SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009

By: MELISSA T. SY, MD

MEDICAL CLEARANCES, PRE-OPERATIVE EVALUATION AND CHILD LABOR

Medical Certificate For School Entrants

Series 2009 Vol. 1 No. 5

AAP Endorsement: do comprehensive periodic health assessment beginning at 3 years old

Benefits/ main purpose of medical evaluation

1. Identify high risk population in the student body
2. Fulfill public health service role

Recommended Elements prior to medical certificate issuance:

1. Medical Interview
a. Medical History – attention to physical, emotional or family problems, previous
preschool experiences, new medical problems, medications
b. Immunization Status - dates of previous, updates
c. Language, Social, and Adaptive Development – changes, updates, school progress or
problems
2. Physical Examination (age appropriate)
a. Height, weight, BP, HR
b. Teeth, gums, tongue and throat
c. Reflexes
d. Eyes (vision), ears (hearing), nose and skin
e. Heart, lungs, abdomen
f. Fine & gross motor development
g. Spinal alignment (scoliosis)
h. Genitalia (infections, hernia, etc)

Pre-operative Evaluation in Pediatric Patients Undergoing Surgery and Other Major Therapeutic or
Diagnostic Procedures
Series 2009 Vol. 1 No. 6

 A major methodology in minimizing surgical complications

 Greatest surgical risks: cardiovascular complications (adults), pulmonary & airway complications
(children)
 A must for all surgical procedures and medical testing requiring anesthesia except in:
 Healthy patients requiring nerve blocks, local/ topical anesthesia and/ or </= 50% nitric oxide,
oxygen and no other sedative or analgesics
 Those receiving sedation analgesia or conscious sedation

High Risk Procedures Needing Further Adjunctive Evaluation

1. Cardiac procedures
2. Aortic & Other Major Vessel Vascular Procedures, Peripheral Arterial Vascular Procedures
3. Pancreatic Resection
4. Major Spinal and orthopedic surgery
5. Intrathoracic, intraperitoneal, head & neck surgery
6. Prolonged surgical procedures with large fluid shifts and/or major blood loss

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

2 Categories of Patients at High Risk (Appendix A)

Cardiovascular Non-cardiovascular
 Unstable coronary syndromes  Pulmonary disease, severe or symptomatic
 Recent MI (<30 days in post MI w/ (COPD requiring O2, respiratory distress at
complete cardiac risk stratification and rest, asthma, cystic fibrosis, etc)
determined as low risk OR 3-6 months  Poorly controlled symptomatic diabetes
if formal risk stratification not done) (causing symptoms with attendant risk of
 Unstable or severe angina hypovolemia)
 Decompensated CHF  Symptomatic anemia
 Significant arrhythmias
 High grade AV block
 Symptomatic ventricular arrhythmias
in the presence of underlying heart
disease
 Supraventricular arrhythmias with
uncontrolled ventricular rate
 Severe Valvular Disease
 Severe hypertension (>180/110)
 Congenital heart abnormalities

Components of Pre-operative Evaluation

1. Medical History
 Indication of surgery, allergies and medication/ anesthesia intolerances, known medical
problems with current status, surgical history, current medications, immunization
history, family history, Review of Systems (heart, pulmonary, functional & hematologic
status)
2. Physical Examination
 Anthropometrics (height & weight), vital signs (BP, HR, RR), complete & thorough exam
of major body systems (head & neck, heart, pulmonary, GI & extremities)
3. Laboratory Tests
 Routine: CBC and CXR PA-lateral
 Other tests (APPENDIX B)
TEST INDICATION
ECG - No ECG w/in last year in patients with diabetes, hypertension, chest pain, CHF,
smoking, peripheral vascular disease, inability to exercise, morbid obesity
- In patients with CV symptoms or with new or unstable cardiac disease
Coagulation - With known history of coagulation abnormalities or recent history suggesting
Studies coagulation problems or on anticoagulants
- Patients needing anticoagulation post-operatively (for baseline)
Hemoglobin - History of anemia or suggesting recent blood loss
Potassium - Those taking digoxin or diuretics
Chest X-ray - With signs and symptoms suggesting new or unstable cardiopulmonary disease

4. Patient Education
 Procedure specific explanation
 General orientation of what is to happen and possible risks & complications during
surgery

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

Sports Clearance
Series 2009 Vol. 1 No. 7
- Known also as pre-participation physical evaluation or athletic screening
- For individual who will indulge in sports activities; given to all children
- Medical evaluation that includes a record of the patient’s medical history, limited PE conducted
by non-medical/ medical personnel prior to sports participation but may be done at interim
periods for athletes
- Leading cause of sports related death in US: hypertrophic cardiomyopathy
- The physician must be duly certified or properly trained to issue sports clearance

Objectives of Pre-participation Physical Evaluation

1. Detect medical/ musculoskeletal conditions predispose to injury/ illness during sports activities
2. Detect potentially life threatening or disabling medical/ musculoskeletal conditions
3. Determine child’s general health
4. Assess fitness level
5. Counsel & educate child on health related issues (drugs, risk of injuries, unhealthy sexual
practices, psychosocial issues)

Recommendations (adopted from AHA 1996)

1. Medical history must include:
a. Prior occurrence of exertional chest pain/ discomfort or syncope/ near-syncope as well
as excessive, unexpected, and unexplained shortness of breath or fatigue associated
with exercise;
b. Past detection of a heart murmur or increased systemic blood pressure; and
c. Family history of premature death (sudden or otherwise), or significant disability from
cardiovascular disease in close relative(s) <50 years old or specific knowledge of the
occurrence of certain conditions: hypertrophic cardiomyopathy, dilated cardiopathy,
long QT syndrome, Marfan syndrome, or clinically important arrhythmias
2. PE includes:
a. Precordial auscultation in both the supine and standing positions to identify heart
murmurs consistent with dynamic left ventricular outflow obstruction;
b. Assessment of the femoral artery pulses to exclude coarctation of the aorta;
c. Recognition of the physical stigmata of Marfan syndrome; and
d. Brachial blood pressure measurement in the sitting position
3. If not cleared, but patient still wants to participate in sports, they must sign a waiver.

Child Labor
Series 2009 Vol.1 No. 2
- Refers to work where children are separated from their families
- any work performed by a child that subject a child to economic exploitation, likely to be
hazardous for the child, interfere with the child’s education, harmful to the child’s health/
physical, mental, spiritual, moral/ social development
- Where the child is compelled to work on a regular basis
- Physical environment is the most common hazard to child labor

Rights of a Child
- Right to life, adequate standard of living, parental care & support
- Right to social security, a name, nationality and identity

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- Information, leisure, recreation & cultural activities

- Opinion, freedom of thought and conscience
- Religion
- Freedom of association and privacy
- Not more than 20% of the child’s income may be used for the collective needs of the family
- 30% of the child’s income must be placed in a Trust Fund, for future use of the child.

RA 9231 – Anti Child Labor Law

1. Prohibits the engagement of a child in worst forms of child labor (slavery, prostitution,
pornography, illegal activities)  or any work that is hazardous to health
2. Provides for the working hours of a working child aged below 15 & those aged 15 but below 18
a. <15 years of age: not allowed to work >4 hours/day, 5 days/ week
b. 15 – 18 years of age: not allowed to work >8 hours/ day, >40 hours/ week
3. Determines ownership, usage & administration of the working child’s income
4. Provides setting up of a trust fund to preserve part of the working child’s income (30% of
earnings)
5. Stiff penalties against acts of child labor  penalizes parents and guardians to do community
service
6. Provides speedy prosecution of child labor cases

Minimum employable age is 15 years old, < 15 years old is permitted if:
1. Children working directly under the sole responsibility of his/ her parents/ guardians/ legal
guardian and if child can go to school and her/his life, safety, health, morals & development are
not endangered
2. Child’s employment/ participation in public entertainment/ information through cinema,
theater, radio/ TV is essential

REPRODUCTIVE HEALTH & CLONING

Reproductive Health Education Among Adolescents

Series 2005 Vol. 1 No. 1
- 1 in every 4 Filipino adolescent is sexually active and 74% do not use any form of contraception
- Average age of first coitus: 18 years old
- Target age for reproductive health education: 15-24 years old
- Comprehensive sexuality education teaches abstinence + contraception is more effective than
abstinence-only education in helping adolescents make healthy decisions regarding sex.
- DOH: Adolescent and Youth Health and Development Program
- 4 Groups of adolescents regarding sex: (1) delayers, (2) anticipators, (3) singles, (4) multiples

4 Primary Goals of Successful Comprehensive Sexuality Education Program

- (1) Information, (2) Attitudes, (3) values and insights, (3)Relationships and interpersonal skills,
(4) Responsibility

 US Adolescent Medicine: Teaching of health & sex education from kindergarten to 12 th grade
o Sex education must not be limited to schools but also to those who are not in school
o Media be involved in relaying messages about responsible sexuality
 AAP: Pediatricians should promote and provide sexuality education to all their patients

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

Human Reproductive Cloning

Series 2006 Vol. 1 No. 1
- Cloning is naturally occurring or laboratory phenomenon- induced production
- 3 types of cloning technologies:
o gene cloning- recombinant DNA technology, molecular/DNA cloning
o therapeutic cloning- biomedical cloning (source: stem cell from the embryo)
o reproductive cloning- somatic cell nuclear transfer
- PPS recommends and supports the worldwide ban on human reproductive cloning
- Senate Bill No. 1509: An act to ban experiments on the cloning of human beings

POISONING

Household Products Poisoning

Series 2005 Vol. 1 No. 5
- Greatest risk for home poisoning: <6 yo due to hand-to-mouth exploratory activities
- Child proof containers are effective in reducing death than warning labels
- In pediatric age group, the most common ingested poison are household items
1. cleaning agents (chlorine, decalcifier, hydrochloric acid, sodium hypochlorite, and phenol)
2. hydrocarbon (kerosene, diesel oil, lighter fluid, paint thinner)
3. Jathropa
4. Ferrous sulfate, paracetamol, isoniazid, acetylsalicylic acid/ aspirin
- Information to give when calling poison center: child’s condition, name of product &
ingredients, quantity taken, time of poisoning, your contact information, age & weight of child
- 2 most important factors to led to dec. in unintentional poisoning:
1. Child resistant closures
2. Safer medications

First Aid for Acute Poisoning

Swallowed poisons Do not give the patient food/ drink before a doctor or the poison center is
contacted
Do not induce vomiting unless instructed by the physician/ poison center
Inhaled poisons Immediately give the victim access to fresh air & contact poison center
Poisons on skin Remove contaminated clothing; rinse affected area w/ running water for 10
minutes; contact poison center
Poisons in the Eye Flush the child’s eye for 15 mins w/ running tap/ lukewarm water, held 2-4
inches above the eye; call poison center

Watusi Poisoning
Series 2005 Vol. 1 No. 7
- Watusi: matchstick like pyrotechnic device made of yellow phosphorus, potassium chlorate,
potassium nitrate & trinitrotoluene. This is a BANNED firecracker.
- s/s of watusi poisoning: burns, burning throat pain and garlic odor breath, nausea, vomiting,
diarrhea, abdominal pain and shock
- Watusi ingestion is due to lack of supervision of parents, easy accessibility of watusi and being
sold in the area despite the ban on watusi.

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- After ingestion: give children 4-6 egg whites and adults 6-8 egg whites (prevent phosphate
absorption; IV NSS hydration, calcium & vit. K supplements, N-acetylcystein; supportive care
- Parents should bathe the child using alkaline soap (ivory/ perla) if a child had dermal exposure
on watusi
- DOH: alternative to fire-crackers  alternative merry-making.

Medicinal Poisoning
Series 2005 Vol. 1 No. 6
- Pain relievers are among the most common poison exposures in children, second to household
products
- Most common: paracetamol (toxic dose 150mg/kg), NSAIDs/ salicylates, Iron (toxic dose 10-
20mg/kg elemental iron), isoniazid (30mg/kg produce seizures)

Classic Stages in the Clinical Course of Acetaminophen Toxicity

STAGE TIME AFTER CHARACTERISTICS
INGESTION
I 0.5 – 24 hr Anorexia, nausea, vomiting, malaise, pallor, diaphoresis
Labs typically normal, except for acetaminophen level
II 24 – 48 hr Resolution of earlier symptoms; right upper quadrant abdominal pain and
tenderness; elevated bilirubin, PT & hepatic enzymes; oliguria
III 72 – 96 hr Peak liver function abnormalities; fulminant hepatic failure (hepatic
necrosis & encephalopathy); multisystem organ failure and potential death
IV 4 days – 2 wk Resolution of liver function abnormalities if damage during phase III is
reversible; Clinical recovery precedes histologic recovery

Clinical Stages of Iron Toxicity

I Nausea, vomiting, abdominal pain, diarrhea, hemodynamic instability due to hematemesis,
melena/ hematochezia
II Period of 6-24 hours following the resolution of GI symptoms; overt systemic toxicity
(latent stage)
III Profound toxicity: hypovolemia, vasodilation, poor urine output w/ decreased tissue
perfusion and metabolic acidosis (shock stage)
Systemic toxicity exacerbates: CNS effects with lethargy, hyperventilation, seizures
IV Hepatic failure occur 2-3 days after ingestion
V Rarely occur; gastric outlet obstruction due to strictures & scarring occur 2-8 wks following
ingestion

- SALICYLATE POISONING:
o Nausea, vomiting, diaphoresis, tinnitus, deafness, vertigo, hallucinations, stupor, coma,
seizure
o May cause GI symptoms, hepatic, metabolic, pulmonary and renal disturbances

- Isoniazid toxicity:
o 30mg/kg/dose  may produce seizure
o Nausea, vomiting, slurred speech, dizziness, inc. HR, metabolic acidosis
o Give pyridoxine (Vit B6): give gram per gram of INH overdose

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

Lead Poisoning in Children

Series 2005 Vol. 1 No. 8
- Blood lead levels (BLL) – defined as 1 venous blood specimen >/= 10mg/dL or 2 capillary blood
specimens >/= 10mg/dL drawn within 12 weeks of each other
- Lead is absorbed either by ingestion or inhalation
- 1985 PD No. 2001 ‘Establishing a Program to gradually withdraw the use of Tetraethyl Lead in
Gasoline & use ethanol as substitute’
- April 1993: reduced lead content in gasoline from 0.6g/L to 0.15g/L then leaded gasoline phased
out nationwide in December 2000
- DOH: Development of National Health Guidelines for lead Exposure among children, pregnant
women & women of child-bearing age
- RA 8749: Philippine Clean Air Act 1999
- At 9mg/dL: affect fine motor, decrease upper extremity dexterity & speed, affect coordination &
visuo-motor functioning
- Lead Encephalopathy most life threatening adverse effect (>/= 70mg/dL)

Risk Factors for Lead Exposure and Prevention Strategies (adapted from AAP)
RISK FACTOR PREVENTION STRATEGY
Environmental
Paint Ensure immediate cleaning of chipping paint; do not allow
children to chew on painted surfaces
Dust Wet mop, frequent handwashing
Soil Restrict play in area, ground cover, frequent handwashing
Drinking water 2 minute flush of morning water; use cold water for cooking,
drinking
Folk remedies, old cooking/ kitchen Avoid use
utensils, cosmetics, toys, crayons
Parental occupations Remove work clothing at work
Hobbies Proper use, storage and ventilation
Home renovation Proper containment, ventilation
Buying/ renting a new home Identify lead hazards
Host
Hand-to-mouth activity (pica) Frequent handwashing
Inadequate nutrition High iron & calcium. Low-fat diet; frequent small meals
Development disabilities Consult doctor about screening

Exposure to Second-Hand Smoke

Series 2004 Vol. 2 No. 3
- Second hand smoke/ passive smoke/ environmental tobacco smoke is considered an indoor
pollutant; home is the single most important location of exposure
- It is the combination of side-stream smoke and mainstream smoke and considered Class A
human carcinogen by EPA in US
- Causally associated with: SIDS, respiratory diseases, middle ear infection, chronic disease of
heart and lungs, cancer
- US- CDC: recommends smoking bans and restrictions

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By: MELISSA T. SY, MD

- RA 8749: Philippine clean air act of 1999; RA 9211: Tobacco Regulation Act of 2003
- Prohibits sale of tobacco products within 100meters from a school, playground, etc.
Hazards of Maternal Smoking During Pregnancy
Series 2004 Vol. 2 No. 4
- WHO : Philippines 3rd highest ranking country in Southeast Asia with adult smokers and top
ranking country with young smokers
- Well established detrimental effects of smoking during pregnancy: spontaneous abortion, Low
birth weight, prematurity, ADHD, SIDS, idiopathic mental retardation and other behavioral
problems
- Increase consciousness of the public about harmful effects of maternal smoking during
pregnancy; outlines the responsibilities of health care professionals, the government, and the
media to promote the cessation of smoking before, during and after pregnancy.

INJURY PREVENTION
rd
- Motor vehicle crashes are the 3 leading cause of mortality among 5-15 yo and accounts for
18% childhood injury deaths
- Traffic related injuries account for 30% of injury consults in previously healthy young children

Child Safety in Private Motor Vehicles

Series 2004 Vol. 1 No. 7
- Modern passenger cars are equipped with safety belts, anti-lock brakes (reduce wheel locking &
skidding), crumple zones (at front of the car to absorb most of collision impact energy), airbags,
head restraints & side impact beams
- AAP lists: Greater risks for traffic injuries are Adolescent drivers due to: lack of driving
experience especially in night time, risk-taking behaviors (influenced by emotion, peers, other
stress), use alcohol and other drugs, none usage of seat belts.
- AAP: use specialized age appropriate child seats and restraints for <9 years old or <60 lbs weight
- RA 4136 Land Transportation & Traffic Code- obtain driver’s license, speed limits, overloading
- Seat Belts Use Act of 1999 (RA 8750) – prohibit <6yo to sit at the front seat of any moving motor
vehicle; installation and use of adult seat belts in front & rear seats

Child Safety in Public Motor Vehicles

Series 2004 Vol. 1 No. 8
- Mode of public transport: buses, jeep, FX, vans, taxis, tricycles, pedicabs
- Jeepney design is suited for utility than for safety. Its safety as a motor vehicle has not yet been
ascertained to date
- Jeepney crashes are 3rd leading cause of injury (6%), passenger tricycle ranks 4 th (5%), Pedicab
injuries (1%) and lowest rates are passenger trains & busses (0.5%)
- US: compartmentalization is currently the major principle by which school bus passenger are
protected; high back seat (46 in above seat surface) & decrease space (26 in) between rows
- AAP: unlicensed all terrain vehicles (mopeds, minibikes, trailbikes) are used for off road sports
and recreation, recommends to be ban on their sale and prohibit use by children.

Child Pedestrian Injury Prevention

Series 2004 Vol. 1 No. 9
- US road engineering changes: narrowing streets to slow traffic, adding sidewalks, crosswalks and
traffic lights, place low speed bumps on where children cross, squaring off intersection, place
crossing guards where children cross, bulbed-out sidewalk curbs at intersections

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- Parents should not allow children to play along highways and roadsides
- Parents are encouraged to accompany young children when walking to and from school to
reinforce safe street-crossing habits
- UNICEF safety measures: efficacy, affordability, feasibility, sustainability ( speed limits, seat
belts, cycle helmets & lanes, marked pedestrian crossings, lighting & visibility measures, safety
education & action against drunk driving, speed bumps, bamboo or steel partitions separating
motorist from pedestrians)

Pedestrian Safety Rules

1. Cross only at corners so drivers can see you.
2. Always use a crooswalk when it is available. But remember, painted lines can’t stop cars
3. Cross only on new green light so you have time to cross safely
4. Cross with the ‘walk sign’ only
5. Look all ways before crossing the street to see cars, pedestrians and bicyclists
6. When crossing, watch for cars that are turning left or right
7. Never cross the street from between parked cars
8. Drivers can’t see you
9. Walk on the left side of the road, facing traffic, if sidewalks are not provided so you can see
oncoming cars
10. Use a flashlight or wear or carry something retroflective at night to help drivers see you.

Child Helmet Use

Series 2004 Vol. 1 No. 10
- Helmets should fit the head snugly and be worn properly over the head. They work by
dissipating the sharp energy of a blow over a large surface area
- Reduce occurrence of brain injury by 63-88%, facial injuries by 65%
- Parents should not allow <9yo to ride as passengers on motorcycles & motorized scooters
- Close supervision to <9yo children when riding skateboards, non-powered scooters, roller
skates/ shoes
- Senate bill No 1027: act to protect consumers by promulgating uniform manufacturing
standards for bicycle helmets and its use (pending?)

Infant Walkers
Series 2009 Vol. 1 No. 3
- Not beneficial to children and are actually a danger to them (risk for: falls, burns, poisonings,
submersion, suffocation, minor injuries & death)
- Can reach speeds of 3ft/sec
- Can delay infant’s motor & mental development  contracture of calf muscles, may mimic
spastic diaparesis
- Policies from other countries:
o Recommend stationary walkers & playpens as alternative to mobile infant walkers
o Require braking mechanism and width >36 in (width of an average door)
o Specified level of stability & a gripping mechanism to stop walker at the edge of a step

Drowning Prevention
Series 2004 Vol. 1 No. 11
- The Philippines is considered the most the most disaster prone country in the world and
typhoons, tropical storms and floods as the most common mode of disaster

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- Causes of flood: deforestration (major cause), reduction in river channels and drainage,
reclamation of flood plains & wetlands, Rapid expansion of urban & residential areas
- The Philippines holds the world record for deaths at sea mostly caused by small wooden hulled
vessels known as bancas, motorboats and fishing boats due to inadequate navigation aids and
perrineal overloading
- US: people with life vests have 85% better chance of survival compared to those without vests
- Prevention:
o Parents with <5 yo should be reminded about drowning risks
o Parents are encourage to enroll children (>/= 4yo) in swimming classes because
swimming skills may be protective factor against drowning
o Need for monitors (lifeguards) at public swimming pools & recreational bodies of water
o Use of life vests or personal flotation device

0-4 years old drown at home while bathing/ in open water in urban setting
>/= 5 yrs old 63% in natural bodies of water & public pools
15-19 yrs old 13% of drowning, alcohol was a major factor

Burn Injury Prevention

Series 2004 Vol.1 No. 12
- 1995: 5th leading cause of childhood mortality in the Philippines
- Scalding is the leading mechanism of injury (in <5yo) followed by naked flame, electrical injuries
and chemical burns
- Smoking and cigarettes cause 10% of fire deaths worldwide

Fire Safety Measures (adapted from Philippine Trauma Manual of PCS)

A. Always have a fire extinguisher available in your house
B. Measures to prevent fire
1. Electrical wirings should be inspected and circuits should never be overloaded
2. Remove accumulations of leaves and paper around your house
3. Do not store any flammable liquid near the stove
4. Do not store any alcohol or gasoline to start a fire
5. Put off all candles and lights before going to bed
6. Do not place candles where wind, children, pets and other moving objects may topple them
7. Lamps should not be placed near curtains or other objects that could easily catch fire
8. Crush cigarette butts before throwing them
9. Do not smoke in bed
10. Keep matches or flammable materials away from children
C. When fire is at hand
1. Call for help
2. Stay close to the floor. A wet cloth over your face may help breathing
3. Close doors and windows behind you to reduce the spread of fire
4. Feel the door before opening it. If hot, keep it closed
5. Know the fire exists of any building you are in
D. When your clothes catch fire
1. Never run, it fans the flame
2. Wrap yourself with a blanket. Drop to the floor and roll over briskly
3. If there is nothing to wrap yourself in, just drop to the floor and roll over briskly

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4. Place yourself close to the floor in a horizontal position to prevent smoke inhalation
5. If there is water, douse yourself with it or roll over spilled water
6. If another person’s clothing catches fire, use similar measures

Fireworks-Related Injuries
Series 2006 Vol. 1 No. 9
- Fireworks-related injuries (FRI), defined as any injury sustained from fireworks
- RA 7183 Fireworks Law 1992: regulates and controls the manufacture, sale and use of certain
types of pyrotechnic devices
- Davao City Ordinance No. 069-02: prohibition of the manufacture, distribution, sale and use of
firecrackers
- 1992 DOH program: Oplan Iwas Paputok and Oplan Torotot
- 2005 DOH reformulated FRI program: FOURmula Kontra Paputok
o Use pots, pans and paper horns
o Never pick up the firecrackers that fail to explode
o Immediately wash wounds with soap and water and go to the nearest hospital for
treatment
o Never fire guns to greet the New Year
- Firecracker (intended to produce more noise); fireworks/ pyrotechnic devices (for visual display)

Backpacks and Children

Series 2006 Vol. 1 No. 3
- Ergonomic training of children on how to lift bags and pack them properly; flexibility and
strengthening exercises to support spinal column
- Produces back-pain, spinal deformities, scoliosis, vertebral subluxation, osteoarthritis,
spondylosis, disc herniation
- WHO-WFC initiative: Straighten Up! Is a series of spine and postural exercises to improve
posture, spinal health and over-all well being
- School administrators to make lockers/areas where to place books for safekeeping so that they
don’t need to carry it all the time and device ways to lessen the load carried by children to &
from school
- Parents should make sure that the weight of backpack used by their child is no more than 10%
of the child’s body weight and backpacks worn properly with both straps on and never 4 inches
below the waistline
- Backpacks should be appropriate size, made of light material, with compartments and wide,
soft, S shaped, padded straps that fit the child’s back; have waist/ chest straps w/ built in back
support/ lumbar pillow

NOISE

- From greek word noxia which means injury/ hurt; defined as undesirable and irregular sound
- A sound loud enough to cause hearing damage
- Is measured in terms of its strength (amplitude by means of decibel), frequency, and duration
- A sound <75dB will not cause hearing damage even in high frequencies.
o 85 dB at 8 hours exposure = inc. risk of hearing loss
o 75 dB = minimal risk for hearing loss
- US EPA recommendation

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By: MELISSA T. SY, MD

o Max average day night sound level (DNL) during waking hours 55dB, night time 45 dB
o In hospitals: daytime 45dB, night time 35dB
- Noise is the most common causes of preventable hearing loss

Noise in the Environment

Series 2006 Vol. 1 No. 5
- Community noise/ Environmental noise/ Residential noise/ Domestic noise- a noise emitted
from all sources except from industrial workplace
- The following sources of noise pollution involve direct & cumulative adverse health effects
o Street traffic: most prevalent and most damaging source
o Air traffic noise: subsonic airplanes, helicopters (periodic & non-periodic broadband
noise), supersonic airplanes (sonic booms)
o Construction noise
o Consumer products:
 Recreational (guns, fireworks, video arcades, snowmobiles)
 Hobbies/ workshop (chain saws, vaccums, lawn mowers)
 Household (food blender, washers, airconditioners, refrigerators)
 Music (concerts, stereos, MP3)
o Sirens, railroads, hospitals, schools, agriculture, humans
- Adverse effect of noise- a change in morphology and physiology of an organism resulting in
impaired functional capacity, impaired capacity to compensate for additional stress, or
susceptibility of an organism to harmful effects of other environmental influences
- 2 types of health effects:
o Non-auditory effects- stress, psychological & behavioral changes, safety concerns
o Auditory effects- hearing impairment (increase hearing threshold with ringing or buzzing
sound in the ear), acoustic trauma (from short but extremely loud bursts of noise)
- Annoyance is a global phenomenon and the most common effect of noise on people; widely
used as gauge to measure and monitor community noise.
- Danger signs of noise induced hearing loss: ringing in the ears and speech sounding muffled
- OSHA: max set point of noise level exposure is 85 dBA which adverse effects can result
- Toys shall not produce impulsive noises with instantaneous sound pressure level exceeding 138
dBA when measured at any point 25cm from the surface of the toys
- PD N0. 1152 Philippine Environmental Code, sets standards for community noise levels; pending
senate bill 632 Aviation Noise management and House bill 02905 Anti-Noise Pollution Act 2004
- Sleep disturbance: >50 noise events/night with a maximum level of 50dBA

Occupational Noise Exposure

Series 2006 Vol. 1 No. 6
- Noise present in the workplace classified as continuous type (sound level peaks are <1 sec apart)
and impulsive type (having a steep rise in sound level to high peak followed by rapid decay/
sounds with separation intervals >1 sec)
- WHO: recommended exposure limit (REL)
o for continuous type: 80-85 dBA max 8 hours
o for impulsive: 140 dBA at any one exposure
- Effects of excessive noise: heart disease, lung disease, nervous system and sleep, work related
injury, noise induced hearing loss

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- WHO: transient threshold shift (TTS) a precursor to noise induced hearing loss where a change in
hearing threshold of an average of 10dBA or more at 2000-4000Hz in either ear
- Hearing loss prevention program (HLPP) components: exposure assessment, audiometric
evaluation, education and motivation, record keeping, program audits and evaluation
- Methods to minimize noise: engineering control, administrative and work practice control
(schedule work rotation), personal hearing protection
- Permissible noise level of 90dB for 8 hour period
- Foam-type ear plug: largest sound attenuation (decrease effect of noise)

Recreational Noise
Series 2006 Vol. 1 No. 7
- Noise derived from leisure activities
- Volume levels for listening to portable music players with earphones
o All type of earphones (earbud, isolator, supraaural/ stock), no time limits at 0-50%
volume
o Stock earphones: 60% volume for 18 hours, 70% volume for 4.6 hours, full volume for
not more than 5mins/day
o Supraaural: full volume not > 18 mins/ day
o Isolator: full volume <3mins a day
- A sound is too loud when: one’s MP3 is set >60% of the maximum, one cannot hear
conversation going on around oneself, people nearby can hear one’s music, one finds oneself
shouting to people nearby
- 60% volume per 30 mins/ day rule
- PPS recommends limit to the duration and intensity of recreational noise exposure as means of
protecting one’s hearing and continued enjoyment of recreational activities

Fetal and Neonatal Exposure to Noise

Series 2006 Vol. 1 No. 8
- At 23rd – 26th weeks of life: fetus can perceive, store, react to auditory information
- Pregnant women exposed to >85-90 dB for long periods was associated with birth defects, low
birth weight, IUGR, premature delivery, SGA, high frequency hearing loss
- Infants heart rate, RR, BP and ICP rises while oxygenation level drops with exposure to noise
- One of the most important effects of excessive noise exposure to infants: robbing them from
adequate and peaceful sleep

Sound Levels and Human Response

COMMON SOUNDS NOISE LEVEL (dB) EFFECT
Pyrotechnic display at 1meter 162 Beyond threshold of pain (125 dB)
Handgun/rifle 160
Firecracker 150 120dB = threshold of “feeling” the sound
Boom cars 145
Squeeze toy 135
Shotgun firing 130
Rock concert 110-140
Thunderclap (near) 120
Sports game/movie stadium 117
Stereos (>100 watts) 110-125 Regular exposure of more than 1 minute risk

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By: MELISSA T. SY, MD

permanent hearing loss (over 10dB)

Chain saw 110 No more than 15 minutes unprotected
Symphony orchestra/rock 110 exposure recommended (90-100 dB)
concert or video arcade
Snowmobile 105
Jetfly (over 1000 ft) 103
Garbage truck/ cement mixer 100
Farm tractor 98 Very annoying level at which hearing damage
Newspaper press 97 begins (8 hours)
Fitness class music 95
Subway, motorcycle 90
Lawnmower, food blender 85-90 Annoying, interferes with conversations
Diesel truck (40mph) 84
Average city traffic noise 80
Garbage Disposal 80 Intrusive, interferes with telephone use
Vacuum cleaner, hair dryer 70
Inside a car (loud engine) 70 Comfortable (under 60 dB)
Normal conversation 50-65
Refrigerator humming 40
Whisper 30 Very quiet
Rustling leaves 20
Normal breathing 10 Just Audible

EFFECTS OF MEDIA ON CHILDREN AND ADOLESCENTS

Effects of Media Sex and Violence on Children and Adolescents

Series 2004 Vol. 2 No. 5
- DOH: 10-14 years old with injuries undetermined whether accidental or purposely inflicted ranks
4th leading cause of overall mortality
- Teenagers have an average of 30hrs TV exposure/week
- Effects of media violence
o desensitization: decreased in arousal or emotional disturbance while witnessing
violence, reduce tendency to intervene in a fight and reduced sympathy for victims of
violence.
o Higher levels of anti-social behavior, acceptance of violence as a solution to a problem,
feelings of hostility and the delivery of painful stimulation to another paerson
o High risk behaviors: tobacco use, alcohol use, early onset of sexual activity
- PPS advocates minimization of media exposure for Filipino youths and urges parents to create a
healthier and friendlier environment for their children to reduce negative effects of media
influence
- Social (Observational) Learning Theory by Albert Bandura formulated 4 steps pattern of learning:
attention, retention, reproduction and motivation
- RA 8370 Children’s Television Act of 1997 recognized the importance and impact of broadcast
media on the value formation and intellectual development of children
- Parents should avoid using media as surrogate electronic babysitter and always accompany their
children while watching TV whenever as possible

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- KBP: radio programs not suitable for children shall be aired after 9pm
- Children should be taught that media ratings should be followed strictly
Effects of Media Advertisements on Dietary Habits of Children and Adolescents
Series 2004 Vol. 2 No. 6
- Media advertisements: has behavioral effects on children, creates misperceptions about the
nutritional value of food and how to maintain good health
- < 8 years old: developmentally unable to differentiate advertising and regular programs
- Impact of TV on obesity: reduce energy expenditure from displacement of physical activity and
increased dietary intake as a result of food advertising
- Fashion magazines and music videos are associated with drive for thinness
- Subliminal inducements: hidden advertisements in editorials, comics, games
- RA 8980 Early Childhood and Development Act promote child survival, protection, participation
and development especially on the quality of television shows, media prints and coverage which
are detrimental to children and with appropriate funding support.
- Pending Senate Bills
o Senate bill 1337: act proving for a school nutrition program and for other purposes
o Senate bill 223: act of regulating the advertising industry
- DOH-PHA: Mag-HL Tayo sa Resto Project, encourages restaurant owners to provide healthy food
choices
- Measures on regulating food advertisements: reduce number of ads aimed at young children for
foods high in fat, calories, sugar or salt and balancing such ads with messages promoting better
nutrition

Evaluating Food Advertisements

1. What method (animation, bright colors, celebrities) was used to sell the product?
2. How do these methods affect your children’s thought on these products?
3. What is the message?
4. Does your child believe it?

ORPHAN DISORDER
Series 2006 Vol. 1 No. 2
- Orphan disorders- a heterogenous group of disorders that have not been prioritized by the
pharmaceutical industry for research and for development of diagnostic and therapeutic
modalities
o WHO definition: conditions affects <1000 people/ million
o Philippines: disorders affecting 1 in every 20,000 individuals
- Orphan drugs – medicinal products intended for the prevention of or treatment of orphan
disorders ( laronidae –mucopolysaccharoidosis VI; nelarabine-T-ALL; sodium phenylacetate &
sodium benzoate – urea cycle enzyme deficiency; nitisone- tyrosinemia; imiglucerase-Gaucher’s)
- Orphan disorders in the Philippines: MSUD (most number of documented cases), X-linked
Adrenoleukodystrophy, Methylmalonic aciduria, Gaucher Disease, Mucopolysaccharoidosis,
Urea cycle disorder, Classical Hormocystinuria, Tyrosinemia, Citrullinemia, Lowe syndrome,
Multiple sulfatase deficiency, Galactosemia, Phenylketonuria, Pompe Disease

NUTRITION
Pacifiers and Children
Series 2006 Vol. 1 No. 4

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

- Pacifier use is a most common form of non-nutritive sucking but can lead to serious health
problems if continuous, unmonitored use
- Recommended only until the infant is 1 yo
- Some contains diisononyl phthalate, PVC, N-nitrosamine compounds cause premature breast
development thus discourage its use in manufacturing pacifiers
- Well established adverse effects:
o On breastfeeding: not to use during initiation but only after breastfeeding has been well
established
o Dental and Oral structures: use orthodontic pacifiers and should be discontinued before
permanent incisors erupt, ideally before 4 yo. May cause malocclusion and open bite
o Risk of trauma and obstruction
- Proper manufacture of pacifiers: presence of ventilation holes, flanges having a minimum
horizontal and vertical diameter of 43mm and rings attached to flanges to facilitate removal
- If parents choose to use pacifiers:
o Avoid use at the beginning or early weeks of breastfeeding,
o Not substitute for holding and nurturing infants as means to comfort him
o Not attach the pacifier to child’s clothing
o Be aware of its proper use
o Discontinue before age 4 years
o Use orthodontic pacifiers

Soft Drinks in School

Series 2005 Vol. 1 No. 4
- 1991 survey: Philippines ranks 28th of worldwide soft drink consumption
- It increases risk for dental caries, obesity and poor nutrient intake
- Average 12 oz soda contains about 10 teaspoons of sugar and 150 calories; providing 12-19 yo
male- 15 tsp of sugar/day and female-10 tsp of sugar/day
- DECS Memorandum No. 373, s.1996 Encouraging the Sale and Consumption of Healthy and
Nutritious Foods in the Schools  prohibits sale of chips and softdrinks in schools
- PPS summarizes recommendations towards the eventual elimination of soft drinks inside the
school premises

Caffeine And Children

Series 2009 Vol. 1 No. 4
- Caffeine- xanthine derivatives & its effects are mediated through its actions on the cerebral
cortex & brainstem of CNS; effects are dose related
o 100-200 mg: increase alertness & wakefulness, promote faster & clearer flow of thought
and better general body coordination; may have loss of fine motor control & dizziness
o >500-600 mg: restlessness, anxiety, irritability, muscle tremors, sleeplessness,
headaches, nausea and diarrhea or other GI problems & abnormal heart rhythms
o Acute exposure >3mg/kg in children consumed little caffeine: produce negative effects –
nervousness, jitteriness, stomachaches & nausea
- Caffeine poisoning: very tense muscles, alternating with overly relaxed muscles; rapid deep
breathing, nausea and vomiting, inc. HR, shock, tremors
- No proven effect on bone growth
- Classified as an addictive substance = may produce withdrawal symptoms, tolerance and
physical cravings

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- Benefits
o Regular intake: decrease Parkison’s disease, type 2 DM, colon CA, liver cirrhosis,
hepatocellular CA, gallstones
o Contains magnesium, Anti-oxidants (chlorogenic acid & tocopherols) & trigonelline (anti-
bacterial & anti-adhesive prevent dental caries)
o Enhance athletic endurance – manage asthma and headache
- Caffeine intake from caffeinated beverages are within safe levels for consumption by young
children
- In Philippines, caffeine in cola type beverages has max level of use is limited to 200ppm
- USA recommendation: 1-2 cups of coffee/day

Recommended Intake of Caffeine in Children: 2.5mg/kg/day (from Canada, Health & Welfare 1990)
4-6 years old 45 mg/day
7-9 years old 62.5 mg/day
10-12 years old 85 mg/day

Item Amount of Item Amount of Caffeine

Mountain Dew 12 oz 55 mg
Coca-cola, classic & cherry 12oz 34 mg
Coke light 12 oz 45 mg
Pepsi 12oz 37 mg
7UP, sprite, Diet Sprite 12 oz 0 mg
Brewed coffee (drip method) 8 oz 135 mg
Instant Coffee 8 oz 95 mg
Decaffeinated brewed coffee 8oz 5 mg
Decaffeinated instant coffee 8 oz 3mg
Starbucks Coffee Grande 16 oz 259mg
Black Tea 8 oz 40 – 70 mg
Green Tea 8 oz 25-40 mg
Decaffeinated black Tea 8 oz 4 mg
Nestea Iced tea 12 oz 26 mg
Dark Chocolate 1 oz 20 mg
Milk Chocolate 1 oz 6 mg
Cocoa beverage 5 oz 4 mg
Chocolate milk beverage 8 oz 5 mg

Healthy and Unhealthy Foods for School Children

Series 2005 Vol. 1 No. 3
- Good nutrition and physical activity are essential for the long term health of children
- Meals taken at school play a critical role in the development of children’s eating patterns
- In the Philippines, the problem of undernutrition has decreased while overweight is increasing
- Unhealthy foods: too salty, sweet, oily or fatty; non-nutritious foods: do not contribute to
nutrients that the body needs except empty calories
- 10 simple messages to provide easy to follow recommendations to attain good health
o Eat a variety of foods everyday

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o Breastfeed infants exclusively from birth to six months, then give appropriate foods
while continuing breastfeeding
o Maintain children’s normal growth through proper diet and monitor their growth
regularly
o Consume fish, lean meat, poultry or dried beans
o Eat more vegetables, fruits and root crops
o Eat foods cooked in edible/ cooking oil daily
o Consume milk, milk products or other calcium-rich foods such as small fish and dark
green leafy vegetables everyday
o Use iodized salt but avoid excessive intake of salty foods
o Eat clean and safe food
o For a healthy lifestyle and good nutrition, exercise regularly, do not smoke and avoid
drinking alcoholic beverages
- DECS Memorandum No. 372 s. 1995 ( Revitalizing Supplementary Feeding as Primary
Intervention to Undernutrition among School Children); DECS Memorandum No. 373 s. 1996
(Encouraging Sale and Consumption of Healthy and Nutritious Foods in Schools); DepED Order
No. 17 ban sale of carbonated drinks, sugar based synthetic/ artificial flavored juices, junk foods
in all public schools  Health and Nutrition Center
- Strengthen implementation of existing programs:
o School Milk Project: provide milk to Grade 1 students for 120 days
o Breakfast Feeding Program: provide fortified noodles and biscuits
o Applied Nutrition Program, Alay Tanim at Pangkabuhayan; Teacher-Child-Parent
approach (TCP)

Obesity in Children and Adolescents

Series 2009 Vol. 1 No. 1
- Risk for overweight: BMI between 85th & 95th percentile for age & gender
- Overweight: BMI at or above the 95th percentile for age & gender
- Obesity epidemics cause by increase urbanization, consumption of high energy and high fat
foods; decrease physical activity
- DECS Memo 373: “Encouraging the sale and consumption of Healthy and Nutritious Foods in
school”
- Laboratory investigations to identify co-morbidities of obesity:
o Thyroid function, lipid profile, complete chemistry & hepatic profile, FBS & insulin,
OGTT- if w/ family history of DM2/ metabolic syndrome in >10yo; serum/urinary
cortisol- r/o cushings syndrome in high risk patients
- Recommendations
o Preventive measures: breastfeeding, encourage home cooked meals and avoid fast
foods, physical activity- 60mins/day on most times of the week
o Provide healthy food options with adequate calories but low in saturated fat, low salt,
low simple sugar
o Reduce sedentary lifestyle </= 2 hours/day
o Refrain from using food as rewards for kids

Physical Activity for School Children

Series 2004 Vol. 2 No. 7
- Regular physical activity along with well balanced diet is a key component to healthy living

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- School plays an important role in developing good exercise habits in children

- DOH National Healthy Lifestyle Campaign
o Objectives: raise awareness of Filipinos on the need to practice healthier lifestyles &
raise the consciousness of policy makers on the need to provide environment
supportive of healthy lifestyle
o 6 messages: do not smoke, regular exercise, eat healthy diet everyday, watch your
weight, manage stress, regular health check ups
o Music, Arts, Physical Education (MAPE): PPS Recommendation for PE CLASSES
 grade school at least 150 mins/week
 high school at least 225mins per week
- One of the essential means for normal skeletal development during childhood & adolescence
and for achieving & maintaining peak bone mass in young adult is weight-bearing physical
activity
- AHA: children & adolescents participate in at least 60 mins of moderate to vigorous physical
activity everyday

DISEASE PREVENTION

Fluorides in the Prevention of Dental Caries in Children

Series 2004 No. 2 Vol. 2
- Early childhood caries (ECC) – presence of 1 or more decayed (noncavitated/ cavitated lesions),
missing (due to caries), or filled tooth surfaces in any primary tooth in a child ≤71 months of age.
- Severe Early Childhood Caries (S-ECC)- in <3yo with any sign of smooth surface caries; in 3-5yo 1
or more cavitated, missing (due to caries); or filled smooth surfaces in primary maxillary anterior
teeth or a decayed, missing, filled score of >/=4 (age 3), >/=5(age 4), >/=6(age 5)
- Tooth decay is the most common chronic childhood diseases. Most common bacteria are
streptococcus mutans and lactobacilli
- Prevention of dental caries: good oral hygiene, proper feeding practices, promotion of eating
healthy foods, fluoride use
- At risk for dental carries or ECC:
1. History of cavities, white spot lesions, stained fissures
2. Continues to use bottle after 1y/o
3. Sleeps with bottle in mouth, other than water
4. Breastfeeds on demand at night
5. Developmental disability
6. Chronic use of high sugar meds
7. Family members with ECC
8. Prolonged use of bottle or sippy cup during the day
- Fluoride varnish- liquid made from a natural/ synthetic base in which fluoride salts are dissolved
in a solvent like ethanol; applied to retard, arrest and reverse cavity formation process and
reduce enamel demineralization
- Recommendations:
o Avoid putting infants to sleep with a bottle, wean from breastfeeding/bottle feeding at
2yo, encourage cup from 6mos onwards, child’s daily tooth brushing with right amount
of fluoridated toothpaste (<3yo smear; 3-6yo half a pea; >6yo pea size)
o Regular dental check up & proper application of fluoride varnish 500mcg/mL every 6
months as needed

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- Dental Fluorosis: excessive exposure to fluoride

o mild: white opaque areas covering 50% of a tooth
o severe: brown, black stains and pitting
- maximum fluoride in water: 1.0ppm

5 Step Fluoride Varnish (500mcg/mL) Application Technique (10-15 mins/ child)

Cleaning Elimination of plaques to secure adhesion and prolong retention of varnish
Isolation and Drying Use cotton rolls, compressed air, aspirator of saliva
Application Thin layer and avoid spreading onto soft tissues
Setting Use gentle steam of compressed air to speed up
Instructions to parents Avoid eating & drinking for 2 hours after application and no oral hygiene
procedures/ floss use within the day of varnish

Drinking Water Quality and Diarrhea Prevention

Series 2004 Vol. 2 No. 8
- Diarrhea – 2nd leading cause of mortality among Filipino children
- Filipino children drinking water >1000 E.coli/ 100mL had high rates of diarrhea compared to
moderately contaminated (2-100/100mL) or good quality water (1/100mL)
- Chlorination- most effective means for the disinfection of public water supply to date and most
acceptable current means of mass water treatment. (charcoal filter & 10 mins boiling removes
chlorine in water)
- Water supply service
o Level I –from shallow wells, deep wells or springs
o Level II – communal faucet system w/ average 5 households/ faucet and 100
households/system
o Level III – piped system with individual household connections
- Ground water = most common source of drinking water
- Senate Bill No. 1116 An act Establishing Quality Standards for Mineral Water and Carbonated
Water; RA 9275 Philippine Clean Water Act 2004
- DOH: National Objectives for Health (2004)
o Increase to 50% from 10% of households practicing boiling of water from doubtful
sources
o Increase to 91% from 87% household with access to safe water supplies
o Increase the proportion of the population using sanitary toilets
- Information on Nationwide anti-diarrheal campaign:
o Breastfeeding, Proper hand washing, proper waste disposal, potability of properly
chlorinated public tap water
o Boiling at least 1 minute of untreated water/ water from natural resources
 Boiling should be continued for 1 more minute for every 1,000meters of altitude
above sea level
o Proper identification of water: sterilized, mineral, tap and chlorinated
o Bottle water is not a necessity & safety of water from all refilling stations, uncertain
o Ozone and UV treatments of water = temporary effect only and NOT recommended

The Role of Folic Acid in the Prevention of Neural Tube Defects

Series 2004 Vol. 1 No. 3

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- Neural Tube Defects (NTD) – congenital deformities that occur when the embryonic neural tube
fails to completely close during its development; neural tube usually closes 21-28 days of life
- Folate levels can be determined using RBC folate levels (reflects long term tissue store) &
serum/plasma folate (reflects short term dietary intake)
- Strategies to achieve adequate levels of folic acid in the body:
o Increase intake of folate-rich foods
o Dietary folic acid supplementation
o Folic acid fortification of food
- RA 8976 The Philippine Food Fortification Act 2000; DOH Sangkap Pinoy Seal Program (iron, vitA,
iodine)
- Recommendations
o All women of reproductive age should take 0.4mg (400µg) folic acid daily with folate rich
diet
o Those planning pregnancy, should take 0.4mg (400µg) folic acid daily at least 1 month
before conception
o Women with previous NTD and planning another pregnancy, take 4mg (4000µg) folic
acid at least 1 month prior to conceptions until the 1 st 3 months of pregnancy

Pediatric Blindness Prevention and Vision Screening

Series 2004 Vol. 1 No.6
- Leading cause of blindness are vitamin A deficiency, malnutrition, measles and premature birth
- WHO definition of blindness: inability to count fingers at 3 meters
- Vitamin A capsules to be given to 9-11 months, 12-59 months and sick, malnourished children
- In newborn, special attention is directed towards ocular abnormalities such as corneal opacity,
congenital cataract and ptosis
- Earliest possible age for visual acuity measurement is 3 yo
- Main components of Prevention of Blindness Program (PBP): cataract program, primary eye
care, vitamin A deficiency prevention and control
- Visual screening should not be limited to visual acuity testing. Visual skills, color perception,
motility, binocular vision, fusion and depth perception ability should be tested
- Proper nutrition and timely Measles vaccination (6-9 months)

NEWBORN CARE
Breastfeeding
Series 2004 Vol. 1 No. 1
- Exclusive breastfeeding is ideal during the first 6 months of life then introduction of
complementary foods as well as continued breastfeeding is recommended until at least 1 year
of preferably beyond
- Advantages in infants
o Boost infant’s host defense – bioactive components: lysozymes, Ig, hormones, growth
factors, immune function modulators, anti-inflammatory & cellular components
o Protect against URTI, AOM, UTI, NEC, botulism, meningitis, bacteremia
o Low risk for SIDS anf IDDM
- Advantages in mothers
o Better postpartum uterine involution, infant bonding/ emotional satisfaction, reduced
risk of breast and endometrial CA, enhances maternal weight loss postpartum, enhance
lactation amenorrhea, reduce health care costs

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- Contraindications
o Absolute: galactosemia in infants, maternal use of illegal drugs, chemo & radiotherapy
o Relative: Active TB (after 2 weeks anti-Kochs), HIV infection (heat treatment of EBM)
- UNICEF/WHO/ UNAIDS:
o When children born to women living with HIV can be ensured uninterrupted access to
nutritionally adequate breast-milk substitutes that are safely prepared and fed to them,
they are at less risk of illness and death if they are not breastfed. However, when these
conditions are not fulfilled, like infectious disease and malnutrition are primary cause of
death, artificial breast milk substitutes substantially increase children’s risk of illness and
death.
- WHO/UNICEF ten step program ‘Baby Friendly Hospital Initiative’ 1992
o Have a written breastfeeding policy routinely communicated to all health care staff
o Train all health care staff in skills necessary to implement this policy
o Inform all pregnant women about the benefits and management of breastfeeding
o Help mothers initiate breastfeeding within half an hour of birth
o Show mothers how to breastfeed, and how to maintain lactation even if they should be
separated from their infants
o Give newborn infants no food or drink other than breast milk, unless medically indicated
o Practice rooming-in that is, allow mothers and infants to remain together 24 hours a day
o Encourage breastfeeding on demand
o Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants, and
o Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic.

Breastfeeding in the Workplace

Series 2004 Vol. 1 No. 2
Components of a Workplace Breastfeeding Support Program
ADEQUATE EXPANDED COMPREHENSIVE
Facilities A clean, private, A BMBR for use only by BMBR close to women’s
comfortable multi- breastfeeding women worksites.
purpose space (that is
not a bathroom) with Employer provides one Employer provides
an electrical outlet in multi-user electric collection kits.
order to pump milk or breast pump, and Additional multi-user
to breastfeed. employees provide electric pumps are
their own collection kits provided if needed
Employee provides her
own breast pump. Improved aesthetics to Room large enough to
promote relaxation accommodate several
Table & comfortable users comfortably
chair. If sink, soap, Items listed in
water & paper towels is ‘adequate’ column are Items listed in
far from BMBR, extra available near the ‘adequate’ column are
time is allowed for BMBR available in BMBR
cleaning hands and
equipment Employer makes Employer provides a

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By: MELISSA T. SY, MD

available refrigerator small refrigerator in the

Employee supplies cold space designated for BMBR for storage of
packs for storage of food near BMBR human milk
milk
Written Company Employer grants a 6 Employer grants 12 Employer offers a 6-14
Policy week unpaid maternity week unpaid maternity week paid maternity
leave leave (FMLA) leave (ILO)

Employer allows In addition, employer In addition, mother can

creative use of accrued allows part-time work, bring child to
vacation days, personal job sharing, workplace, or on site
time, sick days and individualized day care is available
holiday pay after scheduling of work
childbirth hours, compressed Nursing breaks are paid
work week, or and are counted as
Employer allows two telecommuting working time
breaks and a lunch
period during an 8 hour Employer allows
work for expressing expanded unpaid
milk or breastfeeding breaks during the
the child workday for expressing
milk or breastfeeding
the child
Wrokplace Education Company breastfeeding New employees, Breastfeeding
support policy is supervisors, and co- education is offered to
communicated to all workers all receive the partners of
pregnant employees training on the employees who are
breastfeeding support expectant fathers
Employer provides a list policy
of community resources Employer hires a skilled
for breastfeeding Employer contracts lactation care provider
support with skilled lactation to coordinate a
care provider on an ‘as breastfeeding support
needed’ basis program.
BMBR- breastfeeding mothers’ break room; FMLA – the family & Medical Leave Act; ILO- International
Labor Organization

Flexible Scheduling Options

1. Part time work
2. Earned Time – sick time, vacation time, personal days are lumped together into one set of paid
days off work, from which employees can take time at their own discretion
3. Job-sharing – two employees, each working part time, share the responsibilities and benefits of
one job
4. Phase back – employees allowed to return from leave to their full time work load over several
weeks/ months
5. Flex-time – employees can opt to work unusual hours to accommodate their home schedules
6. Compressed work week – employees work more hours on fewer days
7. Telecommuting – employees work all or part of their jobs from home

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Series 2004 Vol. 1; Series 2004 Vol. 2; Series 2005 Vol. 1; Series 2006 Vol. 1; Series 2009 Vol. 1
 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

Screening for Inborn Errors of Metabolism

Series 2004 Vol. 1 No. 4
- 1996 – Newborn Screening (NBS) started in the Philippines – PKU, CAH, CH, galactosemia & HCY
- 1998- homocystinuria (HCY) was replaced by G6PD
- 2000- DOH AO No. 1-A ‘Policies on the Nationwide Implementation of NBS’
- 2003- DOH AO No 121 establish National NBS system
- Newborn Screening Act 2004 – part of standard newborn care
o Establish and integrate a sustainable newborn screening system in the public health
delivery system
o Ensure that all health practitioners are aware of the advantages of NBS & their
responsibilities in offering newborn the opportunity to undergo NBS
o Ensure that parents recognize their responsibilities in promoting their child’s right to
health and full development within the context of responsible parenthood, by
protecting their child from preventable causes of disability & death through NBS

Neonatal Hearing Screening

Series 2004 Vol. 1 No. 5
- In the Philippines, hearing impairement is 3 rd leading cause of disability
- Detection of hearing impairment at 3months and intervention/ habilitation at 6months prevent
and reduce consequences of hearing loss such as deficit in language development, academic
performance, personal & social maladjustments & emotional difficulties
- AAP recognizes 5 essential elements to an effective universal newborn hearing screening
program (UNHSP): screening, tracking and follow-up, identification, intervention and evaluation
- The currently recommended method for physiologic hearing screening is evoked otoacoustic
emissions (EOAE) and auditory brainstem response (ABR)

CIRCUMCISION
Series 2004 Vol. 2 No. 1
- Male circumcision performed for any reason other than medical or clinical indications is called
non-therapeutic or ritual circumcision
- PPS: non-therapeutic, ritual, routine circumcision is unnecessary procedure and is without
medical indications. Potential benefits not sufficient enough to warrant the society’s
recommendation for its routine practice
- Encourage physician to provide accurate and unbiased information to all parents to enable them
to make an informed decision regarding circumcision for their child/ baby.

Retinopathy of Prematurity Screening

Series 2005 Vol. 1 No. 2
- Retinopathy of Prematurity (ROP) – potential cause of blindness affecting premature infants
with incompletely vascularized retinas; a condition that disrupts the normal progression of
retinal vascular development in the preterm infants & results in abnormal proliferation of blood
vessels in the developing retina
- ROP complications: refractive errors/myopia (most common), ambylopia, strabismus, blindness
due to retinal detachment
- Primary risk factor of ROP is prematurity due to incomplete vascularization of the retina
- Treatment options:

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

o cryotherapy – prevent progression by destroying the cells that may release VEGF-
angiogenic factors
o laser photocoagulation- at least as effective as cryotherapy
o retinal reattachment

RECOMMENDATIONS FOR SCREENING EXAMINATION OF PREMATURE INFANTS FOR ROP

- ROP is a significant cause of blindness and decreased visual acuity among premature low birth
weight infants.
- 2 phase of Pathogenesis
o An initial disruption in the arborization of the retinal vasculature
o A subsequent hyperproliferation of retinal vessels
- Risk factors:
o decreasing gestational age and birth weight (the only consistent)
o recommend judicious use & proper titration of oxygen using pulse ox & ABG if possible
- Classification:
- 3 components: zone (position in which ROP occurs); stage (severity); presence or absence of
plus disease (presence of posterior vessel tortuosity
o ZONE
ZONE I Most posterior area, within twice the distance
from the optic nerve head to the fovea
ZONE II ROP outside zone I
ZONE III ROP only present on the temporal side of the eye

o STAGE (International Classification of Prematurity)

Stage 1 Demarcation line separating the avascular retina anteriorly from the
vascularized retina posteriorly with abnormal branching of small vessels
immediately posterior to this
Stage 2 Intraretinal ridge; the demarcation line has increased in volume, but this
proliferation tissue remains intraretinal
Stage 3 Ridge with extra-retinal fibrovascular proliferation
Stage 4 Partial retinal detachment
Stage 5 Total retinal detachment

o Composite Eye Findings for prognosis

 Prethreshold ROP
 Zone I, Stage 1-2 ROP w/o plus disease
 Zone II ROP with any of the following:
o Stage 2 ROP w/ plus disease
o Stage 3 ROP w/o plus disease
o Stage 3 ROP w/ plus disease but cannot justify ablative surgery
 Threshold ROP
 Zone I or II w/ 5 contiguous or 8 discontiguous clock hours of stage 3
(extraretinal) with plus disease
 Current conventional basis for surgical intervention, carries 50% risk for
retinal detachment

- Screening for ROP

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

o Infants BW </= 1,500grams OR </= 32 weeks AOG

o Selected infants between BW 1,500 – 2000grams with unstable clinical course
o ROP exam should be performed by Pediatric Ophthalmologist, Retina Specialist or
General Ophthalmologist w/ knowledge & experienced with ROP in premature infants
o 1st ROP exam should be performed at minimum age of 4 weeks (chronological) OR
within 31st-33rd weeks PCA – whichever comes later
o If there is risk of ROP on the 1st ROP exam, follow up schedule as follows:
2 weeks intervals Less severe ROP in Zone II
1-2 weeks intervals w/o ROP but w/ incomplete vascularization
2-3 weeks intervals w/o ROP with complete vascularization in Zone II
1 repeat exam within 2-3 weeks Zone III w/ incomplete or immature vascular
maturation -needing verification
1 week interval ROP less than threshold in Zone I; ROP in Zone II
with stage 2+ or Stage 3
Repeat recommended intervals until vascularization reaches zone III.

o ROP treatment should be accomplished w/in 72 hours of determination of the presence

of threshold ROP to minimize the risk of retinal detachment
o Regular eye evaluations at 1yo, 2 ½ yo & 4yo and then yearly are recommended for
premature infants born </=1,500 grams or </=32 weeks AOG whether w/ or w/o ROP

- Management of ROP
o Surgery is the mainstay of the treatment, by 1 or combination of the following:
 Peripheral retinal ablation w/ cryotherapy or laser to halt neovascularization
 Repair of retinal detachment (sclera buckling)
 Release of retinal traction by access into the vitreous cavity (vitrecomy)
o Infants reaching Threshold ROP disease should receive ablative therapy for at least one
eye w/in 72 hours of diagnosis, generally before the onset of retinal detachment.

TB TREATMENT FAILURE OR INTERRUPTION (2006 WHO Definitions)

- Defaulters:
o Completed only 1 month of treatment or returned after ≥2 months of interruption
o Recommended tx: 2HRZES/1HRZE/5HRE
o If <2 weeks interruption = may continue tx
o If 2-8 weeks interruption , but smear (-) = continue tx. If smear (+) = restart tx
o > 8 weeks interruption = “Return after Default”
- Treatment interruptions:
o During intensive phase:
 ≥ 2 weeks interruption = restart tx
 <2 weeks interruption = continue tx and add missed days to complete intensive
phase
o During continuation phase:
 ≥80% completed = continue as scheduled
 If smear (-) = may stop on original scheduled date (w/o additional days)

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 SUMMARY OF PPS POLICY STATEMENTS SERIES 2004 – 2009
By: MELISSA T. SY, MD

If smear (+) = complete continuation phase, by adding no. of missed

days at the end of treatment
 <80% completed and
 >3 months interruption = restart from beginning (resume intensive
phase)
 <3 months interruption = complete full course or add missed no. of days
to complete tx.

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