What is Myopia?
Myopia is a condition of the eye that causes distant objects to appear blurred because their images are focused in front of the retina rather than on it. Also called short-sightedness or near-sightedness, those with myopia are unable to see clearly in the distance and can see better up close than far away. Treatments such as control lenses or spectacles may be required to correct blurred vision caused by myopia.
The Myopic Eye
Myopia occurs when there is a disruption or variation to the normal growth of the eyeball. The myopic eye is elongated in shape, stretched longer than it should be, which means light from far away objects are focused in front of the retina rather than directly on it, resulting in blurred distance vision.
The Normal Eye
The human eye is incredible. As the eyeball grows in a child, the components of the eye normally develop in unison so that light is focused perfectly onto the retina at the back of the eye. Vision is sharpest when light is focused precisely on the retinal plane. This is how nature through evolution had programmed the normal eye to grow.
What causes myopia?
Genetics and environmental factors both contribute to the development of myopia in children and adolescents.
A family history of myopia is a known risk — one or both parents with short-sightedness significantly increases the risk of the child developing it also.
Environmental influences include excessive near work, reading, studying, computer and tablet use, and time spent indoors. Significant growth of the eye occurs in children between the ages of 6 and 12. During this critical time, factors which increase the risk of abnormal elongation growth of the eye will result in myopia.
As society has developed with urbanisation, education and constant use of digital technology in everyday life from a young age, the evolution of the human eye has not kept up with these rapid changes. That's why myopia in children and young adults is dramatically on the rise not just in Singapore but globally. Myopia is becoming such a problem all around the world that it's been termed The Myopia Epidemic by eye experts and researchers.
Thankfully with early intervention and treatment, it is possible to lessen or manage the severity of myopia through childhood and adolescence.
Degrees of myopia
Myopia is generally classified according to the degree of myopia, that is the power of the prescription control lens required to correct the blurred vision, measured in dioptres (D). The higher the myopia, the greater the physical elongation of the eye.
Low myopia -0.50 to -3.00
Moderate myopia -3.25 to -5.75
High myopia -6.00 & above
Extreme myopia is sometimes used to describe myopia in excess of -10.00
In some countries, the amount of myopia may be specified in 'degrees'. For example, -6.00 is commonly referred to in Hong Kong and Southeast Asia as 600 degrees of myopia (600 度近視), and -10.00 as 1000 degrees of myopia (1000 度近視), and so on. Tests performed by accredited optometrists or opticians in Singapore often use dioptres, but many Singaporeans tend to refer to treatment options such as spectacles or control lenses using the ‘degrees’ descriptor.
The Dangers Of Myopia
Having myopia is much more than just the inconvenience of needing to depend on treatments such as control spectacles or contact lenses to see.
Myopia is a danger to the long-term health of the eyes. While glasses and contact lenses correct vision by refocusing light onto the retina, lenses do not address the underlying problem — that the eye is physically stretched and elongated. And that means the retina is thinner (think of an elastic band that's been stretched) and more prone to damage and disease.
Some of the potential consequences of high myopia are detailed below. There is no 'safe' level of myopia — even moderate myopia can have consequences — but the higher the myopia, the greater the danger of vision loss in an individual's lifetime.
CONSEQUENCES OF HIGH MYOPIA
While high myopia can be managed through several common treatment options, it still poses high health risks that can severely impact quality of life over time.
Glasses become thicker and heavier with higher levels of myopia. High-index spectacle lenses to reduce thickness also add extra expense to each pair of new glasses.
High myopia is associated with cataract formation, and also increases the risk of complications during and after cataract surgery.
High myopia has been linked to a higher incidence of glaucoma, and development of more severe cases of glaucoma.
Myopia commonly causes earlier vitreous detachment, leading to many visually-disruptive spots and floaters and increases glare.
Thinning of the retina in a highly myopic eye increases the risk of developing myopic macular degeneration, causing loss of central vision.
A small tear in the retina can quickly develop into a retinal detachment, which, if not detected and managed promptly, can lead to permanent vision loss.
Symptoms of a retinal detachment may include flashes of light, sudden increase of floaters, and a large shadow moving across the line of sight.
Retinal detachment surgery to repair a torn retina and restore sight is a complex, risky and invasive procedure. Vision may never fully return to normal.
Myopia is irreversible
Myopia Epidemic
Myopia is no longer just a problem in Asia.
It's well known that myopia is a widespread vision problem in East Asian countries and has been for some time. Over 80% of teenagers and young adults in Hong Kong, China, Taiwan, Korea and Singapore are near-sighted, with some countries now exceeding 90%.
But there's a dramatic increase in myopia happening around the world, including Australia, the United States and Europe. The number of young people with myopia outside of Asia have doubled in just one generation, and continues to increase.
It's interesting to see, as illustrated in the graph below, that myopia around the world in 30 years is in an increasing trend. With rising population density and urbanisation in most countries, the rise of myopia in Singapore is predicted to follow a similar course. Children and teenagers wearing control spectacles or lenses to treat near-sightedness in Singapore will become the norm, rather than the exception.
"The prevalence of myopia and high myopia is increasing globally at an alarming rate, with significant increases in the risks for vision impairment from pathological conditions associated with high myopia, including retinal damage, cataract and glaucoma."
The World Health Organization Report on Myopia, 2016.
THE CAUSES?
Genetics
Genetics plays a big part. A child with one myopic parent has a three times risk of developing myopia, and a child with both parents being myopic has a six times risk.
As myopic children become myopic adults, it creates a cascade that increases the prevalence of myopia in the world's population. Scientists have already identified the exact gene involved in myopia that may one day lead to the development of gene therapy to prevent myopia in individuals.
Environment
Kids can also develop myopia without having myopic parents, and that is believed to be related to environmental influences. Consider the digital age we live in. Kids are using digital devices - phones, tablets, laptops, computers - far earlier now than even a generation ago.
Digital technology is a huge part of a child's life and in their education, which is also more demanding and competitive in Singapore than ever before. More reading, more studying, more tutoring, and from a younger age.
Our society and living conditions are also changing. With our increasing population and higher density housing, our living space is becoming more confined. More children are growing up in smaller houses with smaller backyards, and many in apartments. They are spending less time outdoors in the sun and more time on indoor activities and on their screens interacting with their friends online.
All these are contributing to the myopia epidemic.
Slowing Down Myopia
Myopia Control
a new approach
Our MyopiaControl treatment program represents a new approach to managing short-sightedness (myopia) in Singapore.
In the past, the main method of correcting and controlling short-sightedness in children and teenagers has been with spectacles or corrective contact lenses, which is still the case with the majority of regular optometrists. There is usually little or no attempt at slowing the rate of eyesight deterioration in these children, while their short-sightedness progressed year by year, and their lenses got stronger and thicker at each visit. Meanwhile, with their increasing level of short-sightedness and growth of their eyeball, the risk to the child's long-term eye health is also increasing each year.
At EMME Visioncare, we take a proactive approach in controlling childhood myopia. By prescribing treatments to prevent and delay the onset of myopia, and slowing the rate of myopia progression in short-sighted children and teenagers, we reduce the risk of potential myopia-related vision loss in these children's lifetime. This way, they can enjoy better vision and the confidence of healthier eyes for the rest of their lives.
Diagram of the Myopia trend in a Singaporean boy across the years without myopia control treatments
Let's change the old way of thinking
In our MyopiaControl programme, we apply the latest scientific research in myopia control to help stabilise your child's eyesight. Effective and safe treatment options are now available in Singapore to slow short-sightedness progression by 25-75% (average reduction of 50%) in suitable children. This significantly reduces your child's risk of developing high degrees of short-sightedness and the associated risks of serious eye diseases and potential vision loss later in adulthood.
Myopia is preventable
Theory
Myopia typically occurs when the eyeball grows too quickly during childhood and adolescence, at around 6 to 12 years of age. As the eyeball grows the eye structures stretch in length. Earlier onset of myopia is becoming more common, likely due to kids' earlier access to handheld electronic devices and increased reading and learning at a younger age. This also means that children in Singapore are being prescribed myopia control treatments at an earlier age, making it more important than ever to ensure their vision and eyesight can continue to safely develop throughout the process.
It is believed that the peripheral parts of the retinal tissues send stimulation signals to induce the growth of the eyeball. Ordinary spectacle lenses and contact lenses correct vision equally from the centre to the periphery.
Recent research has found that when the peripheral retina receives different light signals, via a modification of the optics of the corrective lenses or by changing the shape of the eye surface with orthokeratology, the stimulating signals to promote eye growth are suppressed, thereby slowing down myopia progression.
When do you begin?
As soon as significant myopia increase has been documented
We review children with myopia at least every 3 to 6 months. We assess the child's risk of progression based on factors such as their age, current level of myopia, eyesight history, and genetic and environmental influences.
Where a high risk of progression is identified, we recommend starting myopia control treatment as soon as a significant and consistent myopia increase has been observed. A documented increase of -1.00D or more in one year (or over 2 review visits) over the baseline prescription is considered significant progression.
There is no minimum age to start myopia control treatment
The types of suitable treatment available in Singapore may vary with age, but there is no minimum age for starting myopia control in a child with advancing myopia. The earlier the treatment is started, the better the eventual outcome for the child. Your optometrist will guide you through the options and, together with you, decide on an individualised treatment plan most suited for your child.
The goal of treatment is to avoid developing high myopia
The age of initiating myopia control treatment can greatly affect the eventual amount of myopia developed. Each year of delay during the critical period of rapid progression makes a considerable difference to whether or not the child will have high myopia, or even extreme myopia, for life.
Avoiding high myopia means healthier eyes
High levels of myopia are associated with significantly increased risks of eye diseases. Glaucoma, retinal detachment and myopic macular degeneration are all serious, sight-threatening eye conditions. Vision loss at any age can be life-changing, and certainly prevention is better than cure. While there is no 'safe' level of short-sightedness, we can lessen the risk of vision loss in an individual's lifetime by aiming to keep a child's level of myopia as low as possible with treatment.
Myopia Control Solutions
Our optometrist in Singapore starts with a detailed assessment of your child's eyes, analysis of their past and current eyesight changes, and with careful consideration of their age, family history and risk factors. We will decide with you on an individualised treatment plan to best manage your child's short-sightedness.
We graph your child's prescription changes to visualise their rate of myopia progression and to forecast their eventual level of myopia with different treatment options. And we will continue to monitor their progression closely while on treatment, to tailor and adjust the treatment plan for maximum myopia control.
The treatment options in our MyopiaControl treatment are detailed below.
1. Orthokeratology
Orthokeratology (Ortho-K or OK lens) is currently the most effective optical treatment for myopia control in Singapore.
Ortho-K lenses are custom-designed rigid contact lenses worn during sleep. The lenses are made of a high-oxygen, breathable material and precision-shaped to fit your child's cornea so that gentle pressure is placed on the eyes at night to re-shape the corneal surfaces.
Our experienced Ortho-K optometrist uses a precision instrument called a corneal topographer to accurately assess and monitor minute changes in the shape of the eye.
Reversible. Safe. Non-invasive.
This process of night-time corneal reshaping can be thought of as braces for the eyes. As well as controlling myopia progression, Ortho-K lenses will restore your child's vision which means glasses are not needed during the day and at school. That gives your child the freedom to participate in sport, swimming and all their other activities without the inconvenience of wearing spectacles or daytime contact lenses.
Orthokeratology is an excellent option for kids with rapidly increasing myopia between -1.00 and -6.00.
2. Dual-focus myopia control soft contact lenses
Specific designs of soft contact lenses have demonstrated effectiveness for myopia control.
A myopia control soft contact lens, such as the CooperVision MiSight 1 Day, is a 'dual-focus' design with special peripheral optics that help treat and reduce myopia progression by modulating eye growth.
The lenses are worn daily during waking hours, they are comfortable to wear and are a good option for children with milder myopia progression, and those not yet ready or not suitable for orthokeratology.
Please note that ordinary soft contact lenses do not produce these myopia control effects.
3. Atropine eye drops
Atropine eye drops is a medical treatment for myopia control that can effectively achieve desired results.
Atropine works in the eye to relax the ciliary muscle that controls lens focusing (accommodation). Simply put one drop into each eye before sleep, daily. The child continues to wear their spectacles or contact lenses to correct their vision during their waking hours.
Easy. With almost no side effects.
For myopia control, a very low-dose concentration of just 0.01% atropine is used. Extensive clinical trials on children have shown little to no side effects or adverse reactions at this dosage.
0.01% atropine is considered safe for long-term use in children for myopia control, and is a treatment approach that has also been advocated by paediatric ophthalmologists.
Our optometrist in Singapore will co-manage this treatment for your child with an ophthalmologist, and the eye drops are prepared and dispensed accordingly.
4. Myopia control spectacle lenses
Glasses are generally a less effective form of myopia control compared to the other options described above. However, for children who are less tolerant to contact lenses or atropine eye drops, or prefer to wear glasses, there are spectacles lens designs which may still help with treatment.
We can prescribe multifocal or bifocal glasses that incorporate your child's distance vision correction with an additional reading power in the same lens. The reading power is designed to reduce their eyes' focusing (accommodation) demands when doing concentrated near tasks such as reading, homework, study and computer use, and help to relax their eyes' focusing muscles.
Multifocal and bifocal lenses are particularly effective for children with binocular eye coordination and near focusing issues. And for children showing myopia progression but wish to stay with glasses, we recommend these lenses over standard single vision lenses that provide no myopia control.
Please note that ordinary single vision lenses do not produce these myopia control effects.
5. Lifestyle changes
Some simple lifestyle changes can also help manage myopia progression, although these are not a replacement for treatment options such as control lenses or spectacles.
Spend at least 90 minutes outdoors each day
Take regular breaks from near work
Limit time on smartphones and tablets
Take a 5 minute break every 30 minutes on a computer
Limit intensive focusing tasks to 2 hours after school
Maintain proper posture for all reading and writing
Keep at least an elbow's distance from the page
Always read under good lighting
Everything we do is based on facts
We believe in being transparent about what we offer for your children. Our myopia treatment strategies are based on published peer-reviewed scientific research in Singapore and worldwide, which we are happy to share with you. Book an appointment with us to get started today.
Find out more about our scientific approach to treating myopia.
MiSight 1 Day
The MiSight 1 Day disposable soft contact lens is available in Singapore at EMME Visioncare.
As an optometrist trained in myopia control in Singapore, MiSight 1 Day is one of the treatment options we use in our comprehensive, tailored myopia control programme for children and teenagers.
What is MiSight?
CooperVision MiSight 1 Day is the world's first FDA-approved daily disposable myopia control soft contact lens, with breakthrough lens technology designed specifically to slow myopia progression in children.
How does MiSight actually work?
MiSight is not a standard soft contact lens. It is a special dual-focus lens, meaning it has alternating distance correction and treatment zones. The principles behind MiSight for myopia control are similar to orthokeratology (Ortho-K), in that it changes the peripheral optics at the front of the eye, thereby affecting the focusing of light in the peripheral parts of the retina and modulating the growth of the eyeball. The long-term effect is that eyeball elongation is reduced, which slows the myopia prescription change and lowers the risk of developing high myopia.
Who can use MiSight?
Any child or teenager who is short-sighted, particularly those who have shown yearly progression and are identified as at risk of further myopia progression and eye elongation. There is no minimum age for a child to be fitted with MiSight lenses, although younger children may need assistance from parents with daily lens insertion and removal.
At present, MiSight lenses are available for prescriptions from -0.25 to -6.00D.
How effective are MiSight in myopia control lenses?
A number of studies evaluating dual-focus lens designs like MiSight have found a significant reduction in myopia progression and eye elongation in children wearing dual-focus lenses compared to children who wore regular single vision contact lenses. A multi-country, three-year clinical evaluation of the MiSight lens treatment worn by 144 children aged 8-12 years showed an effectiveness in slowing myopia progression by up to 59%.
MiSight 1 Day has been available for about 8 years in East Asian countries such as Hong Kong, Singapore and Malaysia, where the prevalence of childhood myopia is the highest in the world. Optometrists in these countries have reported positive and encouraging results fitting these control lenses on myopic children, with similar effectiveness to Ortho-K in slowing myopia progression.
How does MiSight compare with Orthokeratology?
Orthokeratology lenses are worn during sleep; MiSight is a daytime contact lens.
MiSight is only effective when the lens is worn, so we recommend a minimum wearing time of 6+ days per week, 10+ hours per day, for best myopia control. Ortho-K's reshaping effect on the cornea may last a day or two without lens wear, although the recommendation is to wear nightly where possible.
MiSight soft lenses have better initial comfort than Ortho-K rigid lenses, although patients do generally adapt well to wearing Ortho-K lenses over time.
As a 1 day disposable lens without the need for disinfection and cleaning, MiSight is potentially more hygienic and safer for younger kids to wear. A good level of hygiene and vigilance is still required, however, and MiSight lenses should not be worn if it may come into contact with water (eg. swimming). A child treated with Ortho-K has the advantage of clear vision during the day without lenses.
A pair of Ortho-K lenses lasts 1 year, requires delicate care and has the potential to be lost or broken.
Ortho-K lenses can correct a mild amount of astigmatism, generally up to around -1.50D, while MiSight lenses cannot. MiSight can be prescribed for short-sight prescriptions as low as -0.25D, and Ortho-K from around -1.00D. The highest myopia correction available for MiSight is -6.00D; Ortho-K can correct higher levels of myopia depending on patient suitability.
At EMME Visioncare, we believe MiSight and Ortho-K lenses are both excellent contact lens treatment options for myopia control in Singapore, and the choice between the two options may depend on age, maturity level, individual preferences and suitability. Following an initial assessment our optometrists will be able to advise you on your child's suitability for these lenses.
Stellest
The Stellest spectacle lenses are available at EMME Visioncare.
As an optometrist trained in myopia control in Singapore and overseas, EMME offers Stellest spectacle lenses as one of the treatment options we use in our comprehensive, tailored myopia control programme for children and teenagers.
WHAT ARE ESSILOR® STELLEST® LENSES?
Essilor® Stellest™ control spectacle lenses are clinically proven to slow down myopia progression by 67% on average.
With Essilor® Stellest™ lenses:
-
Correct
Enjoy sharp vision in all activities -
Control
Slows down myopia progression with H.A.L.T** technology -
No Compromises
Clear, light and durable
Essilor® Stellest™ lenses with H.A.L.T Technology is proven to help slow down Myopia Progression
Unlike ordinary lenses which only correct myopia, Essilor® Stellest® lenses control Myopia to provide sharp vision and help slow down its progression with the exclusive H.A.L.T** technology.
Essilor® Sellest® lenses consist of a constellation of 1021 invisible micro lenses spread on 11 rings. This creates a volume of signal in front of the retina to help slow down elongation of the eye, which helps control Myopia progression.
WEARING ESSILOR® STELLEST® LENSES IS EASY FOR CHILDREN
(1) Eyeglasses for Global Development: Bridging the Visual Divide; World Economic Forum, Social Entrepreneurs, EYElliance; June 2016.
(2) Essilor See Change – Put Vision First global campaign 2017.
(3) Vongphanlt et al, 2002, Ogawa & Tanaka et al, 1988, Lim et al, 1999, Marcus et al, 2011
(4) A less myopic future: what are the prospects? Clin Exp Optom, 98
*Compared to single vision lenses, when worn at least 12 hours a day. Two-year prospective, controlled, randomized, double-masked clinical trial results - 104 myopic children split in two groups: Single vision lenses (50) and Stellest™ lenses (54) - Efficacy results are based on 32 children who declared wearing Stellest™ lenses at least 12 hours per day every day - Eye Hospital of the Wenzhou Medical University - J. Bao, A. Yang, Y. Huang, X. Li, Y Pan, C. Ding, E. W. Lim,J Zheng, D. P. Spiegel, Y. L. Wong, B. Drobe, F. Lu, H. Chen.
MiyoSmart
The MiyoSmart spectacle lenses are available at EMME Visioncare.
As an optometrist trained in myopia control in Singapore and overseas, EMME has various treatments available within our comprehensive, tailored myopia control programme for children and teenagers. MiyoSmart is just one of the options available, and our optometrists can recommend whether it is suitable for your child.
What is MiyoSmart?
MiyoSmart is an innovative spectacle lens for myopia control developed by Hoya together with The Hong Kong Polytechnic University. Based on two-year clinical trial results, MiyoSmart is proven to curb myopia progression by an average of 60% with its D.I.M.S. (Defocus Incorporated Multiple Segments) technology. This lens technology is an easy, effective and non-invasive method to manage myopia for the child.
How does MiyoSmart actually work?
MiyoSmart is not a standard prescription lens. It is a specially designed honeycomb-like lens with hundreds of small segments, each providing myopic defocus. The principles of MiyoSmart for myopia control changes the periphery optics at the front of the eye, directing the light in front of the peripheral retina. This effect allows eyeball elongation to reduce, which slows the myopia prescription change and lowers the risk of developing into high myopia.
Who can use MiyoSmart?
Any child or teenager who is short-sighted, particularly those who have shown yearly progression and have been identified to be at risk of experiencing further myopia progression and eye elongation, can be suitable for MiyoSmart treatment. There is no minimum age for a child to be fitted with MiyoSmart control spectacle lenses. These lenses have UV protection, and are light-weight, thin and impact-resistant, making it a safe material for active kids.
At present, MiyoSmart lenses are available for prescriptions from 0.00 to -10.00D.
How effective are MiyoSmart lenses in myopia control?
A study evaluating spectacle lens designs like MiyoSmart has found a significant reduction in myopia progression and eyeball elongation in children wearing DIMS technology lenses compared to children who wore regular single vision spectacle lenses. The evaluation of MiyoSmart lenses worn by 183 children aged 8-13 years showed an effectiveness in slowing myopia progression by up to 60%.
MiyoSmart has been available in countries such as Hong Kong, Australia, Malaysia and Singapore, where the prevalence of childhood myopia is the most common in the world. The effectiveness is similar to other modes of myopia control treatment options like MiSight or Ortho-K.
HOW DOES MIYOSMART COMPARE WITH MYOPIA CONTROL CONTACT LENSES?
MiyoSmart is worn during the day; MiSight myopia control contact lenses can be worn during the day or Ortho-K lenses while sleeping.
MiyoSmart is only effective when the lens is worn, thus we recommend wearing it full time, except during sleeping or showering. MiSight is only effective with a minimum wearing time of 6+ days per week, 10+ hours per day, for the best myopia control outcomes. Ortho-K reshaping effects on the cornea may last a day or two without regular lens wear, although the recommendation is to wear daily where possible.
MiyoSmart is easy to adapt to, similar to MiSight contact lenses. Compared to these 2 options, Ortho-K is a rigid lens where patients may experience initial discomfort before generally adapting well to wearing Ortho-K lenses over time.
MiyoSmart is safe and less invasive compared to myopia control contact lenses. However, activities such as swimming are not convenient for MiyoSmart to be worn. A good level of hygiene is necessary when wearing contact lenses like MiSight day lenses. MiSight contact lens should not be worn if it may come into contact with water (eg. swimming). A child treated with Ortho-K has the advantage of clear vision during the day without lenses or spectacles.
MiyoSmart can correct up to -10.00D of short-sighted prescription and -4.00D of astigmatism, whereas the highest myopia correction available for MiSight is -6.00D with no astigmatism. Ortho-K can correct higher levels of myopia depending on patient suitability.
At EMME Visioncare, we believe MiyoSmart, MiSight and Ortho-K lenses are excellent optical treatment options for myopia control in Singapore, and the choice between the three options may depend on age, maturity level, individual preferences and suitability. Following an initial assessment our optometrists will be able to advise you on your child's suitability for these lenses.
Lam, C. S. Y., Tang, W. C., Tse, D. Y. Y., Lee, R. P. K., Chun, R. K. M., Hasegawa, K., ... & To, C. H. (2020). Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. British Journal of Ophthalmology, 104(3), 363-368.
Evidence-Based Approach
At EMME Visioncare, our MyopiaControl treatment strategies are based on published research data, in line with the most up-to-date international clinical approaches to controlling myopia progression in children.
Science is always advancing. We update our treatment strategies as new research comes to light, to ensure the children we look after always receive the latest and most effective myopia control treatments available in Singapore.
Below are links to selected published research on current myopia control treatment options.
Multifocal soft contact lenses
Undercorrection of myopia
wearing a weaker glasses or no glasses
Some people believe that wearing a weaker prescription lens will help 'preserve' eyesight and control or avoid myopia progression. Some parents also want their child to avoid or delay wearing spectacles, thinking that spectacles will make their child's eyesight worse.
Unfortunately, this approach is not supported by current scientific evidence. Research has found that, on the contrary, wearing undercorrected glasses, or no glasses when needed, may actually be harmful and accelerate myopia progression, due to the effects of blurred vision on eye growth.
For this reason we do not recommend prescribing undercorrection for myopic children at our clinic.