Acta Ophthalmologica 2008

Eye blink in newborn and

preschool-age children
Marcelo M. Lavezzo,1 Silvana A. Schellini,1 Carlos R. Padovani2
and Flavio Eduardo Hirai1
1
Department of Ophthalmology, Botucatu School of Medicine, Universidade
Estadual Pauliste, Botucatu, São Paulo, Brazil
2
Department of Biostatistics, Bioscience Institute, Universidade Estadual Pauliste,
Botucatu, São Paulo, Brazil

ABSTRACT. 2005). In normal adults, blink rates

Purpose: To investigate the dynamics of ocular eyelid movements in newborn range from two to 50 blinks ⁄ min
infants and preschool-age children. (Monster et al. 1978; Tsubota 1998).
Methods: Fifty newborn infants and 200 preschool children aged 4)6 years The blink reflex is present at birth,
were examined. Images of each child, with his or her eyes in the primary eye but spontaneous blink rates are low
position looking at an object placed at the child’s height, were recorded with a in very young children (Zametkin
digital videocamera for 3 mins. Complete and incomplete blink rates, opening, et al. 1979; Lawrenson et al. 2003).
Blink rates increase rapidly during
closing and complete blink times were calculated.
the first year of life, but remain
Results: Newborn infants presented a lower number of incomplete movements
lower than those in adults (Tsubota
than preschool children. The complete blink rate was lower in newborn infants 1998).
(6.2 blinks ⁄ min) than in preschool children (8.0 blinks ⁄ minute). Eyelid closing, The evaluation of blink rates in
opening and compete blink times were longer in newborn infants than in pre- newborn infants and young children is
school children at all observation times. difficult, particularly because of meth-
Conclusions: Newborn infants had a different pattern of eyelid movement com- odological issues. The purpose of this
pared with preschool children. Specific characteristics that are found in this study was to investigate eyelid dynam-
group of children particularly, such as immaturity of the neural system and ics in normal newborn infants and
more resistant tear film, may explain these findings in part. preschool-age children using a digital
image processing system.
Key words: eye blink – newborn – preschool children – eyelid closing time – eyelid opening time –
digital image
Materials and Methods
Acta Ophthalmol. 2008: 86: 275–278
A total of 250 children were evaluated
ª 2007 The Authors
Journal compilation ª 2007 Acta Ophthalmol Scand at the Faculty of Medicine at Botu-
catu, São Paulo, Brazil. Fifty newborn
doi: 10.1111/j.1600-0420.2007.00969.x infants (aged up to 30 days) and
200 healthy preschool children aged
4 years (66 children), 5 years (54 chil-
dren) and 6 years (80 children) parti-
cipated in this study. Children with
conditions, including time of day eyelid abnormalities (e.g. congenital
Introduction (rates increase at night) (Barbato ptosis) or diseases that might affect
There are two types of blinking: invol- et al. 2000), gender (men have higher blink rate (e.g. ocular allergies) were
untary or reflex (corresponding with rates than women) (Bentivoglio et al. not enrolled.
spontaneous) and voluntary (which 1997), cognitive processes and atten- Eye movement patterns were evalu-
depends on the individual’s intent). tion level (Bentivoglio et al. 1997) and ated by recording digital images (fron-
Blink rate influences lacrimal drainage ocular alterations (Dumery & Toi Vo tal and lateral shots) of newborn
(Sahlin & Chen 1997) and ocular sur- Van 1997). infants and children fully awake, in
face integrity (Tsubota & Nakamori Blink rates in adults vary across the primary eye position, with the
1995), and depends on various different age groups (Schellini et al. observation target placed at the

275
 17553768, 2008, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0420.2007.00969.x by National Institutes Of Health Malaysia, Wiley Online Library on [29/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Acta Ophthalmologica 2008

subject’s height at a distance of 1 m. 25

All images were taken by the same
observer under the same environmen-
tal conditions using a Sony Lithium 20
digital video camera (Sony DCR-

Median (in 3 mins)

TRV110, Sony, Manus, Brazil) and
15
8-mm videotapes. Images were trans-
ferred to an Apple MacIntosh
G4computer and processed with 10
iMovie software (Apple Computer
Inc., Cupertino, CA, USA). This soft- Complete eyelid movement
ware detects intervals of 1 ⁄ 30 sec (one 5
Incomplete eyelid movement
frame), which allowed us to capture
the high speeds of the human blink
(Dumery & Toi Vo Van 1997). 0
Spontaneous blinking was evaluated Newborns 4 years old 5 years old 6 years old
Age
over a 3-min period and included eye-
lid opening and closing times (in milli- Fig. 1. Median values of blink rate for complete and incomplete movements according to age.
seconds), complete blink time (sum of
eyelid opening and closing times in
milliseconds) and the rate of eyelid respectively). Newborn infants presen- and preschool children (8.0 and
movements per minute. In order to ted a lower number of incomplete 6.3 blinks ⁄ min, respectively).
evaluate these parameters (i.e. closing, movements than preschool-age chil- Eyelid closing time as well as eyelid
opening and complete blink times), dren. Newborn infants made five opening time was longer in newborn
one complete eyelid movement from incomplete eyelid movements during infants than in preschool children at
each minute of observation was ran- the 3-min period, whereas 4-, 5- and all observation times (p < 0.0001).
domly chosen. Eyelid movement was 6-year-old children presented 15, 18 Similar results were seen for complete
considered complete when the super- and 16 incomplete eyelid movements, blink time: newborn infants demon-
ior eyelid touched the inferior eyelid; respectively (median values, p < strated a longer complete blink time
otherwise, it was defined as incom- 0.001). The complete blink rate was than preschool children (p < 0.0001)
plete. lower in newborn infants (6.2 blinks ⁄ (Table 1).
Because blink rates can be affected min) than in preschool children
by many internal (e.g. concentration (8.0 blinks ⁄ min). The complete blink
level, humour) and external (e.g. dust, rate was higher than the incomplete
Discussion
wind, smoke) factors (Monster et al. blink rate in both newborn infants Our study evaluated the dynamics of
1978; Bentivoglio et al. 1997), we deci- (6.2 and 2.5 blinks ⁄ min, respectively) eyelid movements in a group of
ded to record eyelid movements over
a 3-min period to allow the children
to become more comfortable with the
environment. The images were also Table 1. Mean (± standard deviation) eyelid closing, opening and complete blink times (in mil-
recorded from a lateral position and liseconds) over a 3-min period, according to age.
the children were distracted from the Eyelid closing time
fact that they were being filmed in
order to capture spontaneous blink- Newborns 4-year-olds 5-year-olds 6-year-olds p-value*
ing.
Min 1 433.3 ± 92.7 225.0 ± 68.3 226.7 ± 84.3 228.0 ± 55.0 p < 0.0001
Results were analysed and presen- Min 2 435.3 ± 76.0 231.3 ± 59.3 240.3 ± 88.3 230.7 ± 57.0 p < 0.0001
ted according to descriptive statistics Min 3 424.3 ± 88.0 234.3 ± 63.0 230.7 ± 72.7 232.0 ± 75.0 p < 0.0001
(mean, standard deviation and med-
ian) and non-parametric tests were Eyelid opening time
used to compare groups.
Newborns 4-year-olds 5-year-olds 6-year-olds p-value*

Min 1 330.7 ± 64.3 192.3 ± 51.7 187.7 ± 54.7 200.7 ± 40.7 p < 0.0001
Min 2 333.3 ± 61.0 201.0 ± 49.0 194.0 ± 52.0 201.7 ± 40.7 p < 0.0001
Results Min 3 319.3 ± 60.0 200.3 ± 55.3 189.0 ± 47.0 206.0 ± 49.0 p < 0.0001
Figure 1 shows median values of blink
Complete blink time
rates according to age. Newborn
infants made 19 complete eyelid Newborns 4-year-olds 5-year-olds 6-year-olds p-value*
movements during the 3-min period,
Min 1 764.0 ± 139.0 417.3 ± 113.0 414.3 ± 127.0 428.7 ± 88.7 p < 0.0001
which was similar to the number of
Min 2 768.7 ± 124.3 432.3 ± 99.3 434.7 ± 126.3 432.3 ± 89.7 p < 0.0001
complete eyelid movements presented Min 3 743.7 ± 123.3 435.0 ± 111.0 420.0 ± 106.7 438.0 ± 117.3 p < 0.0001
by 4-, 5- and 6-year-old children
(median values of 12, 16 and 22, * p-value ¼ comparison between newborn infants and the 4-, 5-, and 6-year-old age groups.

276

healthy newborn infants and pre-
school-age children. The ocular sur-
face, together with the eyelids and
lacrimal system, represents a func-
tional unit that ensures the quality of
the refractive surface of the eye and
also protects ocular structures from
noxious stimuli arising from the envi-
ronment (Rolando & Zierhut 2001).
The preocular tear film is the most
dynamic structure within this unit,
and an adequate rate of tear produc-
tion and a rapid turnover is essential
for ocular health. Tears cleanse, lubri-
cate and defend the ocular surface
against infection. Furthermore, by
smoothing out irregularities of the
corneal epithelium, the precorneal tear
film creates an even surface of excel-
lent optical quality that is reformed
with each blink. In newborn infants,
the optical characteristics of the tear
film are important for the generation
of a clear retinal image, which is an
essential prerequisite for normal visual
development (Lawrenson et al. 2003).
As the tear film is inherently unstable,
frequent blinking is normally required
to prevent surface drying. The repor-
ted low rate of spontaneous blinking
in neonates and infants (Zametkin
et al. 1979) thus raises important
questions regarding tear stability and
the ability of ocular surface receptors
to detect tear break-up.
In addition, a reduced rate of reflex
tear secretion may limit the dilution
of topical ocular medication, leading
to a longer period of contact between
the drug and the ocular surface and
thus increasing the risk of adverse
reactions (Isenberg et al. 1998).
One important finding from our
study was that the pattern of eyelid
movement in newborn infants clearly
differed from that in preschool chil-
dren. Newborn infants, for example,
had lower blink rates and longer
opening and closing times than
4–6-year-old children.
Other authors have also reported
that newborn infants present a
decreased blink rate compared with
older children (Zametkin et al. 1979;
Lawrenson et al. 2003) and this rate
increases until adolescence. After
adolescence, it appears to remain con-
stant throughout life (Barbato et al.
2000).
The lipid layer of tear film in
newborn infants is thicker than in
adults, slowing evaporation and
increasing tear film stability, and
thus preventing ocular surface drying
(Isenberg et al. 1998; Lawrenson
et al. 2005). In addition, less ocular
surface area is exposed in newborn
infants (Fox 1966). The combination
of these factors (i.e. more stable tear
film and a smaller ocular surface
area) may in part explain why chil-
dren in this age group have lower
blink rates. This idea is supported
by Tsubota (1998), who observed
that an increase in blink rate repre-
sents an important mechanism with
which to compensate for the greater
tear film evaporation resulting from
the increase in ocular surface
exposure caused by ocular globe
growth.
Another hypothesis to explain the
lower blink rate in newborn infants
relates to the development of the vis-
ual and central nervous systems.
Newborn infants do not achieve the
same level of image formation in the
retina and brain as older children,
and external stimuli are probably less
important to the blinking process
because of the immaturity of the
neural circuit and the eye. Moreover,
the immaturity of other systems may
also contribute to the lower blink
rates observed in newborn infants.
For example, afferent pathways that
detect a reduction in tear film on the
ocular surface, caused by evapor-
ation, may not yet be fully formed.
In addition, although the relationship
between dopaminergic plasticity and
spontaneous blink frequency in new-
born infants is unclear (Meng et al.
1999; Herlenius & Lagercrantz 2001),
it is believed that the reduced
blink rate in newborn infants, as
seen in this study, may reflect a rel-
atively underdeveloped dopaminergic
system.
The main limitation of our study
concerned the difficulty of recording
eyelid movements in newborn infants
because they were awake for only
short periods of time and, as a conse-
quence, a lower number of children in
this age group were examined.
Although the number of newborn
infants (50) differed from that of
children aged 4)6 years (200), non-
parametric statistical tests allowed us
to make comparisons between the two
groups.
17553768, 2008, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0420.2007.00969.x by National Institutes Of Health Malaysia, Wiley Online Library on [29/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Acta Ophthalmologica 2008
Conclusions
In conclusion, blink rates were
lower and blinking times longer in
newborn infants compared with
preschool children. Specific character-
istics found only in this group of
children, such as immaturity of the
neural system and more resistant tear
film, may explain these findings in
part.
Acknowledgement
This study was supported by the Con-
selho Nacional de Desenvolvimento
Cientı́fico e Tecnológico (National
Council for Scientific and Technologi-
cal Research), Brasilia, Brazil.
References
Barbato G, Ficca G, Muscettola G, Fichele
M, Beatrice M & Rinaldi F (2000): Diurnal
variation in spontaneous eye blink rate.
Psychiatry Res 93: 145–151.
Bentivoglio AR, Bressman SB, Cassetta E,
Carretta D, Tonali P & Albanese A
(1997): Analysis of blink rate patterns in
normal subjects. Mov Disord 12: 1028–
1034.
Dumery B & Toi Vo Van (1997): Relation-
ship between blink rate, ocular discomfort
and visual tasks. Invest Ophthalmol Vis Sci
38 (Suppl): 68.
Fox SA (1966): The palpebral fissure. Am J
Ophthalmol 62: 73–78.
Herlenius E & Lagercrantz H (2001): Neuro-
transmitters and neuromodulators during
early human development. Early Hum Dev
65: 21–37.
Isenberg SJ, Apt L, McCarty J, Cooper LL,
Lim L & Del Signore M (1998):
Development of tearing in preterm and
term neonates. Arch Ophthalmol 116: 773–
776.
Lawrenson JG, Birhah R & Murphy PJ
(2005): Tear-film lipid layer morphology
and corneal sensation in the development
of blinking in neonates and infants. J Anat
206: 265–270.
Lawrenson JG, Murphy PJ & Esmaeelpour
M (2003): The neonatal tear film. Cont
Lens Anterior Eye 26: 197–202.
Meng SZ, Ozawa Y, Itoh M & Takashima S
(1999): Developmental and age-related
changes of dopamine transporter, and
dopamine D1 and D2 receptors in
human basal ganglia. Brain Res 843: 136–
144.
Monster AW, Chan HC & O’Connor D
(1978): Longterm trends in human eye
blink rate. Biotelem Patient Monit 5: 206–
222.
277

Acta Ophthalmologica 2008
Rolando M & Zierhut M (2001): The ocular
surface and tear film and their dysfunction
in dry eye disease. Surv Ophthalmol 45:
S203–S210.
Sahlin S & Chen E (1997): Gravity, blink rate
and lacrimal drainage capacity. Am J Oph-
thalmol 124: 758–764.
Schellini SA, Sampaio AA, Hoyama E, Cruz
AAV & Padovani CR (2005): Spontaneous
eye blink analysis in the normal individual.
Orbit 24: 239–242.
Tsubota K (1998): Tear dynamics and dry
eye. Prog Retin Eye Res 17: 565–596.
278
Tsubota K & Nakamori K (1995): Effects of
ocular surface area and blink rate on
tear dynamics. Arch Ophthalmol 113: 155–
158.
Zametkin AJ, Stevens JR & Pittman R
(1979): Ontogeny of spontaneous blinking
and of habituation of the blink reflex. Ann
Neurol 5: 453–457.
Received on January 5th, 2007.
Accepted on May 13th, 2007.
17553768, 2008, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0420.2007.00969.x by National Institutes Of Health Malaysia, Wiley Online Library on [29/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Correspondence:
Silvana Artioli Schellini MD
Departamento de Oftalmologia
Faculdade de Medicina de Botucatu
Universidade Estadual Paulista
Botucatu
Cep 18618–970 São Paulo
Brazil
Tel: + 55 (14) 3811 6256
Fax: + 55 (14) 3811 6256
Email: sartioli@fmb.unesp.br