop the child’s vision developing (amblyopia). Therefore, if children present late to health services it leads to poorer outcomes after treatment and avoidable permanent visual loss.

The inclusion of NES in the postnatal care guidelines sets the priorities for national health policies and means countries will need to consider how they can implement NES for every newborn, leading to more children being diagnosed with eye conditions while there is still potential for effective treatment.

What will be required to implement this new guideline?

Training, equipment, robust referral mechanisms and inclusion in newborn health checklists for the babies who fail the screening test are the basic requirements.

• Most primary healthcare workers, nurses and midwives may not have been taught how to examine newborn babies’ eyes therefore will need to be trained. This training needs to be included within their training programs both pre-service and in-service and followed up by supported supervision to ensure the quality of the testing is adequate. Studies in Tanzania have shown that primary health care workers can be trained in newborn eye screening within routine child health training programmes, and that these can be scaled up to national level. (2,3).Further studies evaluating models of inclusion of NES in routine maternal and child health services in different settings are needed.

• A torch alone is not sufficient for NES and the standard equipment has been a direct ophthalmoscope for red reflex testing. However this is relatively expensive for the primary healthcare setting in many places, and requires batteries. Several alternate devices to the direct ophthalmoscope have been tested and the Arclight has been found to be a practical, low-cost, solar powered alternative which is easy to use in primary healthcare settings. (4) Future challenges include ensuring there are adequate supplies of the Arclight and that it is on national medical devices lists.

• Strengthening referral mechanisms to ensure children reach the correct health service facility is complex but is essential to ensure children reach the care they need. Key factors include; education of healthcare staff and parents, improved transport/logistics, and communication and feedback between primary, secondary, and tertiary services. The referral system for eye conditions must be supported from within the maternal and child health system ensuring it works for the whole child.

• Finally, the inclusion of NES in newborn checklists ensures its implementation is being monitored nationally, raises awareness of its importance to healthcare staff and can speed up the pace of its implementation. 

What could be the potential outcomes and impact?

The majority of blind children are either born with potentially blinding conditions or develop them before the age of 5 years. (6,7) Therefore universal NES is the first opportunity in the health system to detect these children and refer for potentially sight-saving treatment. Recommending NES in the postnatal care guidelines places it within maternal and child health programmes and care highlighting its importance for all maternal and child health providers.

What is needed next?

Delivering universal NES will be a challenge for many national governments. Health systems models of how NES can be effectively included in maternal and child services are needed, and sharing both the best strategies and challenges will be important. This is a huge opportunity for those within the child eye health sector to work with those implementing maternal and child health services in order to provide good quality services for NES.

Ensuring that right from when a child is born, they have access to eye screening gives them the best possible chance to see, thrive and develop to their full potential.

References

1. WHO recommendations on maternal and newborn care for a positive postnatal experience. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/9789240045989/a>

2. Mafwiri et al. A pilot study to evaluate incorporating eye care for children into reproductive and child health services in Dar-es-Salaam, Tanzania: a historical comparison study. BMC Nursing 2014,13:15

3. Malik ANJ et al. Integrating eye health training into the primary child healthcare programme in Tanzania: a pre-training and post-training study. BMJ Pediatric Open. 2020; 4(1)

4. https://med.st-andrews.ac.uk/arclight/teaching-materials/fundal-reflex/

5. Furahini G et al. Red reflex examination in reproductive and child health clinics for early detection of pediatric cataract and ocular media disorders: cross-sectional diagnostic accuracy and feasibility studies from Kilimanjaro, Tanzania. Eye 2021(35): 1347-53

6. Rahi JS, Cable N, British Childhood Visual Impairment Study G. Severe visual impairment and blindness in children in the UK. Lancet. 2003;362(9393):1359-65.

7. Muhit MA, Shah SP, Gilbert CE, Hartley SD, Foster A. The key informant method: a novel means of ascertaining blind children in Bangladesh. Br J Ophthalmol. 2007;91(8):995-9.

Image on top: Red reflex testing with poster on the wall/ANJ Malik

Focus on Child Eye Health engages some of the world’s best and brightest thought leaders throughout the year to share knowledge, inspire action, discuss ideas and push Child Eye Health to the forefront of pressing development issues. It is supported by CooperVision.