Blinking, squeezing and tics: telling the three apart

A parent often shows me a video before she says anything. It is filmed across a living room: a four year old watching television, squeezing both eyes shut hard every few seconds. She has already spent a night on her phone reading about brain conditions, and she wants me to look at the screen and tell her it is nothing.

I cannot tell her that from a video alone, but I can tell her what I am looking for. Hard blinking and eye squeezing in a small child is nearly always one of three things, and they behave differently enough that a parent can usually tell which one she is watching before she gets to me.

My child has started blinking strangely a lot, why?

Because something is irritating the eye, because something is making it itch, or because it has become a habit tic. Those are the three, in that order of how often I find them. A fourth possibility, that the blinking comes from a problem in the brain, is the one parents fear most and the one I find least. The American Association for Pediatric Ophthalmology and Strabismus puts it plainly: it is very rare for too much blinking to mean there is a brain problem.

Some ordinary numbers help, because most of us have no idea what normal looks like. Babies blink about twice a minute. Adults blink fourteen to seventeen times a minute. Anyone blinks more in pain, in bright light, or while talking. So a child whose blinking has gone up is not automatically abnormal, and what matters is the pattern around it.

The three questions I ask first are these. When did it start, and was anything happening that week? Is it worse at any particular time of day or in any particular room? And does your child seem bothered by the eye itself, or only by you noticing?

How do I know if it is dry or irritated eyes?

The eye tells you. Irritation usually comes with something visible or describable: redness, watering, a gritty or sandy complaint, light feeling harsh, or vision that goes briefly blurry and clears with a blink. The blinking is the child's own attempt to wipe the surface clean, and it settles when the cause is dealt with.

The Malaysian version of this is specific. Air conditioning at home and in the car, a fan pointed at a face on a hot night, a dusty week, a haze week. All of them dry the eye surface and make a child blink harder. So does an eyelash growing inwards and brushing the eye all day, which is easy to miss, because lashes that turn in against the eye look perfectly normal from across a room.

Screens matter here too, in a way that has been measured. In a small study, thirty six children aged six to fifteen played a smartphone game for an hour while their blinking was tracked. Within the first minute their blink rate fell from about twenty one blinks a minute to about nine, and stayed down for the whole hour while their symptoms worsened. One session, thirty six children, not done in Malaysia, so I would not build a rule on it. It does fit the hard blinking that arrives at the end of a long tablet afternoon, and makes taking breaks from the screen worth trying before anything else.

He rubs his eyes all day too, is it allergies?

Very possibly, and the giveaway is the itch. Allergic eyes itch rather than hurt, they affect both eyes, the lids can look puffy, and the eyes water. Almost always there is a nose in the story: sniffing, a blocked nose at night, a child who wakes up snuffly and settles by lunchtime. Allergic conjunctivitis is not catching, so nobody at the tadika gave it to your child and your child is not giving it to anybody.

The distinction I want a parent to make is between rubbing and blinking, because they point in slightly different directions. There is more to say about what the rubbing itself means, including why I would rather a child with itchy eyes did less of it. And if the eye is red and sticky rather than red and itchy, that is a different problem again, and sakit mata in a child has its own answer.

Is it a tic, and will ignoring it make it worse?

It may well be a tic, and no, not commenting on it is the kinder approach, not the neglectful one. A tic is a fast, repetitive muscle movement that happens on its own. Blinking is one of the commonest, along with nose wrinkling and face grimacing. Tics are fairly common in childhood, they typically first appear around five years old, and they are more common in boys.

What identifies a tic is not how it looks but what it responds to. Tics can happen at random, and they cluster with stress, tiredness, excitement or even happiness. Many children describe an uncomfortable build-up first, a feeling relieved by the movement, and some can hold it in for a while at a cost. Most importantly for a parent, tics tend to get worse if they are talked about or focused on. Every reminder to stop is a spotlight.

The course is reassuring. Most tics improve over time or stop completely. Some last a few months, others come and go over several years, and they are usually strongest from around eight until the teenage years, settling after puberty. Avoiding stress and tiredness genuinely helps most families, which is unglamorous advice and the honest kind. What does not help is punishment, or a bargain about stopping, or a household where four people are watching one child's face.

Someone told me hard blinking means short sight, is that right?

Not on its own, no, but needing glasses is on the list of causes we check. An uncorrected focusing error is one of the recognised reasons a child blinks more, and so is an eye that is not lining up with the other. That is why a child who comes in only about blinking gets a full examination, not a look at the lids and a wave home.

What I would not do is take blinking as proof that glasses are needed and go straight to an optical shop. The blinking is a symptom with several possible owners. Some of the myths around children's eyes are harmless, but the ones that send parents to the wrong place cost time, and this is one of them.

Should I film it to show the doctor?

Yes, and there is a right way to do it. A doctor can usually recognise a tic from a description and from seeing it, so a short video is useful, especially since the movement has a habit of disappearing in a consulting room. Film it quietly, without saying anything about what you are doing, because drawing attention to a tic while you record it can make it worse.

Bring three other things with you. When it started, to the week if you can. What makes it better or worse, including rooms, times of day, screens and sleep. And whether anything else has appeared alongside it, particularly a movement somewhere other than the eyes, or a sound. Those answers shape the appointment more than the video.

What happens at the appointment, and when is it something else?

The mechanical causes get ruled out first, because they are the ones with a fix. I look for eyelashes poking the eye, tiny scratches on the surface, infection, anything stuck under the lid, and signs of allergy, then check whether your child needs glasses and whether the two eyes are lining up. Treatment follows the cause. If your child needs something for the eye surface, that is a prescription decision made after an examination, not a purchase at a pharmacy counter on the way home.

If the eyes are entirely clear, the honest answer is often that we watch it for a while, and sometimes that a doctor who deals with the nervous system should have a look. That referral is not a verdict. It is what happens when the eye examination has done its job and found nothing to explain the movement.

The parts that are not a waiting game are short. A painful red eye, an eye gone very dark red, light that hurts to look at, or any change in your child's sight all need to be seen rather than filmed. So does a movement that spreads beyond the eyes, one going on for more than a year, one that is hurting your child, or a child being teased about it at school. Everything else can take the next available appointment, which is the sentence most parents in this situation have been waiting for.

Common questions

References

1. AAPOS · Excessive blinking in children · www.aapos.org
2. NHS · Tics · www.nhs.uk
3. NHS · Dry eyes · www.nhs.uk
4. Smartphone gaming induces dry eye symptoms and reduces blinking in school-aged children, Contact Lens and Anterior Eye 2022 · pmc.ncbi.nlm.nih.gov
5. American Academy of Ophthalmology · Child eye problems parents should never ignore · www.aao.org
6. American Academy of Ophthalmology · Pink eye (conjunctivitis) · www.aao.org
7. NHS · Red eye · www.nhs.uk

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.