Policy Statement 2009

Policy Statements of the Philippine Pediatric Society, Inc.

Committee on Policy Statements Series 2009 Vol. 1 Nos. 1-7

SERIES 2009 VOL. 1 ISSUE
Obesity in Children and Adolescents Child Labor Infant Walkers Caffeine and Children Medical Certificate for school Entrants Pre-Operative Evaluation in Pediatric Patients Undergoing Surgery and other Major Therapeutic or Diagnostic Procedures Sports Clearance 1 7 13 17 23 27

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PPS Policy Statements
OFFICIAL PUBLICATION OF THE PHILIPPINE PEDIATRIC SOCIETY, INC. MD, MAHPS Carmencita D. Padilla,
Editor-in-Chief Cynthia Cuayo-Juico, MD Irma R. Makalinao, MD Co-chairpersons Jocelyn J. Yambao-Franco, MD Joel S. Elises, MD Salvacion R. Gatchalian, MD Genesis C. Rivera, MD Advisers Nerissa M. Dando, MD Joselyn A. Eusebio, MD Edilberto B. Garcia, Jr., MD Ramon C. Severino, MD Editorial Board Maria Theresa H. Santos, MD Gloria Nenita V. Velasco, MD Research Associates

Message
The Philippine Pediatric Society, Inc., a Specialty Division of the Philippine Medical Association, has its membership composed of hardcore advocates of children. Its medical concerns are far beyond diagnosis and treatment. Child welfare, protection of the environment, caring about the future, growing and enjoying life and living humanely are among the many concerns of Pediatricians. Pediatricians, therefore, are the closest allies of children starting from conception until they have become adults. The child’s early life must be remembered as blissful years of youth, though he struggles through psychological and physical health challenges, even if he does not feel the direct guidance of his Pediatricians, must feel and realize later that there was someone else – and it is that Pediatrician. The PPS, through its officers and members of the board of Trustees commends this output of the committee headed by Dr. Carmencita David Padilla on the series of Policy Statements. Short of being a legal document, this publication should be adopted as a doctrine of reference for all child advocates. Mabuhay ang Filipino.

Philippine Pediatric Society, Inc. Board of Trustees
OFFICERS Victor S. Doctor, MD President Genesis C. Rivera, MD Vice President Melinda M. Atienza, MD Secretary Ma. Noemi T. Salazar, MD Assistant Secretary Milagros S. Bautista, MD Treasurer May B. Montellano, MD Assistant Treasurer Jocelyn J. Yambao-Franco, MD Immediate Past President Fe V. Del Mundo, MD Honorary President MEMBERS Stephen C. Callang, MD Joselyn A. Eusebio, MD Salvacion R. Gatchalian, MD Alexander O. Tuazon, MD Florentina U. Ty, MD Grace Marilou L. Vega, MD Ma. Victoria C. Villareal, MD

Victor S. Doctor, MD
President Philippine Pediatric Society, Inc.

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PREFACE

More than 50% of the population are pediatric in age. The Philippine Pediatric Society remains committed to protect the Filipino children through its various services by the network of pediatricians throughout the country. Advocacy remains at the heart of the organization. Child advocacy is worth all the challenges and difficulties that are experienced, for, in the end, it is ultimately for the benefit of the child. With this fourth volume of Policy Statements, the Philippine Pediatric Society renews and strengthens its commitment to the Filipino child. The PPS policy statements have had a major impact on Philippine Health Policy Development since the first publication in 2003. A policy statement in the first issue, newborn screening, has been enacted into Republic Act 9288 or the Newborn Screening Law. The Newborn Screening Law mandates that every child must be given the opportunity to be offered newborn screening. Today, 2 other policy statements have been crafted into bills – universal newborn hearing screening (Senate Bill No 2390 sponsored by Senators Miriam Defensor-Santiago, Pilar Juliana Cayetano, Loren Legarda and Manuel Lapid) and orphan disorders (Senate Bill No. 3087 sponsored by Senator Edgardo Angara). The Department of Health (DOH) has included folic acid supplementation among its recommendations to women of reproductive age in its Maternal-Newborn Health And Policy Strategy Framework. It is envisioned that the PPS policy statements will serve as basis for health policies that will eventually impact on better health for the Filipino child. With the assistance and support of the PPS Board of Trustees, committee members, the different subspecialties, and chapters, the committee presents 9 policy statements. There are policy statements that have been withdrawn from this volume due to further review and information from expert reviewers still coming in and due to topics that require further investigation and consultation. Acknowledgement of the panel of expert reviewers is given at the end of each statement. Some policy statements were also jointly sponsored. This issue presents policy statements on: Obesity in Children and Adolescents, jointly sponsored with the Society of Adolescent Medicine of the Philippines, Inc;, the Philippine Society of Pediatric Metabolism & Endocrinology. Inc; and the Philippine Society of Pediatric Gastroenterology and Nutrition; Child Labor; Infant Walkers; Caffeine and Children; Medical Certificate for School Entrants, jointly sponsored with the Philippine School Health Officers Association, the Philippine Society of Pediatric Cardiology and Department of Education; Pre-Operative Evaluaion in Pediatric Patients Undergoing Surgery and Other Major Therapeutic or Diagnostic Procedures, jointly sponsored with the Philippine Society for Pediatric Cardiology; the Child Neurology Society of the Philippines; the Philippine Society for Pediatric Anesthesia; and the Philippine Society of Pediatric Surgeons;
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Sports Clearance, jointly sponsored with the Philippine Society of Pediatric Cardiology The issues that the committee were covered in its four publications are just a few of many issues affecting our children; hence, a lot of areas need to be covered and a lot of work remains. The committee remains unfazed and ever more ready to accept these challenges as it continues to research and work towards this goal in the hopes of protecting the future of Filipino children.

The Editors

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PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 1

Obesity in Children and the Adolescents
Philippine Pediatric Society, Inc. Society of Adolescent Medicine of the Philippines, Inc. Philippine Society of Pediatric Metabolism & Endocrinology, Inc. Philippine Society of Pediatric Gastroenterology and Nutrition
The problem of obesity has affected not only the affluent Western countries but also the Asian countries that experienced rapid economic and epidemiological transition in the past 20 years. The effect of this transition led to increasing prevalence of overweight and obesity among children and adolescents. The obesity epidemic is said to be caused by the increasing urbanization and the consumption of highenergy and high-fat foods in populations with reduced levels of physical activity. Obesity in children and adolescents is related to a lot of diseases and complications and studies have shown that it increases the risk of serious illnesses and death later in life, thus raising public health concerns. Prevention of obesity in children and adolescents should be of primary concern. This policy statement presents information on the prevailing obesity among children and adolescents and cites strategies for the prevention and early identification of obesity. KEYWORDS: obesity epidemic, overweight, sedentary lifestyle, body mass index, diabetes, stroke, cancer, high-fat, high-calorie food URL: http://www.pps.org.ph/policy_statements/obesity.pdf

BACKGROUND Being at risk for overweight is defined as a BMI between the 85 th and 95 th percentile for age and gender, and being overweight is defined as a BMI at or above the 95th percentile for age and gender. Disadvantages of using BMI include the inability to distinguish increased fat mass from increase fatfree mass and reference populations derived largely from nonHispanic whites, potentially limiting its applicability to nonwhite populations.1,2 Weight for length is usually used in the under 2 year age group. In the United States, being overweight in this age group is defined as greater than the 95th percentile of the weight for length. The definition is purely statistical, and the percentile values are age and gender specific. It is important to measure head circumference because a very large head may alter weight-for-length ratio.3 The number of overweight children and adolescents has more than doubled since the early 1970s. From 1999 to 2000, the prevalence of overweight (BMI 95th percentile for age and gender) for children aged 2 to 19 years ranged from 9.9% to 15.5%. The prevalence increased with age and was higher in racial-ethnic minorities than in non-Hispanic whites. For example, Mexican American children were significantly more overweight (23.7%) than non-Hispanic white children (11.8%)

beginning at age 6.10 years. Representative national data are unavailable to estimate reliably the prevalence of overweight in Asian children and adolescents.4 In the Philippines, the sixth National Nutrition Survey conducted by the Food and Nutrition Research Institute in 2003 showed that among the 4,110 children aged 0-5 surveyed, 1.4% were overweight (only 0.4% in 1998). Among children between ages 6-10, 1.3% were overweight (negligible percentage in 1998); and among 11-19-year-olds, 3.5% were overweight. These data showed that the number of overweight children increased between the years 1998 and 2003.5 These figures were based on the old system of classification using weight for age, not BMI. The Department of Education, through the Health and Nutrition Center (HNC), conducts nutritional assessment of public school students twice within each school year. The nutritional assessment of elementary students based on weightfor-height and body mass index (BMI) conducted towards the end of school year 2003-2004 showed that out of 10,383,276 children assessed, 1,870,404 or 18.01% were below normal; 8,188,319 or 78.86% were normal; and 324,553 or 3.13% were above normal. Nutritional assessment of secondary school students based on body mass index conducted in March 2004 showed that out of 3,145,011 students weighed, 12.59% were below normal, 84.50% were normal, and 2.91% were above normal.6

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PPS Policy Statement

Obesity in Children and the Adolescents

In 2001, a local study was done among schoolchildren aged 8 to 10 years from private and public schools in Manila which showed that undernutrition was much more prevalent among public schoolchildren while overnutrition was much more prevalent among private schoolchildren.7 The increasing prevalence of overweight among private school children was also seen in a study done by Chan-Cua. The study included 1822 boys from Grade I-VII of a private school in Metro Manila. Weight:Height ratio (WHR) was used to assess overweight and obesity in the students. Based on the Philippine (FNRI-PPS) growth reference chart, 17% of the boys were overweight and 47% were obese. Based on the National Center for Health Statistics (NCHS) growth reference chart, 16% were assessed to be overweight and 41% obese. Obesity was also assessed based on BMI. A striking 47% had BMI of >20. Majority of the boys assessed came from the middle and upper socioeconomic classes with Chinese ancestry, which could be considered a “high risk” population.8 Genes are important in determining a person’s susceptibility to weight gain, but energy balance is determined by calorie intake and physical activity. Some forces thought to underlie this epidemic are economic growth, modernization, urbanization and globalization of food markets.3 Pathologic obesity is associated with endocrine or neurologic disorders or is due to iatrogenic causes, e.g. medications.3 Obesity, at first glance, may seem to be a problem of the individual himself, but we must also recognize that it as a problem rooted in neighborhoods and schools, modes of transportation, local food availability, food advertising to children and governmental policies.9 Food intake and activity in young children are strongly influenced by parents. During early childhood, the more parents encourage children to eat certain foods, the less likely they are to do so. Thus, foods that have been forbidden in childhood may be overconsumed when children finally have access to them later on.10 Social support from parents, siblings and other members of the community correlates strongly with involvement in physical activity. It is, therefore, not surprising that children who suffer from neglect, depression, or other related problems are at significantly increased risk for obesity during childhood and later in life.11 The rise in consumption of fast food may be relevant to the childhood obesity epidemic. Fast food incorporates all of the potentially adverse dietary factors, such as saturated and trans fat, high glycemic index, high energy density, and large portion size. A large fast food meal (double cheeseburger, French fries, soft drink, dessert) could contain 2200 kcal, which, at 85 kcal per mile, would require a full marathon to burn off.11 Family life has changed a lot over the past years, with trends towards eating out and greater access to television than before. It is

said that children consume more energy when meals are eaten in restaurants than at home, possibly because restaurants tend to serve larger portions of energy dense foods.11 Today’s youth are considered the most inactive generation in history. This is caused in part by reductions in school physical education programs and unavailable or unsafe community recreational facilities. 12 According to the World Health Organization, nearly two-thirds of children in both developed and developing countries are insufficiently active, with serious implications on their future health.13 In the 1998 Asian Conference on Early and Childhood Nutrition, the Food and Nutrition Research Institute reported that the most common leisure activities of Filipino children aged 8 to 10 were playing computer games, reading, and watching television.14 Another survey of children aged 8 to 10 years in Manila conducted by FNRI showed that only one out of four children participated in actual physical exercise everyday. Three out of four spent their time playing computer games, watching television, and reading. It was also reported that children had physical education lessons only once or twice a week.15 Television viewing is thought to promote weight gain by increasing energy intake and displacing physical activity. Children seem to passively consume excessive amounts of energy-dense foods while watching television. Television advertising could adversely affect dietary patterns at other times throughout the day and exposure to commercials increases the likelihood that children later select an advertised food when presented with options.11 Being severely overweight in childhood is associated with relatively rare immediate morbidity from conditions, such as pseudotumor cerebri, slipped capital femoral epiphysis, steatohepatitis, cholelithiasis, and sleep apnea. Being overweight is also associated with a higher prevalence of intermediate metabolic consequences, such as insulin resistance, elevated blood lipids, increased blood pressure, and impaired glucose tolerance. These conditions, which are often asymptomatic, increase the long-term risk for developing diabetes and heart disease in adulthood and are associated with persistent obesity into adulthood. However, the recent emergence of medical conditions that are “new” to overweight children, such as type 2 diabetes, represents the increasing prevalence of more serious, shorter term morbidity. Perhaps the most significant morbidities for overweight children and adolescents are psychosocial.3,5 Laboratory investigations directed at identifying co-morbidities of obesity may include thyroid functions, lipid profile, complete chemistries and hepatic profile, and fasting glucose and insulin. An oral glucose tolerance test (OGTT) should be considered to exclude impaired glucose tolerance or T2DM in individuals at high risk, e.g. family history of T2DM and/or metabolic syndrome, after 10 years of age. Determination of serum or urinary cortisol

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Obesity in Children and the Adolescents

PPS Policy Statement

levels should be reserved to exclude the presence of Cushing’s syndrome in obese individuals who have appropriate historical information and/or physical findings. Infants who are hypoglycemic or require very frequent feedings as well as infants with dysmorphic features require further evaluation. Examples include persistent hyperinsulinemic hypoglycemia of infancy (OMIM no. 61820) and BWS with hypoglycemia, or PWS and BBS with dysmorphism.3

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5. Recommendations 6. 1. The PPS recognizes that the battle against childhood obesity in the Philippines is both difficult and laborious. Thus, in addition to the abovementioned policies, it is the position of the PPS to adopt the following (additional) preventive measures: i. Breastfeeding seems to lower the risk of future obesity. A review of current literature support a strong relationship between exclusivity and duration of breastfeeding to reduction of childhood obesity. These evidences showed the advantages of breastfeeding, especially if exclusive, and noted that the favorable effects are more prominent in adolescence. Plausible mechanisms why breastfeeding lowers obesity risk include learned self-regulation of energy intake, metabolic programming in early life and inherent properties of breast milk.20,21 Metabolic programming will lead to higher plasma insulin in bottle/formula fed infants resulting to stimulation in fat deposition and early development of adipocytes. Breast milk, on the other hand, contains bioactive factors which modulate epidermal growth and tumor necrosis factors that inhibit adipocyte differentiation. ii. Nutrition a. Home-cooked meals should be encouraged as opposed to eating out in restaurants. b. Avoidance of fast food iii. Physical activity a. Engage in regular exercise. b. Minimize viewing of television. c. Encourage family support. To solve the problem of obesity, however, a cooperative effort among various individuals and groups of people from all segments of society is of prime importance. Each one has a role in preventing childhood obesity and ensuring that our children become healthy, well-nourished adults.

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Community leaders should make safe community facilities available for children’s physical activities. The government, through its agencies, should intensify information campaigns on proper nutrition and healthy lifestyle. The government should regulate marketing and promotion of food products to children. The government, through the Department of Education, should monitor the strict implementation of the DECS Memorandum No. 373 s. 1996: “Encouraging the Sale and Consumption of Healthy and Nutritious Foods in the Schools.” The government should support researches on overweight and obesity of Filipino children and adolescents. The government should give due recognition to food manufacturers and establishments that promote healthy foods. The government, through the Department of Health, should push for the approval of the pending Administrative Order regarding the mandatory labeling of nutrition facts and health claims on pre-packaged food. The government should retrain health workers on the use of the Center for Disease Control percentile charts for classification of overweight and obese.

Roles of Marketing, Media and Advertising Industry 1. The media and advertising industry should intensify information dissemination on the prevention and control of childhood obesity and its harmful consequences. 2. The Ad Board should strengthen its commitment to safeguard truth in food advertising. 3. The Ad Board should invite physicians from concerned medical societies to serve as members of their technical committee that screens advertisements. Roles of School Administrators and Teachers 1. School administrators and teachers should ensure the implementation of physical education in their curriculum. 2. School administrators should provide safe facilities to encourage children to be more active: bigger playgrounds, basketball courts, and the like. 3. School administrators and teachers should ensure that school cafeterias provide healthy food and beverages. 4. School administrators and teachers should work together with the school health personnel in monitoring the nutritional status of all pupils and students. Roles of Parents and Primary Caregivers 1. Parents should be role models for their children. Parents should be mindful of their eating habits and physical activities. 2. Parents should introduce at around 6 months of age a variety of foods, including vegetables and fruits in the diet. 3. Parent should provide healthy food options (adequate calories but low in saturated fat, low salt, low simple sugar). Meals consisting of nutritious foods prepared at home should be encouraged instead of consuming fast 3 food meals.

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Roles of Government and Community Leaders

PPS Policy Statement

Obesity in Children and the Adolescents

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Parents should encourage and provide opportunities for more physical and sports activities and reduce sedentary activities (watching television, playing computer or video games). Parents should give their children home prepared nutritious foods as school snacks and meals. Parents should discourage their children from buying unhealthy food (soft drinks, candies, chips) in school cafeterias. Parents should refrain from using food as reward for their children. Physical activity and quality time with parents should reward desired behavior instead. Parents should read nutrition information on food labels.

*Lead Reviewer PANEL OF EXPERT REVIEWERS Society of Adolescent Medicine of the Philippines, Inc. Rosa Ma. Nancho, MD Erlinda Cuisia-Cruz, MD Alicia Berbano-Tamesis, MD Philippine Society of Pediatric Metabolism and Endocrinology, Inc. Sioksoan Chan-Cua, MD Susana Campos, MD Nutrition Foundation of the Philippines Rodolfo Florentino, MD, PhD Philippine Society of Pediatric Gastroenterology and Nutrition Randy P. Urtula, MD Juliet Sio-Aguilar, MD Mary Jean Guno, MD Grace Battad, MD Paciencia Macalino, MD Aurora Genuino, MD Rebecca Castro, MD PPS Committee on Nutrition and Promotion of Breastfeeding Mary Jean Guno, MD Randy Urtula, MD PPS Obesity Working Group Grace Uy, MD Susan Jimenez, MD Grace Battad, MD Sioksoan Chan-Cua, MD Gemma Dimaano, RD

Roles of Physicians 1. Physicians should obtain a thorough dietary, psychosocial and family history on the pediatric patient. Hypertension, dyslipidemias, tobacco use, and other conditions that can be cardiovascular risk factors should be identified and addressed. 2. Physicians should monitor height, weight, and BMI of children and adolescents at every clinic visit. They should identify those at risk for overweight and obesity. 3. Physicians should advocate exclusive breastfeeding for at least 6 months and onwards; and proper complementary feeding. 4. Physicians should educate the family on healthy eating and regular exercise habits early in the child’s development. Useful information may be made available through brochures or waiting room posters. 5. Physicians should refer to registered nutritionist dietitians for proper dietary management. 6. Physicians should refrain from using food as “rewards.”

Document prepared by Committee on Policy Statements: Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD and Irma R. Makalinao, MD Members: Nerissa M. Dando, MD; Joselyn A. Eusebio, MD*; Edilberto B. Garcia, Jr., MD; Ramon C. Severino, MD Advisers: Joel S. Elises, MD; Genesis C. Rivera, MD; Jocelyn J. Yambao-Franco, MD Council on Community Service and Child Advocacy Directors: Salvacion Gatchalian, MD; Roberto Espos, Jr., MD; Gregorio Cardona, Jr., MD Research Associates: Lady Christine Ong Sio, MD; Maria Corazon Martin, MD; Tiffany Tanganco, MD; Aizel de la Paz, MD; Domiline Coniconde, MD; Emmanuel Arca, MD; Gloria Nenita Velasco, MD; Maria Theresa Santos, MD

ACKNOWLEDGEMENTS Participants of the Round Table Discussion on Obesity in Children and Adolescents (01 October 2004): Ma. Theresa Bacud – Health Education Promotion Officer III, Health and Nutrition Center, Department of Education Jane Mari Cabulisan, MD – Medical Specialist II, National Center for Disease Prevention and Control, Department of Health Frances Prescilla Cuevas – Chief, Health Program Officer, National Center for Disease Prevention and Control, Department of Health Sioksoan Chan-Cua, MD – Director, Philippine Association for the Study of Overweight and Obesity; President, Philippine Society of Pediatric Metabolism and Endocrinology, Inc.

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Obesity in Children and the Adolescents

PPS Policy Statement

Cristina Dablo, MD – Division Chief, Medical Officer VII, Healthy Lifestyle Division, National Center for Disease Prevention and Control, Department of Health Aurora Gamponia, MD – Secretary, Philippine Society of Pediatric Cardiology Ma. Rhodora Garcia-De Leon, MD – President, Philippine Society of Pediatric Cardiology Merlita Nolido – Chief Education Program Specialist, Bureau of Elementary Education, Department of Education Antonia Siy – Senior Counselor, Center for Family Ministries Foundation Florentino Solon, MD – President and Executive Director, Nutrition Center of Philippines Alicia Berbano-Tamesis, MD – Founding President, Society of Adolescent Medicine of the Philippines, Inc. Maria Lourdes Vega – Chief, Nutrition Information and Education Division, National Nutrition Council Virgie Velasco – Performance Officer, Kapisanan ng mga Brodkaster ng Pilipinas Estrella Paje-Villar, MD – President, Philippine Pediatric Society Salvacion Gatchalian, MD – Director, Council on Community Service and Child Advocacy, Philippine Pediatric Society, Inc. Carmencita David-Padilla, MD – Chairperson, Committee on Policy Statements, Philippine Pediatric Society, Inc. Cynthia Cuayo-Juico, MD – Co-chairperson, Committee on Policy Statements, Philippine Pediatric Society, Inc. Nerissa Dando, MD – Member, Committee on Policy Statements, Philippine Pediatric Society, Inc. Joselyn Eusebio, MD – Member, Committee on Policy Statements, Philippine Pediatric Society, Inc. Edilberto Garcia Jr., MD – Member, Committee on Policy Statements, Philippine Pediatric Society, Inc. Irma Makalinao, MD – Member, Committee on Policy Statements, Philippine Pediatric Society, Inc. Ramon Severino, MD – Member, Committee on Policy Statements, Philippine Pediatric Society, Inc. Aizel de la Paz, MD – Research Associate, Committee on Policy Statements, Philippine Pediatric Society, Inc. Tiffany Tanganco, MD – Research Associate, Committee on Policy Statements, Philippine Pediatric Society, Inc. Participants of the Round Table Discussion on Obesity in Children and Adolescents (11 October 2005): Lorna Abad, MD – Member, Philippine Society of Pediatric Metabolism & Endocrinology, Inc. Sofia Amarra, PhD - Senior Science Research Specialist, Food and Nutrition Research Institute Nerissa Babaran - Nutrition Officer IV, National Nutrition Council Jane Mari Cabulisan, MD – Medical Specialist II, National Center for Disease Prevention and Control, Department of Health

Sioksoan Chan-Cua, MD – Director, Philippine Association for the Study of Overweight and Obesity; President, Philippine Society of Pediatric Metabolism and Endocrinology, Inc. Sylvia Estrada, MD – Member, Philippine Society of Pediatric Metabolism & Endocrinology, Inc. Ma. Rhodora Garcia-De Leon, MD – President, Philippine Society of Pediatric Cardiology Rosa Maria Nancho, MD – President, Society of Adolescent Medicine of the Philippines, Inc. Thelma Navarrez, MD - Director II, Health and Nutrition Division, Department of Education Juliet Sio-Aguilar – Member, Philippine Society of Pediatric Gastroenterology and Nutrition, Inc. Edison Ty, MD - Board Member, Philippine Society of Pediatric Cardiology Randy Urtula, MD – President, Philippine Society of Pediatric Gastroenterology and Nutrition, Inc. Grace Uy, MD - Chair, Obesity Working Group, Philippine Pediatric Society, Inc. Committee Felicidad Velandria - Treasurer - Philippine Association of Nutrition, Inc. Estrella Paje-Villar, MD – President, Philippine Pediatric Society Jocelyn Yambao-Franco, MD – Vice-President, Philippine Pediatric Society Carmencita David-Padilla, MD – Chairperson, Committee on Policy Statements, Philippine Pediatric Society, Inc. Nerissa Dando, MD – Member, Committee on Policy Statements, Philippine Pediatric Society, Inc. Emmanuel Arca, MD – Research Associate, Committee on Policy Statements, Philippine Pediatric Society, Inc. Domiline Coniconde, MD – Research Associate, Committee on Policy Statements, Philippine Pediatric Society, Inc.

The Committee on Policy Statements recognizes the contribution of the following: Center for Family Ministries Foundation Department of Education – Bureau of Elementary Education Department of Education – Health and Nutrition Center Department of Health – National Center for Disease Prevention and Control Department of Science and Technology - Food and Nutrition Research Institute Kapisanan ng mga Brodkaster ng Pilipinas National Nutrition Council – Nutrition Information and Education Division Nutrition Center of Philippines Philippine Association for the Study of Overweight and Obesity Philippine Association of Nutrition, Inc. Philippine Society of Pediatric Cardiology

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PPS Policy Statement

Obesity in Children and the Adolescents

Philippine Society of Pediatric Metabolism and Endocrinology, Inc. Society of Adolescent Medicine of the Philippines, Inc.

10.

REFERENCES 11. 1. Kuczmarski RJ, Ogden CL, Guo SS et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11. 2002; (246): 1-90. Centers for Disease Control and Prevention. BMI for children and teens. Atlanta, GA: Centers for Disease Control and Prevention; 2003. Available at www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm. Accessed September 24, 2006. Obesity Consensus Working Group. The Journal of Clinical Endocrinology & Metabolism. Mar 2005; 90(3): 1871-1887. Ogden CL, Carroll MD, Flegal KM. Epidemiologic trends in overweight and obesity. Endocrinol Metab Clin North Am. 2003; 32: 741-760. Screening and Interventions for Overweight in Children and Adolescents: Recommendation Statement. US Preventive Services Task Force. Pediatrics 2005; 116: 205-209. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev. 2004; 5(suppl 1):4-104. Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord. 1999;23(suppl 2):S2-S11. Zametkin AJ, Zoon CK, Klein HW, Munson S. Psychiatric aspects of child and adolescent obesity: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2004; 43; 134-150. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and

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Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med. 2003; 157: 821-827. The 6th National Nutrition Surveys: Initial Results. Food and Nutrition Research Institute. Available at http:// www.fnri.dost.gov.ph/nns/6thnns.pdf. Accessed on October 6, 2004. Department of Education – Health and Nutrition Center. Integrated School Health and Nutrition Program Q & A (Questions and Answers). September 2004. Available at the Department of Education. Florentino R. A study of overweight and obesity among school children in Manila. Paper read at the 2nd AsiaOceania Conference on Obesity (MASO 2003), Renaissance Hotel, Kuala Lumpur, Malaysia, September 8, 2003. Chan-Cua S, Cuayo-Juico C, et al. Prevalence of overweight among boys in a Metro Manila private grade school. Journal of ASEAN Federation of Endocrine Societies. 1995:16-20. Galvez MP, Frieden TR, Landrigan PJ. Obesity in the 21 st century. Environmental Health Perspectives. 2003;111(13):A684-5. Dietz WH. The obesity epidemic in young children. Br Med J 2001;322:313-4. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. The Lancet 360:473-82. American Obesity Association Fact Sheets. Available at h t t p : / / w w w. o b e s i t y. o r g / s u b s / f a s t f a c t s / obesity_youth.shtml. Accessed on August 30, 2004. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. The Lancet 360:473-82. Why childhood obesity levels are rising. Available at http://www.tinajuanfitness.info/articles/art120799.html. Accessed on December 5, 2003. More Filipino kids becoming obese. Available at http:/ /www.inq7.net.lif/2003/nov/13/lif_32-1.htm. Accessed on April 23, 2004.

DISCLAIMER: The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.

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PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 2

Child Labor
Philippine Pediatric Society, Inc.

Child labor is very prevalent specially in developing countries like the Philippines. This puts the children at risk for abuse and exploitation, exposes them to hazardous environments and also compromises their health. This policy statement discusses the impact of child labor in children, the various laws that have been enacted to quell this problem and recommendations for parents, physicians and the government on how to protect our children from child labor and uphold the rights of a child. Keywords: child labor, child abuse, exploitation, children’s right URL: http://www.pps.org.ph/policy_statements/child_labor.pdf

BACKGROUND The Convention on the Rights of the Child outlines the rights of every child. Children have the right to life, an adequate standard of living, parental care and support, social security, a name, nationality, and identity, information, leisure, recreation, and cultural activities, opinion, freedom of thought, conscience, religion, freedom of association, and privacy. In spite of this, childrens’ rights continue to be violated in the form of child labor.1 An estimated 246 million children around the world engage in child labor, of which roughly three-quarters work in hazardous situations or conditions, such as mines, working with chemicals and pesticides in the agricultural sector, or working with dangerous machinery. They are found in homes as domestic servants, behind walls of workshops as laborers, and in plantations. At least 70 percent work in agriculture. Girls, in particular, are especially vulnerable to exploitation and abuse, working as domestic servants or unpaid household help under horrific circumstances. They are either trafficked (1.2 million), forced into debt bondage or other forms of slavery (5.7 million), prostitution and pornography (1.8 million), participating in armed conflict (0.3 million), or other illicit activities (0.6 million). The Asian and Pacific regions have 127.3 million child laborers, representing 19 percent of children, the largest in the 5 to 14 age group.2

A National Statistics Office’s Survey on Children in 2001 recorded a total of 24.9 million Filipino children, of which 4.0 million were economically active, i.e., one out of six (6) children worked. Most working children came from Southern Tagalog, followed by Central Visayas and Eastern Visayas. They were composed of children aged 10-14 years old and 15-17 years old, consisting of more males than females, and majority (7 out of 10) resided in rural areas. More than 50 percent were engaged in agriculture, hunting, and forestry, while others were in wholesale and retail, repair of motor vehicles and personal and household goods, in private households with employed persons, fishing, and manufacturing. Most were unpaid workers in their own household-operated farm or business, while one-fifth were found in private establishments and in private households. Three out of 5 children were not paid. Roughly 25 percent of working children aged 5 to 17 years worked in the evening.3 Sixty percent of the working children, or about 2.4 million, were exposed to hazardous environment. Physical environment hazards were the most common, of which 44.4 percent were exposed. Around 237,000 (9.9%) were exposed to physical, chemical, and biologically hazardous environments. Physical hazards included temperature or humidity (most common), slip/trip fall hazards, noise, radiation/ultraviolet/microwave, pressure. Children in agriculture, hunting, and forestry were greatly exposed to physical hazards. One out of 5 children was exposed to chemical elements (such as silica and saw dust and

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mist/fumes). Almost 1 in 5 working children was in danger of biological infections, fungal and bacterial being the most common. Unfortunately, of the more than 2.4 million working children who used tools/ equipment in their work, only about 683,000 (35.3%) were provided with safety/protective device/ equipment. Approximately 23 percent of working children incurred injuries while at work, such as cuts, wounds and/or punctures, contusions/bruises/hematoma, and abrasions.2 Although 7 in every 10 working children attended school, 1.2 million (44.8%) encountered problems, including difficulty in catching up with the lesson, high cost of school supplies/ books/transportation, far distance of the school from their residence, unsupportive teachers, and lack of time for studying. Not surprisingly, 2 in every 5 working children stopped or dropped out of school. Reasons for dropping out included loss of interest and high cost of schooling.2 Because of the conditions that child laborers are forced to work in, which are intensive and unhygienic, these children tend to be underweight and undernourished. They are also exposed to a variety of chemical, biological, and physical hazards.6 Possible long-term repercussions of child labor include inhibited development of a country’s human resources, reduction of lifetime earnings of individuals, and lowered levels of productivity.6 The ILO Convention No. (ILOC) 138 sets minimum ages above which work can be allowed as necessary or even a useful part of young people’s lives.7,8 ILO Convention No. 182 identifies the different worst forms of child labor. It also sets policies for the elimination of child labor - the worst forms to be eliminated immediately while other forms should be restricted in time by establishing minimum age laws and other legal frameworks that protect children from exploitation.9,10 Republic Act (RA) 9231, more popularly known as the “AntiChild Labor Law,” amended some provisions of RA 7610. The Act provides for the elimination of the worst forms of child labor and affords stronger protection for the working child. It has the following salient features: 1. it prohibits the engagement of a child in worst forms of child labor; 2. provides for the working hours of a working child aged below 15 and those aged 15 but below 18; 3. determines ownership, usage and administration of the working child’s income; 4. provides for the setting up of a trust fund to preserve part of the working child’s income; 5. provides stiffer penalties against acts of child labor, particularly its worst forms, penalizes parents and legal guardians who violate the provisions of the Act with a fine or community service; and 6. provides for the speedy prosecution of child labor cases. The worst forms of child labor are the following: 1) All forms of Slavery as defined under the “Anti-trafficking in Persons Act of 2003”, or practices similar to slavery

like sale and trafficking of children, debt bondage, forced labor, recruitment of children in armed conflict. 2) Child for prostitution, pornography 3) Child for illegal activities/illicit activities 4) Work which is hazardous or harmful to the health, safety or morals of children, such that it: a) Debases, degrades, or demeans the intrinsic worth or dignity of the child b) Exposes child to abuses c) Is performed underground, underwater or dangerous heights d) Involves use of dangerous machineries, equipment or tools e) Exposes child to physical danger like dangerous feats of balancing, physical strength, or manual transport of heavy loads f) Is performed in an unhealthy environment exposing the child to hazardous working conditions, elements or substances, co-agents, or processes g) Is performed under particularly difficult conditions h) Exposes child to biological agents, such as bacteria, fungi, viruses, etc. i) Involves the manufacture of explosives and pyrotechnic products In the Philippines, minimum employable age is set at 15 years old. Children between 15 and 18 years old may be employed in undertakings not hazardous or deleterious in nature, i.e. any kind of work in which the employee is not exposed to any risk that constitutes an imminent danger to his or her life and limb, safety, and health. A child below 15 years old is not permitted to work in any public or private establishment, with two exceptions: children working directly under the sole responsibility of his or her parents or guardians or legal guardian (where only members of the employer’s family are employed) and if the child can go to school and her or his life, safety, health, morals and development are not endangered; and where the child’s employment or participation in public entertainment or information through cinema, theater, radio or television is essential. These are subject to conditions and provisions as determined by the Department of Labor and Employment (DOLE).1 Children of any age, however, are strictly prohibited from performing for advertisements that promote alcoholic beverages, tobacco, and violence.5 Still, children below 15 are not allowed to work more than 4 hours per day, 5 days per week. Children between 15 and 18 are allowed to work in non-hazardous circumstances, for not more than 8 hours per day and not more than 40 hours per week. In addition, working children are to have, at any time, access to primary and secondary education and training (formal or non-formal).10,11 The wages, salaries, earnings, and other income of the working child shall belong to him/her in ownership and shall be set

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aside primarily for his/her support, education or skills acquisition and secondarily to the collective needs of the family. Not more than twenty percent (20%) of the child’s income may be used for the collective needs of the family. A trust fund must be established to preserve part of the working child’s income. The parent or legal guardian of a working child below 18 years of age shall set up a trust fund for at least thirty percent (30%) of the earnings of the child whose wages and salaries from work and other income amount to at least two hundred pesos (P200,000.00) annually, for which he/she shall render a semi-annual accounting of the fund to the Department of Labor and Employment. The child shall have full control over the trust fund upon reaching the age of majority. In addition, the Act provides for maximal penalties for violators (e.g. employers, subcontractors or others facilitating the employment of children in any of the worst forms of child labor) and sets penalties for involving children in hazardous work. It also allows children, parents, or other concerned citizens to file complaints. RA 9231 “holds parents liable in case of violation of the said Act and provides penalties for them such as payment of a fine of not less than Ten Thousand Pesos (P10,000) but not more than One Hundred Thousand Pesos (P100,000), or be required to render community service for not less than thirty (30) days but not more than one (1) year, or both such fine and community services at the discretion of the court. The maximum length of community service shall be imposed on parents who have violated the provisions of this Act three (3) times.”11 Child labor refers to any work performed by a child that: 1. Subjects the child to economic exploitation, or 2. Is likely to be hazardous for the child, or 3. Interferes with the child’s education, or 4. Is harmful to the child’s health or physical, mental, spiritual, moral, or social development. It is a situation wherein children are compelled to work on a regular basis. In addition, it refers to work where children are separated from their families and where children are forced to lead prematurely adult lives.4 As opposed to child labor, child work children’s or adolescent’s participation in economic activity that does not negatively affect their health and development or interfere with their education and, in this light, can be positive and is legal.2 The Philippines has ratified ILOCs 138 and 182. It has developed and implemented a national program for the elimination of the worst forms of child labor. The Philippine Time-Bound Program Against Child Labor, launched in 2002, emphasizes combining sectoral, thematic, and area-based approaches in combating child labor. In support of the

program, the ILO-International Programme on the Elimination of Child Labor (IPEC) has implemented a project that involves strengthening the enabling environment for the elimination of the worst forms of child labor and direct action for child laborers, their families, and communities.7 The Philippine Program Against Child Labor is the flagship program for combating the worst forms of child labor in the country 5 and involves several agencies (such as the Department of Labor and Employment, Department of Justice, Department of Social Welfare and Development (DSWD), Department of Health), the police, and non-government organizations. The Bureau of Working Conditions is responsible for conducting labor inspections and for monitoring the use of child labor.11 The Department of Labor and Employment is the lead agency in the implementation of the Philippine Program Against Child Labor (formerly National Program Against Child Labor). Other program partners include the employers group, such as the Employers Confederation of the Philippines and workers organizations, such as the Federation of Free Workers and the Trade Union Congress of the Philippines. The multi-agency program Sagip Batang Manggagawa allows for the rescue of child laborers and the placement of these children in DSWD-managed centers or institutions where they undergo rehabilitation prior to reintegration. The agency’s Conditional Cash Transfer provides money to families in need on the condition that human capital investments be made, e.g. sending their children to school and bringing them regularly to health centers. Receipt of money is contingent on enrollment and regular attendance of at least 85 percent of school days.12 The Philippine Pediatric Society, Inc. is in support of the elimination of the worst forms of child labor and of protecting children in the employable age.

RECOMMENDATIONS Roles of the National Government 1. The national government should continue to enhance existing legislation that will help in the elimination of the worst forms of child labor in the country. 2. The national government should ensure child-friendly and child-sensitive enforcement of existing anti-child labor legislation. 3. The national government should include child labor concerns in the following areas: a. National Development b. Social Policies c. Labor market policies 4. The national government should enhance education (through information dissemination and developing analytical skills, critical thinking, and decision making)

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and other training policies that respond to the needs of working children and those who are at risk. 5. The national government should provide opportunities for specialized training of inspectors of child labor. 6. The national government should increase social spending and budget allocation to basic social services. 7. The national government should enjoin the participation of private groups, business sectors, and civic organizations. Roles of the Local Government 1. Local governments should develop local laws or ordinances that are in support of the national government’s effort at eliminating the worst forms of child labor. 2. Local governments should provide mechanisms for improving implementation of national legislation. 3. Local governments should set up mechanisms for detecting, monitoring, reporting, and providing action against the worst forms of child labor. 4. Local governments should provide social support and economic opportunities (through training of adults, micro-finance, other credit schemes, establishment of sustainable small industries, and alternative livelihood programs) to families who are vulnerable to the worst forms of child labor. 5. Local governments should enforce and implement the law. 6. Local governments should provide educational and training opportunities and alternatives to children who are at risk of and engage in child labor. 7. Local governments should encourage community involvement and social mobilization through local advocacy for the prevention of child labor. 8. Local governments should provide free rescue and psychosocial recovery and social reintegration services to child laborers. 9. Local governments should provide litigation services to victims of child labor and child economic exploitation. Roles of the Physician and other Health Workers 1. All physicians must be aware of the laws relevant to child labor. 2. Physicians are encouraged to include as part of the medical school curriculum and/or residency training laws and other information relevant to child labor. 3. The physician should detect and report to the proper authorities any child suspected of engaging in child labor. 4. The physician should counsel the parents of child/ children suspected of engaging in child labor regarding the immediate hazards and long-term consequences of child labor. 5. The physician should provide free medical services to

6.

children engaged in child labor. The physician should conduct free annual or semiannual medical check-ups for identified child laborers and other members of their families.

Roles of the Parents 1. The parents should ensure that their child/children does not/do not engage in unacceptable (according to RA 9231) forms of child labor.

Document prepared by the Committee on Policy Statements Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao, MD Members: Nerissa Dando, MD; Joselyn Eusebio, MD; Edilberto Garcia, Jr., MD; Ramon Severino MD Advisers: Joel Elises, MD; Salvacion Gatchalian, MD; Genesis Rivera, MD; Jocelyn Yambao-Franco, MD Research Associates: Maria Theresa H. Santos, MD; Gloria Nenita V. Velasco, MD

EXPERT REVIEWERS Department of Labor and Employment Bureau of Women and Young Workers Chita G. Cilindro (Director) Department of Health National Center for Disease Prevention and Control Yolando E. Oliveros, MD, MPH (Director IV) Department of Social Welfare and Development Gemma Gabuya (Social Welfare Officer V) Round Table Discussion Participants 16 October 2007 Department of Labor and Employment Bureau of Women and Young Workers - Chita G. Cilindro (Director) Department of Labor and Employment - Ruby Dimaano Department of Health National Center for Disease Prevention and Control, Family Health Office – Rodolfo Albornoz, MD (Medical Specialist III) Department of Social Welfare and Development – Nicamil K. Sanchez (Social Welfare Officer IV) Liga ng mga Barangay sa Pilipinas – Rudenio Eduave (Director for Organizational Development)

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ACKNOWLEDGEMENTS The committee would like to acknowledge the following for their contribution: Department of Labor and Employment Bureau of Women and Young Workers - Chita G. Cilindro (Director) Department of Labor and Employment - Ruby Dimaano Department of Health National Center for Disease Prevention and Control - Yolando E. Oliveros, MD, MPH (Director IV) Department of Health National Center for Disease Prevention and Control, Family Health Office – Rodolfo Albornoz, MD (Medical Specialist III) Department of Social Welfare and Development - Gemma Gabuya (Social Welfare Officer V) Department of Social Welfare and Development – Nicamil K. Sanchez (Social Welfare Officer IV) Liga ng mga Barangay sa Pilipinas – Rudenio Eduave (Director for Organizational Development)

REFERENCES 1. 2. 3. 4. DOLE Primer. “Labor in the Philippines.” Available at http://www.dole.gov.ph/primers/rightswyw.htm UNICEF Fact Sheet. 2001 National Statistics Office Survey on Working Children Department of Labor and Employment. “The Child Labor Situation in the Philippines.” Available at http://

www.bwyw.dole.gov.ph/CL%20Situation.htm. Accessed on October 10, 2006. 5. Gomez C. “RP has 4 million working children.” Visayan Daily Star . 31 March 2006. Available at http:// w w w. v i s a y a n d a i l y s t a r. c o m / 2 0 0 6 / M a r c h / 3 1 / topstory7.htm. 6. World Children Organization. Available at http:// world_children.org/WCO%20web%20images/ homepage/phil_cond1.htm. 7. Sardaña MC. “Combating Child Labor in the Philippines.” Prepared for Asian Development Bank Institute’s Seminar on Social Protection for the Poor in Asia and Latin America. 25 October 2002, Manila. 8. ILO Convention No. 138. Available at http://ohchr.org/ english/law/pdf/ageconvention.pdf. Accessed on September 11, 2007. 9. ILO Convention No. 182. Available at http:// www.ilo.org/public/english/standards/relm/ilc/ilc87/ com-chic.htm. Accessed on September 11, 2007. 10. de Boer J. “Sweet Hazards: Child labor on sugarcane plantations in the Philippines.” Terre des Hommes Netherlands. 2005. 11. Republic Act 9231. “An Act Providing for the Elimination of the Worst Forms of Child Labor and Affording Stronger Protection for the Working Child, Amending for this Purpose Republic Act No. 7610. As Amended, Otherwise Known as the ‘Special Protection of Children Against Child Abuse, Exploitation, and Discrimination Act.’” Available at http:// www.ops.gov.ph/records/ra_no9231.htm. Accessed on September 11, 2007. 12. Reactions to the Policy Statement “Child Labor” drafted by the Philippine Pediatric Society, Inc. Department of Social Welfare and Development. October 2007.

DISCLAIMER: The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.

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PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 3

Infant Walkers
Philippine Pediatric Society, Inc.

Infant walkers are commonly employed by parents nowadays. Recent studies have found that infant walkers may put children at risk for accidents and minor injuries as well as cause a delay in motor development. This policy presents the advantages and disadvantages of infant walker use as well as recommendations for its use. Keywords: infant walkers, accidents, minor injuries URL: http://www.pps.org.ph/policy_statements/infant_walkers.pdf

BACKGROUND Infant walkers are commonly used mobile infant carriers today. They allow a pre-ambulatory infant to sit in a suspended seat attached to a circular rim standing on wheels. The device gives the infant precocious locomotion.1-3 Walkers are sometimes equipped with a plastic table or hanging toys that keep the infant entertained while seated. Some are equipped with a braking mechanism whereas others are foldable and can be easily stowed.1 Walkers are employed by parents for various reasons: to keep their infant preoccupied while they are doing other things, to hold their children during feeding, to keep their children quiet and happy, to aid the infant in strengthening their legs and to help infants walk at an earlier age.1,2,4-6 However, recent studies have shown that infant walkers are not beneficial to children and are actually a danger to them. Several studies have shown that contrary to popular belief, walkers do not aid infants to walk at an earlier age but can even delay their motor and mental development.1,2-9 One study showed that walker-experienced infants scored lower on Bayley scales of mental and motor development compared to non-walker experienced.1,3 Another study showed that walker experienced infants had abnormal Denver Developmental Screening Test Results9 while another study showed that

walker assisted infants initially had abnormal gait when they started walking independently.1 Aside from delayed motor development, contractures of the calf muscles and motor development mimicking spastic diaparesis may also appear.2,8 Moreover, walkers make infants more prone to accidents such as falls, burns, poisonings, submersions, suffocation and even death.1,4-6,10-21 All of these accidents are attributed to the increased range and speed of infants when riding the walker. Falls. Inside a walker, the speed of the infant can reach up to 3 feet/sec, and even with a guardian present, this speed may be too fast to catch a falling child. The speed and acceleration endowed to an infant when riding a walker may cause fatal injury from falls even at low heights. Literature has shown that falls from stairs occur in 75 – 96% of cases.1,4,5,12,18-20 Some of these are severe, some cause facial injuries, majority cause head injuries and rarely, fatalities.1,46,10-20 Although some stairs are gated and some walkers are equipped with braking mechanisms that stop the carriage when there are changes in elevation, it has been found that these are not enough to sufficiently decrease the frequency of falls in infants.1 Burns and Poisonings. Infants riding a walker may be more prone to both burn injuries and poisoning due to increased

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access to the kitchen and other dangerous areas in the house.16Reported burn injuries were contact and scald burns, some severe enough to require resuscitation and skin grafting. It has been reported that the incidence of thermal injury associated with baby walker use remains at high levels despite increased safety measures.17,18,21 Submersions and Suffocations. Despite the swimming pool being fenced-in, there have been reports of submersion and drowning of infants on walkers. There was also a report of submersion in a toilet bowl by an infant riding a walker. Likewise, there was also a report of infant suffocation while inside the walker when the infant’s neck was caught in between the walker tray.1 Minor Injuries. These injuries include pinch injuries to the infant’s fingers and toes, abrasions, contusions, lacerations, extremity fractures and other soft tissue injuries.1,4-6,12,17-20

without realizing the danger that they pose. Likewise, many still think that walkers are safe for their children. Both the Philippine government and society have made no moves to educate the public on the effects of walker use. Infant walkers have been in use for many years now and it is only recently that many are realizing the dangers that they pose. Indeed, this is something that deserves attention both from the government and the health sector.

RECOMMENDATIONS Roles of the Government 1. The government should create guidelines and safety standards in the manufacture and import of infant walkers, if not completely ban walkers in the country. 2. The government should launch a media campaign that informs the public of the disadvantages of infant walkers and discourages its use. 3. The government should aid in the education of doctors, midwives and other health personnel on the disadvantages of infant walker use. 4. The government should ban the use of walkers in hospitals and approved child care facilities. 5. The government should initiate and support researches regarding the benefits, disadvantages and safety of infant walker use in the Philippine setting. Roles of Physicians and Health Care Personnel 1. Physicians and health care personnel should educate parents on the hazards of infant walker use. 2. Physicians and health care personnel should conduct researches that will elucidate further the effects and disadvantages of infant walker use. 3. Physicians and health care personnel should make sure that walkers are not used in their clinics and other child health care facilities. Roles of Parents 1. Parents should be informed and should read and research on the hazards of infant walker use. 2. If parents choose to use walkers, they should select a walker that meets the standards set by the government.

Many countries have realized the danger that walkers pose to their children and, thus, started creating policies that will help curb this rising problem. Such policies include recommendations of stationary walkers and playpens as alternative to mobile infant walkers, guidelines that regulate the manufacture of safer walkers, withdrawal of mobile walkers from the market and banning of walker production.2,4,6,18 In 1997, the American Society for Testing and Materials (ASTM) created voluntary guidelines and standards on the manufacture of infant walkers.4 Some of these include a braking mechanism for the walker and a requirement that the walker’s width be greater than 36 inches (the width of an average door).1 Likewise, New South Wales, Australia has set the 2000 baby walker regulation, which required a specified level of stability and a gripping mechanism to stop the walker at the edge of the step.22 All of these moves were noted to decrease the number of infant walker-related injuries.4,22 Another means employed is the education of doctors, nurses, midwives and other health personnel regarding the dangers of walker use which they then share with the parents and guardians of the children.2,5,6,10,21-28 This was done in the United Kingdom, Singapore, US, Canada and other developed countries. It was found that parental knowledge of the dangers associated with baby walkers may be effective in reducing baby walker possession and use.10,23-26,28 However, this only limited the frequency of baby walker-related accidents to some extent and many still believe that banning walkers from the market and recalling existing walkers would be more effective.3,7,8,18,21,22,27,28 In the Philippines, there is very little awareness on the adverse effects of walker use. Many still employ infant walkers with the belief that these aid their children to walk earlier and faster

Document prepared by Committee on Policy Statements: Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD and Irma R. Makalinao, MD Members: Nerissa M. Dando, MD; Joselyn A. Eusebio, MD; Edilberto B. Garcia, Jr., MD; Ramon C. Severino, MD Advisers: Joel S. Elises, MD; Salvacion R. Gatchalian, MD; Genesis C. Rivera, MD; Jocelyn J. Yambao-Franco, MD Research Associates: Maria Theresa H. Santos, MD and Gloria Nenita V. Velasco, MD

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EXPERT REVIEWER Lead reviewer: Joselyn A. Eusebio, MD expert reviewer: Philippine Pediatric Society Committee on ____ Rommel Crisenio M. Lobo, MD

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14. REFERENCES 1. “Injuries associated with infant walkers.” American Academy of Pediatrics: Committee on Injury and Poison Prevention. Pediatrics. Vol. 108, No. 3. September 2001. Pp. 790 – 792. 2. Hadzagic – Catibusic F, Gavrankapetanovic I, Zubcevic S, Meholjic A, Rekic A, Sunjic M. “Infant walkers: the prevalence of use.” Medicine Archives. Vol. 58, No. 3. 2004. Pp. 189 – 190. 3. Siegel AC, Burrows RV. “Effects of baby walkers on motor and mental development in human infants.” Journal of Developmental and Behavioral Pediatrics. Vol. 20, No. 5. October 1999. Pp. 355 – 361. 4. Shields BJ, Smith GA. “ Success in the prevention of infant walker – related injuries: an analysis of national data, 1990 – 2001. Pediatrics. Vol. 117, No. 3. March 2006. Pp. e452 – 459. 5. Santos Serrano L, Paricio Talavero JM, Salom Perez A, Grieco Burucua M, Martin Ruano J, Benlloch Muncharaz MJ, Llobat Estelles T, Beseler Soto B. “Patterns of use , popular beliefs and proneness to accidents of a baby walker. Bases for health information campaign.” An Esp Pediatrica. Vol. 44, No. 4. April 1996. Pp. 337 – 340. 6. Al-Nouri L, Al-Isami S. “Baby walker injuries.” Annals of Tropical Pediatrics. Vol. 26, No. 1. March 2006. Pp. 67 – 71. 7. Burrows P, Griffiths P. “Do baby walkers delay the onset of walking in young children?” British Journal of Community Nursing. Vol. 7, No. 11. November 2002. Pp. 581 – 586. 8. Engelbert RH, van Empelen R, Scheurer ND, Helders PJ, van Nieuwenhuizen O. “Influence of infant walkers on motor development: mimicking spastic diplegia?” European Journal of Pediatric Neurology. Vol. 3, No. 6. 1999. Pp. 273 – 275. 9. Thein MM, Lee J, Tay V, Ling SL. “Infant walker use, injuries, and motor development.” Injury Prevention. Vol. 3, No. 1. March 1997. Pp. 63 – 66. 10. Wishon PM, et. al. “Hazard patterns and injury prevention with infant walkers and strollers.” 11. “Deaths associated with infant carriers – United States, 1986 – 1991. MMWR Morbidity and Mortality Weekly Report. Vol. 41, No. 16. April 24, 1992. Pp. 271 – 272. 12. Dedoukou X, Spyridopoulos T, Kedikoglou S, Alexe DM, Dessypris N, Petridou E. “Incidence and risk factors of

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fall injuries among infants: a study in Greece.” Archives of Pediatric and Adolescent Medicine. Vol. 158, No. 10. October 2004. Pp. 1002 – 1006. Watson WL, Ozanne – Smith J. “The use of child safety restraints with nursery furniture.” Journal of Pediatric Child Health. Vol. 29, No. 3. June 1993. Pp 228 – 232. Leblanc JC, Pless IB, King WJ, Bawden H, Bernard – Bonnin AC, Klassen T, Tenenbein M. “Home and safety measures and the risk of unintentional injury among young children: a multicenter case – control study.” CMAJ. Vol. 175, No. 8. October 10, 2006. Pp. 883 – 887. Emanuelson I. “How safe are childcare products, toys and playground equipment? A Swedish analysis of mild brain injuries at home and during leisure time 1998 – 1999. Injury Control and Safety Promotion. Vol. 10, No. 3. September 2003. Pp. 139 – 144. Mroz LS, Krenzelok EP. “Examining the contribution of infant walkers to childhood poisoning.” Vet Hum Toxicology. Vol. 42, No. 1. February 2000. pp. 39 – 40. Cassell OC, Hubble M, Milling MA, Dickson WA. “Baby walkers – still a major cause of infant burns.” Burns. Vol. 23, No. 5. August 1997. Pp. 451 – 453. Smith GA, Bowman MJ, Luria Jw, Shields BJ. “Baby walker – related injuries continue despite warning labels and public education.” Pediatrics. Vol. 100, No. 2. August 1997. P. E1. Claydon SM. “Fatal extradural hemorrhage following a fall from a baby bouncer.” Pediatric Emergency Care. Vol. 12, No. 6. December 1996. Pp. 432 – 434. Petridou E, Simou E. Skondras C, Pistevos G, Lagos P, Papoutsakis G. “Hazards of baby walkers in a European context.” Injury Prevention. Vol. 2, No. 2. June 1996. Pp. 118 – 120. Sendut IH, Tan KK, Rivara F. “Baby walker associated scalding injuries seen at University Hospital Kuala Lumpur.” Medical Journal Malaysia. Vol. 50, No. 2. June 1995. Pp. 192 – 193. Thompson PG. “Injury caused by baby walkers: the predicted outcomes of mandatory regulations.” Medical Journal of Australia. Vol. 177, No. 3. August 5, 2002. Pp. 147 – 148. Kendrick D, Illingworth R, Woods A, Watts K, Collier J, Dewey M, Hapgood R, Chen CM. “Promoting child safety in primary care: a cluster randomized controlled trial to reduce baby walker use.” British Journal of General Practice. Vol. 55, No. 517. August 2005. pp. 579 – 580. Tan NC, Lim NM, Gu K. “Effectiveness of nurse counselling in discouraging the use of the infant walker.” Asia Pacific Journal of Public Health. Vol. 16, No. 2. 2004. Pp. 104 – 108. Rhodes K, Kendrick D, Collier J. “Baby walkers: pediatricians’ knowledge, attitudes, and health promotion.” Archives of Diseases in Childhood. Vol. 88, No. 12. December 2003. Pp. 1084 – 1085.

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Infant Walkers

26. Conners GP, Veenema TG, Kavanagh CA, Ricci J, Callahan CM. “Still falling: a community – wide infant walker injury prevention initiative.” Patient Educ Couns. Vol. 46, No. 3. March 2002. Pp. 169 – 173.

27. Kendrick D, Marsh P. “Babywalkers: prevalence of use and relationship with other safety practices.” Injury Prevention. Vol. 4, No. 4. December 1998. Pp. 295 – 298. 28. Morrison CD, Stanwick RS, Tenenbein M. “Infant walker injuries persist in Canada after sales have ceased.” Pediatric Emergency Care. Vol. 12, No. 3. June 1996. Pp. 180 – 182.

DISCLAIMER: The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.

16

PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 4

Caffeine and Children
Philippine Pediatric Society, Inc.

Caffeine is both a naturally occurring substance and an additive in many foods, beverages, and medicines. It is a known stimulant that mainly influences the central nervous system but has effects on other body systems. Its consumption is widespread due to its easy accessibility and availability through sodas, chocolate, and coffee, owing to the spread of coffee establishments in the area. Its specific effects on children have been relatively less studied. This policy statement looks into local consumption of caffeine-containing foods and drinks, its effects, and guidelines that have been set by other countries. The Philippine Pediatric Society, Inc. recommends limiting caffeine consumption by children.

Keywords: caffeine, xanthine derivatives, addiction, tea, coffee URL: http://www.pps.org.ph/policy_statements/caffeine_and_children.pdf

BACKGROUND Caffeine has been used as early as the Stone Age when ancient peoples discovered that chewing seeds, bark, and leaves of certain plants eased fatigue, stimulated awareness, and elevated mood.1,2 For thousands of years, it has been used in a variety of forms such as coffee, tea, chocolate, yerba maté, and guarana berries among others. 3 Caffeine is the most widely consumed psychoactive substance, its consumption being estimated at 120,000 tons per annum.1 It has also been added to a variety of carbonated and energy drinks and medicines, such as decongestants, analgesics, stimulants, and appetite suppressants.4 (See Appendix) Children’s exposure to caffeine is largely via carbonated drinks, chocolate, tea, and coffee (especially in urbanized areas) through the deluge of coffee franchises. In a study on beverage caffeine intake in young children in Canada and USA, it was determined that American children consumed more caffeinated beverages at 56% compared to Canadian children at 36%. Canadian children consumed approximately half the amount of caffeine (7 vs. 14 mg/day). It was concluded, however, that caffeine intake from caffeinated beverages remained well within safe levels for consumption by young children.5 Caffeine is a xanthine derivative and its effects are mediated through its action on the cerebral cortex and brain stem of the

central nervous system. Caffeine’s effects are dose-related and most of its undesirable effects are at greater doses. At doses of 100-200 mg, caffeine may increase alertness and wakefulness, promote faster and clearer flow of thought and better general body coordination, and may produce loss of fine motor control and result in dizziness. 6,7 However doses of more than 500-600 mg can cause restlessness, anxiety, irritability, muscle tremors, sleeplessness, headaches, nausea, diarrhea or other gastrointestinal problems, and abnormal heart rhythms.8 Caffeine stimulates the heart, dilates vessels, causes bronchial relaxation, and increases gastric acid production.7 Its other metabolic effects include releasing fatty acids from adipose (fatty) tissue and affecting the kidneys (resulting in increased urination) which could lead to dehydration.9 It is important to note that caffeine also fits the definition of an addictive substance, with withdrawal symptoms, an increase in tolerance over time, and physical cravings.7 Caffeine poisoning from consuming excessive amounts has occurred in other countries.10,11 The symptoms of caffeine poisoning in infants include very tense muscles alternating with overly relaxed muscles, rapid, deep breathing, nausea and/or vomiting, rapid heartbeat, shock, and tremors.12 Though the effects of caffeine have been studied for years, research into its effect on children is a relatively untouched area. A recent study done in Harding University, Arkansas,

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PPS Policy Statement

Caffeine and Children

USA was the first to investigate the effects of caffeine on both cardiovascular and metabolic responses to exercise in healthy boys and girls. The study was done on 52 seven to nine-year old boys and girls, each randomly receiving a placebo and a caffeinated drink twice each on four separate days. The results revealed that caffeine acutely elevated both resting and exercise blood pressure, but acutely reduced heart rate in boys and girls given a moderate to high dose of caffeine an hour before exercise. Caffeine was found to have no effect on metabolism, and there were no significant differences found between boys and girls.13 In the United States, a report by the National Center for Addiction and Substance Abuse at Columbia University found that young women aged 8 to 22 who drank coffee were more likely to smoke and drink alcohol, and to do so at an earlier age than non-coffee drinkers and their male counterparts. The study called caffeine “a little known risk factor” for substance abuse and warned that the glamorizing of addictive substances had contributed to this problem.14 In a study done on caffeine dependence in 36 adolescents, it was determined that there was no significant difference in the amount of caffeine consumed daily by caffeine dependent versus non-dependent teenagers.15 In a study done on 275 students in Italy in 2006, the prevalence and related disability of multiple addictions were assessed. In this population, behavioral addictions were multiple, a source of disability, and were related to substance. However, whether this is a temporary phenomenon among adolescents or a reliable marker for the future development of substance abuse needs to be clarified.16 There has also been concern on the possible negative effects of caffeine on bone growth of children. A cohort study conducted by Lloyd et al. was done to determine whether dietary caffeine consumed by American white females between ages 12 to 18 affected total body bone mineral gain during ages 12 to 18 or affected hip bone density measured at age 18. It was determined that dietary caffeine intake at levels presently consumed by American white, teenage women was not correlated with adolescent total bone mineral gain or hip bone density at age 18.17 A meta-analysis was conducted by Hughes and Hale on the behavioral effects of caffeine and other methylxanthines on children. Acute exposure to or intake of high doses (>3 mg/ kg) of caffeine in children who consumed little caffeine produced negative subjective effects (e.g. nervousness, jitteriness, stomachaches, and nausea). Caffeine appeared to slightly improve vigilance performance and decreased reaction time in healthy children who habitually consumed caffeine.18 The acute effects of caffeine on learning, performance, and anxiety were investigated in 21 children through a double-

blind placebo-controlled crossover design. In the small sample size, there was an indication that caffeine enhanced performance on a test of attention and on a motor task. The participants reported feeling less “sluggish” but somewhat more anxious.19 Cases of rare reactions to caffeine intake including tics20 and urticaria21 have been documented. Aside from the undesirable effects that children may experience with excessive caffeine ingestion, there are other concerns that adults need to be aware of. Excessive intake of carbonated drinks may lead to obesity, nutritional deficiencies, and dental caries.22 Caffeine addiction may also put patients at risk for tooth wear, such as attrition, erosion, and abrasion.23 In addition, there are certain medications that interact negatively with caffeine. The antibiotics ciprofloxacin and norfloxacin may increase the length of time caffeine remains in the body and may amplify its effects. Theophylline has some caffeine-like effects and its concentration may increase in the blood when taken with caffeine-containing food or beverages. Ephedra (or ma-huang), an herbal dietary supplement, has already been banned due to health concerns in the USA but may still be present in herbal teas. Its ingestion in combination with caffeine may be risky.8 In a 2008 retrospective assessment done in the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders, it was concluded that individual differences in psychoactive substance use (in this case alcohol, caffeine, cannabis, and nicotine), in terms of initiation and early patterns of use, were strongly influenced by social and familial environmental factors while later use was more strongly influenced by genetic factors.24 This underscores the importance that parents and schools play in prevention and cessation counseling. However, other beverages that contain caffeine, such as tea and coffee, may have other beneficial effects. The beneficial effects of coffee are a direct result of its higher caffeine content. Its regular intake may reduce the risk of Parkinson’s disease, type 2 diabetes25, colon cancer, liver cirrhosis, hepatocellular carcinoma26, and gallstones.27,28 It may also serve as a powerful aid in enhancing athletic endurance and performance and help manage asthma and headaches. Furthermore, coffee contains antioxidants (e.g. chlorogenic acid and tocopherols) and minerals, such as magnesium, that may improve insulin sensitivity and glucose metabolism. Lastly, trigonelline in coffee has anti-bacterial and anti-adhesive properties that may help prevent dental caries.27 To what extent an individual will be affected will depend on his/her sensitivity to the substance and his/her sensitivity, in turn, will depend on body mass, history of caffeine use, and stress. Those with lower body masses (e.g. children) will experience the effects of caffeine sooner than those with

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Caffeine and Children

PPS Policy Statement

higher body masses (e.g. adults). Those with regular caffeine intake will be less susceptible to experiencing caffeine’s negative effects than those with irregular caffeine intake. And all types of stress can increase a person’s sensitivity to caffeine, e.g. psychological stress or heat stress. Age, smoking habits, drug or hormone use, and other health conditions (e.g. anxiety disorders) are additional factors that need to be considered.8 In the USA, there are no specific guidelines for limiting caffeine intake. Moderate coffee drinking of 1-2 cups per day does not seem to be harmful according to the American Heart Association.9 Health Canada, however, has the following recommendations for maximum caffeine intake levels for children: Children* 4 - 6 years 7 - 9 years 10 - 12 years 45 mg/day 62.5 mg/day 85 mg/day

Note : Labeling may not be enough. It should include : Caffeine may be “habit forming,” “may cause increase in heart rate,” “insomnia,” or even “NOT RECOMMENDED FOR CHILDREN or CONTRAINDICATED IN CHILDREN WITH MEDICAL CONDITIONS,” “OR CONSULT YOUR DOCTORS ON THE SAFETY OF CAFFEINE IN CHILDREN.” Roles of Physicians 1. Physicians should educate parents and caregivers on the effects of caffeine, the products that contain them, and ways in which its intake could be reduced and/or avoided. 2. Physicians should educate parents and caregivers on food and beverage products that are energy rich but nutritionally dense (e.g. fresh fruit juices, milk, etc.) in place of softdrinks and energy drinks. 3. Physicians should be vigilant in prescribing medications that have adverse drug interactions with caffeinecontaining food and beverages, especially if their pediatric patients are consuming diets containing such items. Roles of Parents 1. Parents should educate their children on the effects of caffeine and the products that contain them. 2. Parents should encourage the reduction and/or avoidance of caffeine in their children’s diets. 3. Parents should encourage their children to consume food and beverage products that are energy rich but nutritionally dense (e.g. fresh fruit juices, milk, etc.). 4. Parents should inquire with their children’s primary physician if any of their child’s medications (whether prescription or over-the-counter) contain caffeine and the level at which it is found in the medication. 5. Parent should aim to reduce/avoid administering medication containing caffeine to their children unless otherwise strongly indicated by their child’s pediatrician/ attending physician. 6. Parents should set examples in the moderate intake of coffee.

* Using the recommended intake of 2.5 milligrams per kilogram of body weight per day and based on average body weights of children (Health and Welfare Canada, 1990), based on “behavioral effects”. 29 In the Philippines, caffeine is considered a miscellaneous food additive in cola type beverages and its maximum level of use is limited to 200 ppm.30 At present, there are no existing specific guidelines on limiting caffeine intake for children.

RECOMMENDATIONS Roles of the Government 1. The government should implement laws that mandate labeling of all food, beverage, and medicines that contain caffeine and the level of caffeine found in these products. 2. The government should strengthen and implement programs to promote healthy diet and alternative options to intake of caffeine-containing foods and beverages. 3. Increase awareness of the public, through the Department of Health and DOH accredited hospitals, including schools on the effects of caffeine in children. 4. To encourage the coffee selling establishments to include a warning or caution (posters, signs) on the negative effects of caffeine on children. Roles of Food, Beverage, and Medicine Manufacturers 1. Food, beverage, and medicine manufacturers should properly label their products that contain caffeine and the levels at which it is found in the product.

Document prepared by the Committee on Policy Statements Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao, MD Members: Nerissa Dando, MD; Joselyn Eusebio, MD; Edilberto Garcia, MD; Ramon Severino, MD Advisers: Joel Elises, MD; Salvacion Gatchalian, MD; Genesis Rivera, MD; Jocelyn Yambao-Franco, MD Research Associates: Maria Theresa H. Santos, MD; Gloria Nenita V. Velasco, MD

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PPS Policy Statement

Caffeine and Children

ACKNOWLEDGEMENTS The Committee on Policy Statements recognizes the contribution of the following: Dr. Mario Capanzana -- Officer in Charge, Food and Nutrition Research Institutex REFERENCES 1. “Caffeine.” Available at http://en.wikipedia.org/wiki/ Caffeine. Accessed on May 7, 2007. 2. Suleman A, Siddiqui NH. “Hemodynamic and cardiovascular effects of caffeine.” Available at http:// www.priory.com/pharmol/caffeine.htm. Accessed on May 7, 2007. 3. National Cancer Institute. “Caffeine.” National Cancer Institute Drug Dictionary. National Institutes of Health. Available at http://www.cancer.gov/Templates/ drugdictionary.aspx?CdrID=40817. Accessed on May 11, 2007. 4. National Cancer Institute. “Caffeine.” National Cancer Institute Dictionary of Cancer Terms. National Institutes of Health. Available at http://www.cancer.gov/ Templates/db_alpha.aspx?CdrID=454809. Accessed on May 11, 2007. 5. Knight CA, Knight I, Mitchell DC. Abstract. “Beverage caffeine intakes in young children in Canada and the US.” Canadian journal of dietetic practice and research: a publication of Dietitians of Canada. 2006 Summer. Vol. 67 No. 2. Pages 96-99. 6. “Caffeine.” Available at http://www.stanford.edu/ ~johnbrks/theCafe/substance/caffeine.html. Accessed on May 7, 2007. 7. “Caffeine Effects: The Effects of Caffeine on the Body.” Available at http://mass-spec.chem.cmu.edu/VMSL/ Caffeine/Caffeine_effects.htm. Accessed on May 11, 2007. 8. Mayo Clinic Staff. “Caffeine: How much is too much?” 8 March 2007. Available at http://www.mayoclinic.com/ health/caffeine/NU00600. Accessed on May 21, 2007. 9. American Heart Association. “Caffeine: AHA Recommendation.” Available at http:// w w w . a m e r i c a n h e a r t . o r g / presenter.jhtml?identifier=4445. Accessed on May 21, 2007. 10. Jorens PG, Van Hauwaert JM, Selala MI, Schepens PJ. Abstract. “Acute caffeine poisoning in a child.” European journal of pediatrics. October 1991. Vol. 150 No. 12. Page 860. 11. Walsh I, Wasserman GS, Mestad P, Lanman RC. Abstract. “Near-fatal caffeine intoxication treated with peritoneal dialysis.” Pediatric emergency care. December 1987. Vol. 3 No. 4. Pages 244-249.

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12. Psychology Today Staff. “Caffeine.” Psychology Today. 2002 October 10. Available at http:// www.medicinenet.com/script/main/ art.asp?articlekey=38065. Accessed on May 11, 2007. 13. Turley KR, Gerst JW. Abstract. “Effects of caffeine on physiological responses to exercise in young boys and girls.” Medicine and Science in Sports and Exercise. 2006 March. Vol. 38 No.3. Pages 520-526. 14. Needham C. “Sweet but dark: coffee consumption and teen girls.” Available at http://www.jrn.columbia.edu/ studentwork/cns/2003-06-03/320.asp. Accessed on June 8, 2005. 15. Bernstein GA, Carroll ME, Thuras PD, Cosgrove KP, Roth ME. Abstract. “Caffeine dependence in teenagers.” Drug and alcohol dependence. 1 March 2002. Vol. 66 No. 1. Pages 1-6. 16. Pallanti S, Bernardi S, Quercioli L. Abstract. “The Shorter PROMIS Questionnaire and the Internet Addiction Scale in the assessment of multiple addictions in a high school population: prevalence and related disability.” CNS Spectr. 2006 Dec. Vol. 11 No. 12. Pages 966-974. 17. Lloyd T, Rollings NJ, Kieselhorst K, Eggli DF, Mauger E. Abstract. “Dietary caffeine intake is not correlated with with adolescent bone gain.” Journal of the American College of Nutrition. October 1998. Vol. 17 No. 5. Pages 454-457. 18. Hughes JR, Hale KL. Abstract. “Behavioral effects of caffeine and other methylxanthines on children.” Experimental and clinical psychopharmacology. February 1998. Vol. 6 No. 1. Pages 87-95. 19. Berstein GA, Carroll ME, Crosby RD, Perwien AR, Go FS, Benowitz NL. Abstract. “Caffeine effects on learning, performance, and anxiety in normal schoolage children.” Journal of the American Academy of Child and Adolescent Psychiatry. March-April 1994. Vol. 33 No. 3. Pages 407-415. 20. Davis RE, Osorio I. Abstract. “Childhood caffeine tic syndrome.” Pediatrics. June 1998. Vol. 101 No. 6. Page E4. 21. Caballero T, Garcia-Ara C, Pascual C, Diaz-Pena JM, Ojeda A. Abstract. “Urticaria induced by caffeine.” Journal of investigational allergology & clinical immunology : official organ of the International Association of Asthmology (INTERASMA) and Sociedad Latinoamericana de Alergia e Inmunología. May-June 1993. Vol. 3 No. 3. Pages 160-162. 22. Gavin, ML, ed. “Caffeine and your Child.” 2005 January. Available at http://www.kidshealth.org/parent/ nutrition_fit/nutrition/caffeine.html. Accessed on January 29, 2007. 23. Young WG. Abstract. “Tooth wear: diet analysis and advice.” Int Dent J. 2005 April. Vol. 55. No. 2. Pages 68-72. 24. Kendler KS, Schmitt E, Aggen SH, Prescott CA. “Genetic and environmental influences on alcohol, caffeine, cannabis, and nicotine use from early adolescence to

Caffeine and Children

PPS Policy Statement

middle adulthood.” Archives of General Psychiatry. 2008 June. Vol. 65. No. 6. Pages 674-682. 25. Salazar-Martinez E, Willett WC, Ascherio A, Manson JE, Leitzmann MF, Stampfer MJ, Hu FB. “Coffee Consumption and Risk for Type 2 Diabetes Mellitus.” Annals of Internal Medicine. 2004. Vol. 140. Pages 18. 26. Larsson SC, Wolk A. Abstract. “Coffee consumption and risk of liver cancer: a meta-analysis.”

27.

28.

29.

30.

Gastroenterology. May 2007. Vol. 132 No. 5. Pages 1740-1745. Epub 24 March 2007. Nazario B., ed. “Coffee: The New Health Food?” WedMD. Available at http://www.somalibantu.com/ Health%20Coffee.htm. Accessed on June 8, 2005. Higdon JV, Frei B. Abstract. “Coffee and health: a review of recent human research.” Critical reviews in food science and nutrition. 2006. Vol. 46 No. 2. Health Canada. “Fact Sheet: Caffeine and Your Health.” Available at http://www.hc-sc.gc.ca/fn-an/securit/factsfaits/caf/caffeine_e.html. Accessed on May 11, 2007. Administrative Order No. 88-A s. 1984. “Regulatory Guidelines Concerning Food Additives.” Department of Health. Republic of the Philippines.

DISCLAIMER: The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.

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PPS Policy Statement

Caffeine and Children

APPENDIX Item Mountain Dew Coca-Cola, classic and Cherry Coke Light Pepsi 7-Up, Sprite, Diet Sprite Brewed coffee (drip method) Instant coffee Decaffeinated brewed coffee Decaffeinated instant coffee Starbucks Coffee Grande Black tea Green tea Decaffeinated black tea Nestea Iced tea Dark chocolate Milk chocolate Cocoa beverage Chocolate milk beverage Amount of Item Amount of Caffeine 12 ounces 12 ounces 12 ounces 12 ounces 12 ounces 8 ounces 8 ounces 8 ounces 8 ounces 16 ounces 8 ounces 8 ounces 8 ounces 12 ounces 1 ounce 1 ounce 5 ounces 8 ounces 55.0 mg 34.0 mg 45.0 mg 37.0 mg 0 mg 135 mg* 95 mg* 5 mg* 3 mg* 259 mg 40-70 mg* 25-40 mg* 4 mg* 26 mg 20 mg* 6 mg* 4 mg* 5 mg*

* denotes average amount of caffeine. Adapted from www.kids.health.org and www.mayoclinic.com

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PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 5

Medical Certificate for School Entrants
Philippine Pediatric Society, Inc. Philippine School Health Officers Association Philippine Society of Pediatric Cardiology Department of Education
A medical certificate is required by most schools before a student is allowed admission. However, in the Philippines there is no standard protocol for the health assessment of a child entering school. This policy describes the benefits and limitations of such an examination as well as the elements required for a satisfactory medical certification of school – aged child. Keywords: medical certificate, school entrant medical exam URL: http://www.pps.org.ph/policy_statements/medical_certificate.pdf

BACKGROUND A school entrant is a child, adolescent, or young adult who is about to enter nursery, Grade 1 of elementary school, Grade 6 of middle school, first year of high school, or first year of college or a vocational course. In addition, a school entrant may be a transferee student regardless of the grade or year level he/she will be entering. Philippine situation Schools generally require that their students undergo a physical examination and medical evaluation upon enrollment. This medical certification indicates whether the child is fit to enroll or requires further evaluation. It is issued after a general health assessment by either the child’s primary care physician or the school physician. In the Philippines, there are no existing guidelines/protocols or laws mandating this. Not all private schools require such certification prior to admission. The pending Magna Carta of Students requires that school authorities endeavor to provide free annual physical checkups to students.1 International situation In the USA, schools also require what is known as a school entrant medical examination, school entry physical, or school

entry health assessment. The extent to which it is done and its coverage varies from state to state. The American Academy of Pediatrics (AAP) has endorsed the importance of comprehensive periodic health assessments. These are to be done beginning at 3 years of age with attention to school health issues. Several different types of routine health assessments are performed in US schools. These assessments include health screening (which is mandatory in many US schools), such as screening for vision, hearing, blood pressure, and scoliosis. Students with detected abnormalities are then referred to their medical homes for further assessment and possible treatment. Further actions and/or follow-up are conveyed to the school nurse for documentation purposes.2 Benefits The two main purposes of this medical evaluation is to identify the high-risk population in the student body and fulfill a public health service role. Furthermore, it allows the physician to fully examine and interview the child for any problems and be up-to-date with the child’s development. Physicians may also inquire about previous consultations with other physicians, and establish/enhance communication with the child and his/her parents. At the same time, it provides opportunities for parents to gain information, support, and advice. This way, any potential problems may be dealt with expediently.3

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PPS Policy Statement

Medical Certificate for School Entrants

Limitations There are issues, however, regarding the effectiveness and efficiency of a routine school entry medical examination. A metaanalysis was done of research conducted in the United Kingdom between 1962 and 1996 on the effectiveness and efficiency of the school entry medical examination. It revealed that the data gathered was inadequate and demonstrated the fragility of the evidence on which the school entry medical was based.4 In a study done of 425 low and middle-class school children from West Jerusalem, 84 % of the unknown conditions were diagnosed by the nurse either through screening or interview. The researchers recommended that health screening be performed by the nurses, the physicians’ examination be discontinued with respect to the routine health surveillance, and that a report on the health status of the child be requested from the child’s primary care physician. This would allow the school physicians’ to allocate time for health promotion and health education activities.5 The time allotted for the actual examination is also a limiting factor as the academic period of the students must be taken into consideration. Recommended elements The following are the recommended elements of the medical interview and physical examination prior to issuing a medical certificate: The medical interview 1. Medical history – attention to physical, emotional, or family problems that might influence school achievement, previous participation in preschool experiences, new medical problems, medications 2. Immunization status – dates of previous, updating as necessary 3. Language, social, and adaptive development – changes in child’s developmental and psychosocial status, update on school progress and problems The physical examination (should be age appropriate and performed by a physician) 1. Height and weight 2. Blood pressure and heart rate 3. Teeth, gums, tongue, and throat 4. Reflexes 5. Eyes (to include vision), ears (to include hearing), nose, and skin 6. Heart, lungs, and abdomen 7. Fine-motor development, such as the ability to pick up small objects or tie shoes 8. Gross-motor development, such as the ability to walk, climb stairs or jump 9. Spinal alignment for signs of curvature (scoliosis) 10. Genitalia, confirming a normal level of maturation and checking for hernia, infection and other possible problems

RECOMMENDATIONS Roles of the National Government 1. The national government should mandate general health assessments for school entrants as recommended by medical authorities and other stakeholders. Roles of Local Governments 1. Local governments should support schools that require general health assessments from their school entrants through local ordinances/laws facilitating collaboration with local health personnel and facilities. Roles of the Schools 1. A standardized format of the medical interview and examination should be agreed upon by all schools that require a medical certificate for their school entrants. 2. Schools should provide medical access for students, either through a school physician, pediatrician, or other qualified primary care physician, that will allow them to obtain a medical certificate. Roles of the Physician 1. The physician who is tasked to interview, examine, screen, and counsel the child should examine her/him individually rather than in groups to protect confidentiality and the child’s sense of modesty.2 2. A potential health problem that is detected may be referred to the patient’s primary care physician for management/co-management or to appropriate specialists, if necessary, with proper notification of the child’s parents. 3. The physician should ensure that adequate time is allotted to medical evaluations. Roles of the Parents 1. Parents should consent to medical evaluations that are necessary prior to a medical certification.2 2. Parents should be present when these medical evaluations are done. 2 3. Parents should ensure that adequate time for such medical evaluations will be available for the physician.

Document prepared by the Committee on Policy Statements Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao, MD Members: Nerissa Dando, MD; Joselyn Eusebio, MD; Edilberto Garcia, Jr., MD; Ramon Severino MD Advisers: Joel Elises, MD; Salvacion Gatchalian, MD; Genesis Rivera, MD; Jocelyn Yambao-Franco, MD Research Associates: Maria Theresa H. Santos, MD; Gloria Nenita V. Velasco, MD

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Medical Certificate for School Entrants

PPS Policy Statement

EXPERT REVIEWERS Private School Health Officers’ Association, Inc. Ma. Consuelo Z. Garcia, MD, DPACCD (Immediate Past President) Philippine Ambulatory Pediatric Association Cecilia O. Gan, MD Round Table Discussion Participants

The committee would like to acknowledge the following for their contribution: Philippine School Health Officers’ Association – Dolores Sepacio, RN Philippine Society of Pediatric Cardiology – Della GonzalesPelaez, MD Department of Education – Ma. Corazon Dumlao, MD (Chief, Health Division)

REFERENCES 16 November 2009 Alexander O. Tuazon, MD Philippine School Health Officers’ Association - Consuelo Z. Garcia, MD Child Neurology Society Philippines, Inc. - Marissa Lukban, MD Philippine Ambulatory Pediatric Association - Cecilia Gan, MD Philippine Society of Pediatric Cardiology - Ma. Bernadette A. Azcueta, MD 29 November 2007 Philippine School Health Officers’ Association - Consuelo Z. Garcia, MD Child Neurology Society Philippines, Inc. - Susan Andong, MD Philippine Ambulatory Pediatric Association - Cecilia Gan, MD 1. 2. Senate Bill No. 138. An Act Providing for a Magna Carta for Students. 14th Congress. House of Representatives. American Academy of Pediatrics Policy Statement. School Health Assessments. Committee on School Health. Pediatrics Vol. 105 No. 4 April 2000. Pp.875-7. Child Health Assessments . Available at http:// www.communityindicators.net.au/metadata_items/ child_health_assessments. Accessed on 25 September 2007. Barlow J, Stewart-Brown S, Fletcher J. Abstract. Systematic review of the school entry medical examination. Arch Dis Child April 1998. Vol. 78. Pp. 301311. Gofin R, Palti H, Benson A. Abstract. The Health Status of School Children and the Effectiveness of the School Medical Entrance Examination. The European Journal of Public Health. 1991. Vol. 1 No. 2. Pp. 61-64. School age physicals: what to know before you go. Mayo Clinic. Last updated 1 August 2006. Available at www.mayoclinic.com. Accessed on 23 September 2007.

3.

4.

5.

6. ACKNOWLEDGEMENTS

DISCLAIMER: The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.

25

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PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 6

Pre-Operative Evaluation in Pediatric Patients Undergoing Surgery and other Major Therapeutic or Diagnostic Procedures
Philippine Pediatric Society, Inc. Philippine Society for Pediatric Cardiology Child Neurology Society of the Philippines Philippine Society for Pediatric Anesthesia Philippine Society of Pediatric Surgeons
Abstract. Surgical procedures are always accompanied by risks and complications. To minimize these, the patient must be evaluated pre – operatively through accurate and adequate history taking, and physical and laboratory examinations. This policy statement discusses the risks involved in pediatric surgery and the components and guidelines for preoperative evaluation in the pediatric population. Keywords: pre-operative evaluation, medical history, physical examination, laboratory tests, patient education URL: http://www.pps.org.ph/policy_statements/pre-operative_evaluation.pdf

BACKGROUND With the rapid advancements in technology, surgical procedures have become safer, more sophisticated, and less invasive. Anesthetic procedures have also been improved and streamlined. Surgical morbidity and mortality have decreased. However, despite all these advances, the risks and complications of surgery still can not be eliminated, they can only be minimized. Pre – operative risk assessment and evaluation is the major methodology in minimizing surgical complications. Pre – operative evaluation is a must for almost all surgical procedures and medical testing requiring anesthesia. 1 It is required for all patients undergoing a diagnostic or therapeutic procedure regardless of the setting except in the following cases: (1) Healthy patients requiring nerve blocks, local or topical anesthesia and/or no more than 50% nitrogen oxide, oxygen and no other sedative or analgesic agents, and (2) Patients receiving sedation analgesia or conscious sedation.2 It is commonly believed that the greatest risk in adult surgery is cardiovascular complications, whereas for the pediatric population, the greatest risks are pulmonary and airway complications. However, cardiac conditions together with coagulopathy, anemia, pregnancy and reactions to anesthesia may increase the risk in the pediatric population and must also be given due consideration. In

the general population, cardiovascular risk factors still account for the greatest fraction of operative and post – operative risk and, therefore, necessitate evaluation during surgery. 2,3 Patients at high risk usually fall into two categories: . those at increased risk for cardiovascular complications and those at increased risk for non – cardiovascular complications as given in Appendix A.2 The pre – operative evaluation has several components: history taking, physical examination and laboratory examination, and patient education. Medical History. The patient history is the most important component of the pre – operative evaluation.4 History taking is more difficult in the pediatric population than in adults, as one must rely on the reports and accounts of parents and/or guardians, together with other caregivers, pediatricians and neonatologists2, 5. Nevertheless, accurate history must be obtained which directs the physician as to what laboratory examinations are needed. In the medical history, the indication for the surgical procedure must be elicited as well as allergies and intolerances to medications, anesthesia or other agents; known medical problems and their current status; surgical history; current medications; immunization history; family history and a focused review of each of the following: cardiac, pulmonary, functional and hemostatic (or hematologic) status and the possibility of severe anemia.2, 4, 5

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PPS Policy Statement

Pre-Operative Evaluation in Pediatric Patients

Physical Examination includes obtaining the patient’s anthropometrics, such as height and weight. The patient’s vital signs including the blood pressure, heart or pulse rate and respiratory rate must also be obtained. For the pediatric population, it is imperative that both pulse and respiratory rates be taken for a full minute during sleep or during a quiet moment. A complete and thorough examination of the major body systems must be done, with emphasis on the head and neck, cardiac, pulmonary, gastrointestinal and extremities.2,5 Laboratory Examinations. Abnormal findings elicited from the medical history and physical examination may necessitate further evaluation and laboratory examination to optimize surgery and patient care. Such abnormal findings include the presence of asthma or frequent upper and/or lower respiratory tract infections in children and chest pain or elevated blood pressure in adults. The required laboratory examinations for pre – operative clearance is contentious. There are varying opinions as to what is necessary and what is not. The Institute for Clinical Systems Improvement (ICSI) states that most laboratory examinations including hemoglobin, potassium, coagulation studies, chest X – rays and electrocardiograms (ECG) are not necessary with routine procedures unless a specific indication is present, and that ECGs, regardless of age, are not indicated for those having cataract surgery2. Specific indications for particular tests as recommended by ICSI are given in Appendix B. On the other hand, one author stated that routine hematocrit is of importance in infants less than 6 months old who are undergoing surgery due to an increased incidence of unrecognized anemia which is a risk factor for perioperative apnea and cardiac arrest6. In the Philippines, there are no consensus nor guidelines on the laboratory examinations needed in the pre – operative risk assessment. Most physicians order laboratory examinations based on the routine practices in their institutions. The working group for this policy statement recommends the following laboratory examinations to be done routinely when obtaining pre – operative clearance in the pediatric population: complete blood count with hematocrit, differential count and quantified platelet count as well as a chest X – ray (PA-Lateral). Patient education is essential to prepare the patients and their parents or caregivers for the operation and to ensure the compliance of the patient in the preoperative instructions. Patient education must be procedure-specific and must give a general orientation to the patients and their families of what is to happen and the possible risks and complications during surgery.2 Once the patient has been evaluated by a pediatrician, it is the pediatrician’s prerogative whether to order additional laboratory examinations or to refer the patient to a

corresponding specialist. Patients with existing problems or co-morbidities should have the pediatrician and a specialist on board and should be evaluated by both. At the end of the pre – operative evaluation, the pediatrician should indicate in the patient’s records the complete diagnosis and whether or not there is any contraindication to surgery. For patients undergoing high risk operations, further adjunctive evaluation may be necessary aside from the basic pre – operative risk assessment as above. Such high – risk procedures include cardiac procedures, aortic and other major vessel vascular procedures, peripheral arterial vascular procedures, pancreatic resection, major spinal and orthopedic surgery, intrathoracic, intraperitoneal, head and neck surgery and prolonged surgical procedures associated with large fluid shifts and or major blood loss.2,7 Adequate, appropriate, accurate and thorough pre – operative evaluation and clearance in the pediatric population have several advantages, including reduction of diagnostics performed without clear indication, decreased delay and cancellation of surgical procedures and most of all, decreased operative and post – operative morbidity and mortality.2,4

RECOMMENDATIONS Role of the Government 1. The government should facilitate the dissemination of information to all health facilities. Roles of the Attending Physician 1. The physician must be aware of the policy guideline prepared by the Philippine Pediatric Society on the preoperative evaluation of the pediatric population. 2. The physician must be updated on the risks and complications of the contemplated procedure. 3. The physician must inform the parents of the need for a pre – operative evaluation. 4. The physician must be responsible in explaining to the parents the various components of the evaluation process as well as the risks of the contemplated procedure. Role of the Pediatrician 1. The pediatrician must be aware and guided by the policy guidelines set by the Philippine Pediatric Society. Roles of Parents 1. The parents should inquire on the contemplated procedure, risks and possible complications of the operations that their child will be undergoing. 2. The parents should cooperate with the physicians in the pre – operative evaluation of the patient and should give truthful answers during the interview and history taking.

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Pre-Operative Evaluation in Pediatric Patients

PPS Policy Statement

Document prepared by the Committee on Policy Statements Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao, MD Members: Nerissa Dando, MD; Joselyn Eusebio, MD; Edilberto Garcia, Jr., MD; Ramon Severino MD Advisers: Joel Elises, MD; Salvacion Gatchalian, MD; Genesis Rivera, MD; Jocelyn Yambao-Franco, MD Research Associates: Maria Theresa H. Santos, MD; Gloria Nenita V. Velasco, MD

ACKNOWLEDGEMENTS The Committee on Policy Statements recognizes the contribution of the following: Philippine Society for Pediatric Cardiology Child Neurology Society of the Philippines Philippine Society for Pediatric Anesthesia Philippine Society of Pediatric Surgeons

REFERENCES EXPERT REVIEWERS 1. Philippine Society for Pediatric Cardiology Ma. Bernadette A. Azcueta, M.D. 2. Child Neurology Society of the Philippines Marissa Lukban, M.D. 3. Philippine Society for Pediatric Anesthesia Marichu Battad, M.D. Philippine Society of Pediatric Surgeons Delfin Cuajunco, M.D. 4. 5. Kelly MM and Adkins L. “Ingredients for a successful pediatric preoperative care process – Clinical Innovations.” AORN Journal. May 2003. Institute for Clinical Systems Improvement. “Preoperative evaluation.” Bloomington (MN): Institute for Clinical Systems Improvement. July 2006. Chopko, Michael. “Preoperative cardiac clearance for Non – cardiac surgery.” Available at http:// www.diagnosisheart.com/showarticle.php?articleid=365. Accessed on September 17, 2007. Hawes, D. “Integrated Preoperative Patient Care.” Ferrari LR. “Preoperative Evaluation of Pediatric Surgical Patients with Multisystem Considerations.” Anesthesia and Analgesia. Vol. 99. 2004. Pp. 1058 – 1069. Hollinger, I. “Current Trends in Pediatric Anesthesia.” The Mount Sinai Journal of Medicine.” Vol. 69, No. 1 and 2. January/March 2002. Pp. 51 – 54. Karnath, BM. “Preoperative Cardiac Risk Assessment.” American Family Physician. Vol. 66, No. 10. November 15, 2002. Pp. 1889 – 1896.

6.

7.

DISCLAIMER: The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provision of quality health care to children. The recommendations contained in this publication do not dictate an exclusive course of procedures to be followed but may be used as a springboard for the creation of additional policies. Furthermore, information contained in the policies is not intended to be used as substitute for the medical care and advice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach. All information is based on the current state of knowledge. Changes may be made in this publication at any time.

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Pre-Operative Evaluation in Pediatric Patients

APPENDIX A Cardiovascular • Unstable coronary syndromes o Recent* myocardial infarction (MI) o Unstable or severe angina * Recent can mean less than 30 days if post myocardial infarction cardiac risk stratification is completed and patient determined to be low-risk; 3 to 6 months if formal risk stratification not done. • • Decompensated congestive heart failure Significant arrhythmias o High grade atrioventricular block o Symptomatic ventricular arrhythmias in the presence of underlying heart disease o Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease Severe hypertension (diastolic over 110, systolic over 180) Congenital heart abnormalities in pediatric patients

• • •

Non-Cardiovascular • Pulmonary disease, severe or symptomatic (e.g., chronic obstructive pulmonary disease requiring oxygen, respiratory distress at rest, asthma, cystic fibrosis, etc.) • Poorly controlled symptomatic diabetes (causing symptoms with attendant risk of hypovolemia) • Symptomatic anemia

APPENDIX B Test ECG Consider performing if: No ECG within last year in patients (regardless of age) with history of diabetes, hypertension, chest pain, congestive heart failure, smoking, peripheral vascular disease, inability to exercise, or morbid obesity. At time of preoperative evaluation, testing should occur in patients with any intercurrent cardiovascular symptoms or with signs and symptoms of new or unstable cardiac disease. Patient has a known history of coagulation abnormalities or recent history suggesting coagulation problems or on anticoagulants. Patient needs anticoagulation post-operatively (where a baseline may be needed). Patient has a history of anemia or history suggesting recent blood loss or anemia. Patient is taking digoxin or diuretics. Patient has signs or symptoms suggesting new or unstable cardiopulmonary disease.

Coagulation Studies

Hemoglobin Potassium Chest X-Ray

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PHILIPPINE PEDIATRIC SOCIETY, INC.
A Specialty Society of the Philippine Medical Association In the Service of the Filipino Child

PPS Policy Statements

Series 2009 Vol. 1 No. 7

Sports Clearance
Philippine Pediatric Society, Inc. Philippine Society of Pediatric Cardiology

Children are encouraged to engage in sports and reap its multiple benefits. However, there are instances when this involvement could lead to more harm than good. A sports clearance achieves many goals and may be used to detect life-threatening health conditions, determine readiness for sports participation and as a venue for counseling, among others. Though it has limitations, a sports clearance by qualified medical personnel is nonetheless recommended by the Philippine Pediatric Society, Inc. for all children who are about to engage in sports. Keywords: sports clearance, preparticipation physical evaluation, athletic screening, sports participation URL: http://www.pps.org.ph/policy_statements/sports_clearance.pdf

BACKGROUND Participation in sports on a regular basis allows a child to reap the multiple benefits of physical activity.1-4 The possible physical benefits include improved motor skills, endurance, cardiovascular fitness, muscular strength, lean body mass, and peak bone mass.1,2,3,5,6 It also has social, psychological, and behavioral benefits as well.2,4,5 It may serve as an adjunct therapy for obesity, diabetes, and asthma.7-12 With all its benefits, it is but natural that we encourage our children to engage in sports. Sports participation is even supported by the state as embodied in Article XIV Section 19 of the 1987 Philippine Constitution, “ … [the] State shall promote physical education and encourage sports programs, league competitions, and amateur sports, including training for international competition, to foster self-discipline, teamwork, and excellence for the development of a healthy and alert citizenry.”13 Sports clearance, more commonly known as a preparticipation physical evaluation or athletic screening, is often asked of an individual who will indulge in sports activities. It is a medical evaluation that includes a record of the patient’s medical history (i.e. personal and family history of cardiovascular diseases, history of neurologic and musculoskeletal problems, medications and substance abuse history) and a limited physical examination.14. It is usually

conducted by non-medical or medical personnel prior to sports participation but may be done at interim periods for athletes.4, 15 At present, there is no consensus document that is in use as to when this should be done and who are authorized to conduct the examination. The following are the objectives of a preparticipation physical evaluation: 1. To detect medical or musculoskeletal conditions that may predispose the child to injury or illness during sports activities; To detect potentially life-threatening or disabling medical or musculoskeletal conditions that may limit a child’s safe participation in sports; To determine the general health of the child; To assess the fitness level of the child and his/her appropriateness for a specific sport; and To counsel and educate the child on health related issues, e.g. the use of gateway drugs, unhealthy sexual practices, and psychosocial issues.

2.

3. 4. 5.

A good sports clearance allows the physician to detect an underlying medical problem that may aggravate or increase the risk of injury with sports participation.16 There are medical conditions, usually cardiac in origin, which require special attention because of their associated potential risk for sudden

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Sports Clearance

death. These conditions include hypertrophic cardiomyopathy, coronary artery abnormalities, and increased cardiac mass. Other less common causes include myocarditis, Marfan syndrome, mitral valve prolapse, dysrhythmias, aortic stenosis, Wolff-Parkinson-White syndrome, idiopathic long QT syndrome, arrhythmogenic right ventricular dysplasia, cocaine and anabolic steroid use, bulimia, anorexia nervosa, bronchospasm, and heat-related illness. 18-20 Of these, hypertrophic cardiomyopathy is the leading cause of sportsrelated sudden death in the United States. In the United States and United Kingdom, the incidence of sudden death has been estimated to be 1 in 50,000 to 67,000, occurring mostly in adolescent athletes.21 For the majority of chronic health conditions, however, current evidence supports the participation of children and adolescents in most athletic activities, but their physical condition and progress should be monitored.17 Musculoskeletal conditions may predispose the child to further injury16 if these are not properly recognized. The physician should investigate any old injuries and inquire into their rehabilitation.4,16,22 Possible overuse injuries, e.g. tendinitis, apophysitis, stress fractures, and injuries to epiphyseal growth centers may also be investigated.23 The evaluation may also allow the physician to develop a sound professional relationship with the child and his/her parents. This will allow the following: 1. The child and parents to raise concerns, ask questions, and discuss any issues that may affect the child (e.g. nutrition, substance abuse, pregnancy prevention); The physician to provide counseling that is relevant to sports participation (e.g. risks of injuries, use of protective equipment, risk of heat stress) and to his/her development (e.g. readiness to join sport, sexual maturation, psychosocial development); and For continuing care of the child all throughout and even after his/her sports participation.4,16,17,23-26

successfully identified; other cardiac causes of sudden death were not.29 Furthermore, not all potentially lethal conditions can be detected by a medical history and physical examination. Although the history is recommended as the most practical means of detecting a potentially lethal medical condition, its specificity for detecting cardiovascular abnormalities is low. In addition, asymptomatic patients with cardiovascular problems but with a noncontributory family history may yield unremarkable medical histories. Similarly, not all conditions may be detected during the physical examination.15,18 There is yet no consensus document or protocol in clearing a patient for sports participation, though it is being advocated by many agencies. In the United States, there are those that are comprehensive even by medical standards and those that are inadequate.15 In the Philippines, no study has yet been done and no recommendations have been made on athletic screening, preparticipation physical evaluation or sports clearance. The American Heart Association has published recommendations regarding cardiovascular preparticipation screening of competitive athletes for health professionals in 1996. For the cardiovascular history, the following have been recommended for inclusion: 1. 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; Past detection of a heart murmur or increased systemic blood pressure; and Family history of premature death (sudden or otherwise), or significant disability from cardiovascular disease in close relative(s) younger than 50 years old or specific knowledge of the occurrence of certain conditions (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan syndrome, or clinically important arrhythmias…

2. 3.

2.

3.

There are those, however, who question the usefulness of a sports clearance, i.e. whether the clearance can significantly save lives by preventing sudden death. 27 In a study done by Epstein and Maron in the United States, “[it] was estimated that 200,000 children and adolescents would have to be screened to detect 1,000 athletes who are at risk for sudden death and one person who would actually die.”18 On the other hand, in an Italian study wherein the incidence of mortality among athletes was observed over a period of two decades, there was note of a declining incidence of sudden death that paralleled the implementation of a preparticipation medical clearance required for all athletes.28 The limitation of this study was that only hypertrophic cardiomyopathy was

The cardiovascular physical examination should emphasize (but not be necessarily limited to): 1. Precordial auscultation in both the supine and standing positions to identify, in particular, heart murmurs consistent with dynamic left ventricular outflow obstruction; Assessment of the femoral artery pulses to exclude coarctation of the aorta; Recognition of the physical stigmata of Marfan syndrome; and Brachial blood pressure measurement in the sitting position.15

2. 3. 4.

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Likewise, there is no worldwide consensus on whether or not diagnostics, like electrocardiography or echocardiography, are

Sports Clearance

PPS Policy Statement

to be routinely included in the examination. In Europe, a Study Group of the European Society of Cardiology in 2005 recommended the use of electrocardiography in combination with medical history and physical examination in a sports clearance. 28 In the United States, electrocardiography, echocardiography, or exercise stress testing are not considered to be cost-effective and have yet to be recommended as screening measures by the American Heart Association.15.18 In 1997, a Preparticipation Physical Evaluation Task Force composed of several medical societies in the United States published a second edition of guidelines for physicians who perform preparticipation physical evaluations.18 The need for a screening protocol, however, is recognized and generally advocated.15,28 Sports clearances are done in the Philippines; however, majority may be the kind of medical clearance that is similar to what is required for employment. Of the numerous amateur and professional athletic groups, how many require sports clearances for their athletes? For a child who is interested in sports and has yet to participate, will he/she undergo such a clearance? Who conducts these examinations in the country? Are the medical clearances conducted adequate? Do we subject all those who undergo a sports clearance to electrocardiography and other diagnostics immediately? These questions have yet to be answered.

RECOMMENDATIONS Children and adolescents who may or may not be athletes are referred to as children in the following recommendations. Roles of Government 1. The government should mandate that all children should undergo a sports clearance prior to sports participation. 2. The government should mandate that sports clearances be conducted only by qualified medical personnel. 3. The government should mandate that all medical personnel with an interest to clear children for sports participation must undergo training or certification to do so. Roles of Hospital Administrators 1. Hospital administrators should certify that medical personnel who conduct sports clearances be qualified to clear children for sports participation. 2. Hospital administrators should establish training and certification programs for medical personnel who are interested in performing sports clearances on children. Roles of Physicians 1. Physicians who clear children for sports participation should undergo proper training and acquire certification

that would license them to perform a sports clearance. Physicians must include in the medical history of a child undergoing a sports clearance the following points: (1) 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; (2) past detection of a heart murmur or increased systemic blood pressure; and (3) family history of premature death (sudden or otherwise), or significant disability from cardiovascular disease in close relative(s) younger than 50 years old or specific knowledge of the occurrence of certain conditions (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan syndrome, or clinically important arrhythmias).15 3. Physicians must include in the physical examination of a child undergoing a sports clearance the following systems: (1) precordial auscultation in both the supine and standing positions to identify, in particular, heart murmurs consistent with dynamic left ventricular outflow obstruction; (2) assessment of the femoral artery pulses to exclude coarctation of the aorta; (3) recognition of the physical stigmata of Marfan syndrome; and (4) brachial blood pressure measurement in the sitting position.15 4. If a physician detects an abnormality or raises suspicion on history-taking or physical examination, he/she must refer the child immediately to and coordinate with a qualified specialist (e.g. sports medicine specialist, orthopedic surgeon, cardiologist, physiatrist, etc.) for further evaluation of the child. 5. A p h y s i c i a n w h o c l e a r s a c h i l d f o r s p o r t s participation must coordinate with the child’s primary physician to assure continuing care. If the child is without a primary physician, the physician who conducted the sports clearance must assume the role of primary physician. 6. A physician who clears a child for sports participation must endorse his/her patient to another qualified physician if he/she will be unable to provide the child continuing care during the entire sports participation period. 2. Roles of Parents and Caregivers 1. Parents and caregivers should ensure that children interested in sports participation, or are active in sports (but have never had a sports clearance), be cleared by a qualified physician. 2. Parents and caregivers should ensure that physicians who conduct sports clearances have undergone the proper training and have been certified. 3. If the physician raises suspicion after conducting a sports clearance, the parents and caregivers should ensure that the necessary work-up (e.g. consultation with a specialist, diagnostic examinations) is done.

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Sports Clearance

4.

5.

Regardless of the results of the sports clearance, the parents and caregivers’ decision-making should be directed by what would be in the child’s best interest, i.e. possible non-participation in sports. If the parents and caregivers decide to go against medical advise of non-participation in sports, they and the child must be made aware of the risks of sports participation to the child’s physical health. The parents and caregivers must also sign a waiver that they acknowledge the risks and possible lethal consequences of sports participation (if applicable) and are willing to take those risks.

Private School Health Officers Association REFERENCES 1. Watts K, Jones TW, Davis EA, Green D. Exercise training in obese children and adolescents: current concepts [online]. Sports Med. 2005; 35(5): 375-92. Available at http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlu s&list_uids=15896088&query_hl=6&itool=pubmed_ docsum. Accessed October 27, 2006. Boreham C, Riddoch C. The physical activity, fitness and health of children. J Sports Sci. 2001Dec; 19(12):915-29. Available at http:// www.ncbi.nlm.nih.gov/entrez/ query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlu s&list_uids=11820686&query_hl=8&itool=pubmed_ docsum. Accessed October 27, 2006. Miller TD, Balady GJ, Fletcher GF. Exercise and its role in the prevention and rehabilitation of cardiovascular disease. Ann Behav Med. 1997 Summer; 19(3): 220-9. Available at http://www.ncbi.nlm.nih.gov/ e n t r e z / query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract Plus&list_uids=9603697&query_hl=13&itool= pubmed_DocSum. Accessed October 27, 2006. Metzl JD. Pediatric Sports Medicine: The Changing Role of the Pediatrician. Available at http:// www.medscape.com/viewarticle/420202?src=search. Accessed on July 21, 2004. American Academy of Child and Adolescent Psychiatry. Children and Sports. Updated on January 2002. No. 61. Available at http://www.aacap.org/publications/ factsfam/sports.htm. Accessed July 6, 2004. American Academy of Pediatrics Policy Statement. Physical Fitness and Activity in Schools. Committee on Sports Medicine and Fitness and Committee on School Health. Pediatrics Vol. 105 No. 5 May 2000. Available at http://aappolicy.aappublications.org/cgi/ content/full/pediatrics;105/5/1156. Accessed on October 27, 2006. Reinehr T, de Sousa G, Wabitsch M. Changes of cardiovascular risk factors in obese children effects of inpatient and outpatient interventions. J Pediatr Gastroenterol Nutr. 2006 Oct; 43(4): 433-5. Available at http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract Plus&list_uids=17033527&query_hl=15&itool= pubmed_docsum. Accessed on October 27, 2006. Steinbeck KS. The importance of physical activity in the prevention of overweight and obesity in childhood: a review and an opinion. Obes Rev. 2001 May; 2(2): 117-30. Available at http://www.ncbi.nlm.nih.gov/ e n t r e z / query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus& list_uids=12119663&query_hl=17&itool=pubmed_ docsum. Accessed October 27, 2006. Nicklas T, Johnson R. Position of the American Dietetic Association: Dietary guidance for healthy children ages

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Document prepared by the Committee on Policy Statements Chairperson: Carmencita D. Padilla, MD, MAHPS Co-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao, MD Members: Nerissa Dando, MD; Joselyn Eusebio, MD; Edilberto Garcia, Jr., MD; Ramon Severino MD Advisers: Joel Elises, MD; Salvacion Gatchalian, MD; Genesis Rivera, MD; Jocelyn Yambao-Franco, MD Research Associates: Maria Theresa H. Santos, MD; Gloria Nenita V. Velasco, MD

3.

4. PANEL OF EXPERT REVIEWERS Philippine Center for Sports Medicine Raul C. Canlas, MD Philippine Society for Pediatric Cardiology Jonas del Rosario, MD Pediatric Orthopaedic Society of the Philippines Teresita L. Altre, MD, FPOA PPS School Committee Cynthia Cuayo-Juico, MD 7. Private School Health Officers Association Dolores Sepacio, RN 5.

6.

ACKNOWLEDGEMENTS The Committee on Policy Statements recognizes the contribution of the following: Philippine Center for Sports Medicine Philippine Society for Pediatric Cardiology Pediatric Orthopaedic Society of the Philippines PPS School Committee 8.

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PPS Policy Statement

2 to 11 years. J Am Diet Assoc. 2004 Apr; 104(4): 660-77. Available at http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi?CMD=search&DB=pubmed. Accessed October 27, 2006. 10. Riddell MC, Iscoe KE. Physical activity, sport, and pediatric diabetes. Pediatr Diabetes. 2006 Feb; 7(1): 60-70. Available at http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus& list_uids=16489976&query_hl=20&itool=pubmed_ docsum. Accessed October 27, 2006. 11. Welsh L, Kemp JG, Roberts RG. Effects of physical conditioning on children and adolescents with asthma. Sports Med. 2005; 35(2): 127-41. Available at http:// www.ncbi.nlm.nih.gov/entrez/ query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus &list_uids=15707377&query_hl=22&itool=pubmed_ docsum. Accessed October 27, 2006. 12. Weisgerber MC, Guill M, Weisgerber JM, Butler H. Benefits of swimming in asthma: effect of a session of swimming lessons on symptoms and PFTs with review of the literature. J Asthma. 2003; 40(5): 453-64. Available at http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi? CMD=search&DB=pubmed. Accessed October 27, 2006. 13. Philippine Sports Commission. Sport Laws. Available at http://www.psc.gov.ph/psc_sportlaws.htm. Accessed 11-14-05 14. Kurowski K and S Chandran. The Preparticipation Athletic Evaluation. Available at http://www.aafp.org/ afp/20000501/2683.html. Accessed on November 6, 2006. 15. American Heart Association. Cardiovascular Preparticipation Screening of Competitive Athletes. Available at http://www.americanheart.org/presenter. jhtml?identifier=1478. Accessed on November 7, 2006. 16. McKeag DB and RE Sallis. Editorials: Factors at Play in the Athletic Preparticipation Exam. Available at http://www.aapf.org/afp/20000501/editorials.html. Accessed on November 6, 2006. 17. American Academy of Pediatrics Policy Statement: Medical Conditions Affecting Sports Participation. Committee on Sports Medicine and Fitness. Pediatrics Vol. 107 No. 5 May 2001, pp. 1205-1209. Available at http://aappolicy.aappublications.org/cgi/content/full/ pediatrics;107/5/1205. Accessed on October 5, 2006. 18. Lyznicki, JM, NH Nielsen, JF Schneider. Cardiovascular Screening of Student Athletes. Available at http://www.aafp.org/afp/20000815/765.html. Accessed on November 6, 2006. 19. American Academy of Pediatrics Policy Statement. Cardiac Dysrhythmias and Sports. Committee on Sports Medicine and Fitness. Pediatrics Vol. 95 No. 5 May 1995. Available at http://aappolicy.aappublications.org/

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28.

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Sports Clearance

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29. Staff Writer, Medscape CRM. Sports Activity Triggers – But Does Not Cause – Sudden Death in Athletes Predisposed to Ventricular Arrhythmias. February 19, 2004. Available at http://www.medscape.com/ viewarticle/469572?src=search. Accessed on July 21, 2004.

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