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      Progression of Myopia in School-Aged Children After COVID-19 Home Confinement

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          Key Points

          Question

          Is home confinement due to coronavirus disease 2019 associated with the burden of myopia?

          Findings

          In this cross-sectional study that included 194 904 photoscreening tests conducted in 123 535 children, a substantial myopic shift (−0.3 diopters) was noted after home confinement due to coronavirus disease 2019 for children aged 6 to 8 years. The prevalence of myopia increased 1.4 to 3 times in 2020 compared with the previous 5 years.

          Meaning

          Home confinement due to coronavirus disease 2019 appeared to be associated with a substantial myopic shift in children; younger (aged 6-8 years) children’s refractive status may be more sensitive to environmental changes than older children, given that they are in an important period for the development of myopia.

          Abstract

          Importance

          Time spent in outdoor activities has decreased owing to home confinement for the coronavirus disease 2019 (COVID-19) pandemic. Concerns have been raised about whether home confinement may have worsened the burden of myopia owing to substantially decreased time spent outdoors and increased screen time at home.

          Objective

          To investigate the refractive changes and prevalence of myopia in school-aged children during the COVID-19 home confinement.

          Design, Setting, and Participants

          A prospective cross-sectional study using school-based photoscreenings in 123 535 children aged 6 to 13 years from 10 elementary schools in Feicheng, China, was conducted. The study was performed during 6 consecutive years (2015-2020). Data were analyzed in July 2020.

          Exposures

          Noncycloplegic photorefraction was examined using a photoscreener device.

          Main Outcomes and Measures

          The spherical equivalent refraction was recorded for each child and the prevalence of myopia for each age group during each year was calculated. The mean spherical equivalent refraction and prevalence of myopia were compared between 2020 (after home confinement) and the previous 5 years for each age group.

          Results

          Of the 123 535 children included in the study, 64 335 (52.1%) were boys. A total of 194 904 test results (389 808 eyes) were included in the analysis. A substantial myopic shift (approximately −0.3 diopters [D]) was found in the 2020 school-based photoscreenings compared with previous years (2015-2019) for younger children aged 6 (−0.32 D), 7 (−0.28 D), and 8 (−0.29 D) years. The prevalence of myopia in the 2020 photoscreenings was higher than the highest prevalence of myopia within 2015-2019 for children aged 6 (21.5% vs 5.7%), 7 (26.2% vs 16.2%), and 8 (37.2% vs 27.7%) years. The differences in spherical equivalent refraction and the prevalence of myopia between 2020 and previous years were minimal in children aged 9 to 13 years.

          Conclusions and Relevance

          Home confinement during the COVID-19 pandemic appeared to be associated with a significant myopic shift for children aged 6 to 8 years according to 2020 school-based photoscreenings. However, numerous limitations warrant caution in the interpretation of these associations, including use of noncycloplegic refractions and lack of orthokeratology history or ocular biometry data. Younger children’s refractive status may be more sensitive to environmental changes than older ages, given the younger children are in a critical period for the development of myopia.

          Abstract

          This cross-sectional study compares the prevalence of myopia in school-aged children 5 years before the COVID-19 pandemic with the prevalence during home confinement due to the pandemic.

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          Most cited references41

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          World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.

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            Mitigate the effects of home confinement on children during the COVID-19 outbreak

            In response to the coronavirus disease 2019 (COVID-19) outbreak, the Chinese Government has ordered a nationwide school closure as an emergency measure to prevent spreading of the infection. Public activities are discouraged. The Ministry of Education estimates that more than 220 million children and adolescents are confined to their homes; this includes 180 million primary and secondary students and 47 million preschool children). 1 Thanks to the strong administrative system in China, the emergency home schooling plan has been rigorously implemented. 2 Massive efforts are being made by schools and teachers at all levels to create online courses and deliver them through TV broadcasts and the internet in record time. The new virtual semester has just started in many parts of the country, and various courses are offered online in a well organised manner. These actions are helping to alleviate many parents' concerns about their children's educational attainment by ensuring that school learning is largely undisrupted. Although these measures and efforts are highly commendable and necessary, there are reasons to be concerned because prolonged school closure and home confinement during a disease outbreak might have negative effects on children's physical and mental health.3, 4 Evidence suggests that when children are out of school (eg, weekends and summer holidays), they are physically less active, have much longer screen time, irregular sleep patterns, and less favourable diets, resulting in weight gain and a loss of cardiorespiratory fitness.3, 5 Such negative effects on health are likely to be much worse when children are confined to their homes without outdoor activities and interaction with same aged friends during the outbreak. Perhaps a more important but easily neglected issue is the psychological impact on children and adolescents. Stressors such as prolonged duration, fears of infection, frustration and boredom, inadequate information, lack of in-person contact with classmates, friends, and teachers, lack of personal space at home, and family financial loss can have even more problematic and enduring effects on children and adolescents. 4 For example, Sprang and Silman 6 showed that the mean posttraumatic stress scores were four times higher in children who had been quarantined than in those who were not quarantined. Furthermore, the interaction between lifestyle changes and psychosocial stress caused by home confinement could further aggravate the detrimental effects on child physical and mental health, which could cause a vicious circle. To mitigate the consequences of home confinement, the government, non-governmental organisations (NGOs), the community, school, and parents need to be aware of the downside of the situation and do more to effectively address these issues immediately. Experiences learned from previous outbreaks can be valuable for designing a new programme to tackle these issues in China. 7 The Chinese Government needs to raise the awareness of potential physical and mental health impacts of home confinement during this unusual period. The government should also provide guidelines and principles in effective online learning and ensure that the contents of the courses meet the educational requirements. Yet it is also important not to overburden the students. The government might mobilise existing resources, perhaps involving NGOs, and create a platform for gathering the best online education courses about healthy lifestyle and psychosocial support programmes available for schools to choose from. For example, in addition to innovative courses for a better learning experience, promotional videos can be useful to motivate children to have a healthy lifestyle at home by increasing physical activities, having a balanced diet, regular sleep pattern, and good personal hygiene. 8 To make these educational materials truly effective, they must be age-appropriate and attractive. They require professional expertise and real resources to create. Communities can serve as valuable resources in managing difficulties of family matters. For instance, parents' committees can work together to bridge the needs of students with school requirements and to advocate for children's rights to a healthy lifestyle. Psychologists can provide online services to cope with mental health issues caused by domestic conflicts, tension with parents, and anxiety from becoming infected. 7 Social workers can play an active role in helping parents cope with family issues arising from the situation, when needed. Such a social safety net could be particularly useful for disadvantaged or single-parent families, 9 but action is needed to make it accessible to them. Schools have a critical role, not only in delivering educational materials to children, but in offering an opportunity for students to interact with teachers and obtain psychological counselling. Schools can actively promote a health-conscious schedule, good personal hygiene, encourage physical activities, appropriate diet, and good sleep habits, and integrate such health promotion materials into the school curriculum. 3 A Chinese child studies from home during the COVID-19 outbreak © 2020 Fan Jiang 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. In the event of home confinement, parents are often the closest and best resource for children to seek help from. Close and open communication with children is the key to identifying any physical and psychological issues and to comforting children in prolonged isolation.10, 11 Parents are often important role models in healthy behaviour for children. Good parenting skills become particularly crucial when children are confined at home. Besides monitoring child performance and behaviour, parents also need to respect their identity and needs, and they need to help children develop self-discipline skills. Children are constantly exposed to epidemic-related news, so having direct conversations with children about these issues could alleviate their anxiety and avoid panic.10, 11 Home confinement could offer a good opportunity to enhance the interaction between parents and children, involve children in family activities, and improve their self-sufficiency skills. With the right parenting approaches, family bonds can be strengthened, and child psychological needs met. 12 Since the COVID-19 epidemic is no longer confined to China, 13 school closure and home confinement-related issues also become relevant in other affected countries. As children are vulnerable to environmental risks and their physical health, mental health, and productivity in adult life is deeply rooted in early years, 14 close attention and great efforts are required to address these emergency issues effectively and avoid any long-term consequences in children. Any sustainable programme must involve local professionals to culturally adapt the interventions to the administrative system and to the regional and community environment, and it must develop contextually relevant material for children and adolescents. 7 Finally, children have little voices to advocate for their needs. The latest Commission 14 on the future of the world's children urges a holistic strategy in preparing for the uncertainty that all children are facing. It is the responsibility and keen interests of all stakeholders, from governments to parents, to ensure that the physical and mental impacts of the COVID-19 epidemic on children and adolescents are kept minimal. Immediate actions are warranted.
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              Myopia

              The Lancet, 379(9827), 1739-1748
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                Author and article information

                Journal
                JAMA Ophthalmol
                JAMA Ophthalmol
                JAMA Ophthalmol
                JAMA Ophthalmology
                American Medical Association
                2168-6165
                2168-6173
                14 January 2021
                March 2021
                14 January 2021
                : 139
                : 3
                : 293-300
                Affiliations
                [1 ]Department of Ophthalmology, Emory University, Atlanta, Georgia
                [2 ]Department of Ophthalmology and Visual Sciences, Department of Epidemiology, University of Michigan, Ann Arbor
                [3 ]Department of Strabismus and Pediatric Ophthalmology, Tianjin Medical University Eye Hospital, Tianjin, China
                [4 ]Department of Respiratory and Critical Medicine, Tianjin Medical University General Hospital, Tianjin, China
                Author notes
                Article Information
                Accepted for Publication: November 12, 2020.
                Published Online: January 14, 2021. doi:10.1001/jamaophthalmol.2020.6239
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Wang J et al. JAMA Ophthalmology.
                Corresponding Author: Xuehan Qian, MD, PhD, Department of Strabismus and Pediatric Ophthalmology, Tianjin Medical University Eye Hospital, Tianjin 300384, China ( qianxuehan@ 123456yahoo.com ).
                Author Contributions: Drs Wang and Qian had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Wang and Y. Li contributed equally to this work.
                Concept and design: Wang, Qian.
                Acquisition, analysis, or interpretation of data: Wang, Y. Li, Musch, Wei, Qi, Ding, X. Li, J. Li, Song, Ning, Zhang, Zeng, Hua, S. Li, Qian.
                Drafting of the manuscript: Wang, Y. Li.
                Critical revision of the manuscript for important intellectual content: Musch, Wei, Qi, Ding, X. Li, J. Li, Song, Ning, Zhang, Zeng, Hua, S. Li, Qian.
                Statistical analysis: Wang, Y. Li.
                Obtained funding: Qian.
                Administrative, technical, or material support: Wei, Qi, Ding, X. Li, J. Li, Song, Ning, Zhang, Zeng, Hua, S. Li, Qian.
                Supervision: Qian.
                Conflict of Interest Disclosures: None reported.
                Funding/Support: This work was supported by grant 17ZXHLSY00020 from the Tianjin Municipal Science and Technology Commission and grant YDYYRCXM-B2018-02LC from Tianjin Medical University Eye Hospital High-Level Innovative Talent Program for Distinguished Scholar (Dr Qian).
                Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Additional Contributions: Chris Andrews, PhD (Department of Ophthalmology and Visual Sciences, and Department of Epidemiology, University of Michigan), provided advice on statistical analysis. Lingling Wang, MD (Shandong First Medical University, Feicheng Hospital), contributed to the photoscreening work in Feicheng, China. No compensation was provided for these contributions.
                Article
                eoi200108
                10.1001/jamaophthalmol.2020.6239
                7809617
                33443542
                da6fab19-390d-434e-a9ab-18bd46476b4b
                Copyright 2021 Wang J et al. JAMA Ophthalmology.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 20 August 2020
                : 12 November 2020
                Categories
                Research
                Research
                Original Investigation
                Online First
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