HUMAN REPRODUCTIVE CLONING

 Cloning---refers to natural or induced production of a genetically identical molecule (including

DNA), cell, tissue, plant or animal
 3 Types:
o Gene cloning
o Therapeutic cloning
o Reproductive cloning
 GENE cloning
o recombinant DNA technology
o molecular / DNA cloning
o transferring DNA fragment from one organism to a self-replicating genetic element
such as bacterial plasmid
 THERAPEUTIC cloning
o biomedical cloning
o sourcing stem cells from the embryo
o -->>to produce tissues or organ-->>transplant back into individual
o embryo expires in the process
 REPRODUCTIVE cloning
o "somatic cell nuclear transfer"
o embryo deliberately allowed to develop to maturity
o the chromosomal/nuclear DNA identical to donor but mitochondrial DNA is that of
enucleated egg
 PPS is in support of the worldwide BAN of human reproductive cloning

ORPHAN DISORDERS
 heterogenous group of disorders that have not been prioritized for research and development
of diagnostic and therapeutic modalities
 conditions are rare genetic and/or metabolic disorders including tropical diseases
 conditions affecting <1000 / million people. (WHO)
 conditions affecting 1 in 20,000 individuals (PHIL)
 most are disorders of genetic origin, affect metabolic functions, life threatening and
chronically debilitating
  ORPHAN DRUGS
Drug Disease treated
laronidase mucopolysacharidosis I
idursulfase mucopolusaccharidosis II
galsulfase mucopolysaccharidosis VI
nelarabine T-ALL
sodium phenylacetate and benzoate urea cycle enzyme def.
nitisinon tyrosinemia
imiglucerase gauchers disease

 Philippine Society for Orphan Disorders

OBESITY

risk for overweight: BMI between the 85th and 95th percentile for age and gender
overweight: BMI at or above the 95th percentile for age and gender
Weight for length is usually used in the under 2 year age group

Severely overweight, associated with:

 pseudotumor cerebri
 slipped capital femoral epiphysis
 steatohepatitis
 cholelithiasis
 sleep apnea
Overweight:
 metabolic consqeunces:
o insulin resistance
o elevated blood lipids
o increased blood pressure
o impaired glucose tolerance
 long-term risk: diabetes & heart disease
*Most significant morbidity for overweight: pyschosocial

High risk IGT or Type 2 DM:

1. Fam hx of type 2 DM
2. Metabolic syndrome after 10yrs
*High-risk IGT or T2DM, consider OGTT

Labs to identify co-morbidities of obesity

 thyroid functions
 lipid profile
 complete chemistries
 hepatic profile
 fasting glucose and insulin
 (OGTT)
 serum or urinary cortisol

*Recommendation: preventive measures

 Breastfeeding--lower the risk of future obesity
o mechanisms:
1. self-regulation of energy intake
2. metabolic programming in early life
3. inherent properties of breast milk
o Metabolic programming:
 formula: higher plasma insulin--> stimulate fat deposition--> dev. adipocytes
 breastmilk: bioactive factors-->modulate epidermal growth,TNF-->inhibit
adipocytes
*DECS Memorandum No 373: "encouraging the sale and consumption of healthy and nutritious
foods in schools"
*Introduce vegetables and fruits at 6 months
* Healthy food options: adequate calories but low in saturated fat, low salt, low simple sugar

CHILD LABOR
 Most in: 5-14 yrs age group
 Physical environment hazards---most common hazardous environment
--- temperature or humidity(most common)

 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
 ILO Convention No. 182: different worst forms of child labor; policies for elimination of child
labor
 Republic Act (RA) 9231, more popularly known as the “Anti- Child Labor Law" RA 7610:
o elimination of worst forms of child labor
o stronger protection for the working child
o Following salient features:
1. prohibits engagement of child in worst forms of labor
2. working hours of a working child below 15 and 15 but below 18
3. ownership, usage and admin of working child's income
4. setting up of trust fund
5. penalties against acts of child labor
6. prosecution of child labor
 WORST FORMS of child labor:
1. all forms of slavery: "anti-trafficking in persons act of 2003"
2. prostitution, pornography
3. illegal activities/illicit activities
4. hazardous or harmful to health, safety or morals

 Phil: minimum employable age: 15 years

 <15 years old, not permit to work, but exceptions:
1. 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) & child
can go to school and her or his life, safety, health, morals and development are not
endangered;
2. child’s employment or participation in public entertainment or information through
cinema, theater, radio or television is essential.
 Child of any age, prohibited from performing for advertisements that promote alcohol, tobacco
& violence
 <15yrs
o not allowed to work more than 4 hours per day,
o Not more than 5 days per week.

 15 and 18 y
o work in non-hazardous circumstances,
o not more than 8 hours per day
o not more than 40 hours per week
 Child's Income: Not >20% child’s income for the collective needs of the family
 Trust fund: at least 30% of earnings
 Penalties: RA 9231: holds parents liable in case of violations
 Penalties:
o P10.000-100,000
o Community service: 1month-1yr
*max length of community service if violated provisions 3x.
  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.
 Philippine Program Against Child Labor: flagship program for combating worst forms of child
labor

WALKERS
 delay motor and mental development
 contractures of calf muscles
 prone to accidents: falls, burns, poisoning, submersions, suffocation, death
 Speed: up to 3 feet/sec
 Walker width: >36 inches (width of ave door)

CAFFEINE:
 most widely consumed psychoactive substance
 xanthine derivative
 action on the cerebral cortex and brainstem
 effects are dose related
o 100-200 mg:
 increase alertness and wakefulness,
 promote faster and clearer flow of thought
 better general body coordination
 Loss of fine motor control and result in dizziness
 500-600 mg
 restlessness, anxiety, irritability, muscle tremors,
 sleeplessness, headaches, nausea, diarrhea or other gastrointestinal
 Abnormal heart rhythms

 stimulates the heart, dilates vessels, bronchial relaxation, increases gastric acid production
 metabolic effects: releasing fatty acids from adipose tissue, increase urination-->dehydration
 Caffeine poisoning:
o very tense muscles alternating w/ overly relaxed muscles
o rapid, deep breathing
o nausea &/or vomiting
o rapid heartbeat
o shock
o tremors
 Medications that interact negatively w/ caffeine:
o Ciprofloxacin: increase length of caffeine time in body
o Theophylline: increase in conc when taken w/ caffeine
 Beneficial Effects:
o Reduce risk: parkinson's, Type 2 DM, Colon CA, liver cirrhosis, Hepatocell CA,
gallstones
 o enhance endurance & performance
o help manage asthma & headache
ocontain antioxidants (chlorogenic acid and tocopherols) & minerals (Mg) that improve
insulin sensitivity and glucose metabolism
o trigonelline (in coffee): anti-bacterial and anti-adhesive, prevents dental caries
MAX INTAKE caffeine
Children:
4-6 years 45mg/day
7-9 years 62.5mg/day
10-12 years 85mg/day

 recommended intake: 2.5 mg/kg/day

 phil: caffeine max level 200ppm
 Labeling should include:
o Caffeine is habit forming, may cause increase in heart rate, insomia
o Not recommended for children
o Contraindicated in children with medical conditions
o Consult your doctors on safety of caffeine in children

Item Amount of Item Amount of Caffeine

Mountain Dew 12 ounces 55.0 mg
Coca-Cola (classic , cherry) 12 ounces 34mg
Coke Light 12 ounces 45
Pepsi 12 ounces 37
7-up, sprite, diet sprite 12 ounces 0
Brewed coffee (drip method) 8 ounces 135mg
Instant coffee 8 ounces 95mg
Decaffeinated brewed coffee 8 ounces 5mg
Decaffeinated instant coffee 8 ounces 3 mg
Starbucks Coffee grande 16 ounces 259mg
Black tea 8 ounces 40-70mg
Green tea 8 ounces 25-40mg
Decaffeinated black tea 8 ounces 4mg
Nestea iced tea 12 ounces 26mg
Dark chocolate 1 ounce 20mg
Milk chocolate 1 ounce 6mg
Cocoa beverage 5 ounces 4mg
Chocolate milk beverage 8 ounces 5mg

MEDICAL CERTIFICATE FOR SCHOOL ENTRANTS

 Medical certification: indicates whether the child is fit to enroll or requires further evaluation
 AAP: importance of periodic health assessments, done beginning at 3 years of age
 Purpose of Medical Evaluation:
1. identify high risk population in student body
2. fulfill a public health service role
 Recommended elements of:
 Medical interview:
o medical history
o immunization status
 o language, social and adaptive development
 Physical examination:
o ht & wt
o BP, HR
o teeth, gums, tongue, throat
o reflexes
o eyes, ears, nose, skin
o heart, lungs, abdomen
o fine motor devt
o gross motor devt
o spinal alignment (scoliosis)
o genitalia, hernia

PRE-OPERATIVE EVALUATION:
 all patients undergoing a diagnostic or therapeutic procedure regardless of the setting except:
(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
(2) Patients receiving sedation analgesia or conscious sedation

 greatest risk in pediatric surgery: pulmonary and airway complications

 Pre-operative evaluation components:
o History
o Physical exam
o Laboratory exam
o Education
Medical history:
* most important component of pre – operative evaluation
* includes:
- indication for surgery
- allergies
- medical problems (asthma or frequent upper and/or lower respiratory tract infections)
- prev surgery
- medications
- immunization
- family hx
- cardiac, pulmonary, functional and hematologic status, possibility of severe anemia

PE
* anthropometrics: height & weight
* vital signs: blood pressure, heart or pulse rate and respiratory rate
(HR & RR: full minute during sleep or during a quiet moment
* major body system exam, emphasis: head and neck, cardiac, pulmonary, gastrointestinal and
extremities

LABS:
Hct: infants < 6 months old
 due to increased incidence of unrecognized anemia, risk factor for perioperative apnea
and cardiac arrest
Recommendation: pre – operative clearance pedia, done ROUTINELY:
1. CBC (w/ hct,diff count, plt)
2. Chest Xray (PA-Lateral)

CATEGORIES OF HIGH-RISK PX:

1.cardio 2.non-cardio

HIGH-RISK OPERATION:
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
prolonged surgical procedures associated with large fluid shifts and or major blood loss.

RISK FOR CV & NON-CV COMPLICATIONS:

Cardiovascular
 Congenital heart disease in pedia
Non-Cardiovascular
 Pulmo disease (severe or symptomatic)
 poorly controlled symptomatic diabetes
 symptomatic anemia

Consider performing if:

ECG 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
COAGULATION Patient has a known history of coagulation abnormalities or recent history
STUDIES suggesting coagulation problems or on anticoagulants. Patient needs
anticoagulation post-operatively (where a baseline is needed)
HEMOGLOBIN Patient has a history of anemia or history suggesting recent blood loss or anemia.
POTASSIUM Patient is taking digoxin or diuretics
CXR Patient has signs or symptoms suggesting new or unstable cardiopulmonary
disease.

SPORTS CLEARANCE
Medical conditions associated with potential risk for sudden death:
 hypertrophic cardiomyopathy
 coronary artery abnormalities
 increased cardiac mass
  less common causes: myocarditis, Marfan, MVO, dysrhythmias, Aortic stenosis, WPW
syndrome, idiopathic long QT, arrhythmogenic right ventricular dysplasia, cocaine and
anabolic steroid use, bulimia, anorexia nervosa, bronchospasm, heat-related injuries

(AHA) recommendations in CV preparticipation screening of athletes

cardiovascular history, 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;
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.)

Cardio PE
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

FOLIC ACID.NEURAL TUBE DEFECT:

 Incidence: 1-5 per 1000 births
 6th most common birth defect
 Rate: 2.2 per 10,000 birth
 Female predominantly affected
 Recommend: 0.4mg (400 µg) folic acid daily
 Total: less than 1 mg daily
 Women w/ previous NTD preg:
4 mg (4000 µg) of folic acid daily at least (1 month prior conception until first 3 months of
pregnancy)
 Folate level determination:
* RBC folate levels: longer-term tissue stores
* serum or plasma folate levels: short-term dietary intake
 RA. No. 8976: "Philippine Food Fortification Act of 2000"
o RDA, food fortification introduction.
o Mandatory food fortification in country only covers: iron, vit.A and iodine.

BACKPACKS
 Backpack >10-20% wt increase risk low back pain.
 Increase risk for female and young child.
 Recommendation:
o Backpack wt must not be >10% of child total body wt
o Use both straps
o Backpack never 4 inches below waistline
 Injuries related:
o back pain
 o spinal disease, deformities
 vertebral subluxation
 osteroarthritis
 spondylosis
 disc herniation
 postural misalignments
o skin and muscle blood flow impingement: 2-3x grater than threshold for reduced blood
flow
o balance problems
o Pulmonary

PACIFIERS AND CHILDREN

 sucking activity greatest occurence 0-18 months
 Pacifiers
o most common non-nutritive sucking (NNS) materials
o made of latex or silicon
o contain: phthalate, nitrosamine
 Recommendations:
o manufacture:
 (+) ventilation holes
 flanges: min horizontal and vertical diameter of 43mm
 (+) rings attached to flanges for removal if aspirated
o NOT use for analgesia in preterm neonates
o avoid at beginning of breastfeeding
o discontinue before 4 yrs old
o use orthodontic pacifiers
 Adverse effects:
1. Breastfeeding
o shorten duration
o poor development of latch-on technique
o less frequent breatfeeding
o diminished breast stimulation
o breast feeding failure
2. Dental and oral structures
o altered dental arches and oral myofunctional structures
o malocclusion
o open bite
o recommendation:
 orthodontic pacifiers
 discontinue before permanent incisors erupt: before 4 yrs old
3. Infections
o gastroenteritis
o respiratory tract infection
o otitis media
o oral candida
o latex--higher carriage C. albicans
4. Trauma obstruction
 o asphyxia

ENVIRONMENTAL NOISE
o noise emitted from all sources except industrial workplace
o safe level: <85 dB
o Street traffic ---most prevalent and most damaging source of noise
o noise:
o cars: 65-75 dB
o motorcycle: 72-83 dB
o guns: >120 dB
o rock concerts: 120 dB
o adverse effect
o change in morphology and physiology of organism that results in impairment of
functional capacity, impairment of capacity to compensate for additional stress or w/c
increases susceptibility to harmful effects of other environmental influences
o NON-auditory effects
 stress related to physio and behavior effects and safety
o AUDITORY effects
 acoustic trauma
 hearing impairment
o Hearing impairment:
o defined as increase in threshold of hearing
o characterized as ringing or buzzing sound in ear
o noise induced hearing loss occurs at higher frequencies first
o acoustic trauma: from short but extremely loud bursts of noise
o Annoyance---most common effect of noise on people
 used as gauge to measure and monitor community noise
o Sleep disturbance
o >50 noise events/ night w/ max level of 50 dBA

OCCUPATIONAL NOISE
 noise in the workplace
 continuous noise: sound level peaks are ≤1 second apart
impulsive noise: steep rise to high peak then rapid decay or peaks have intervals >1 second
 WHO:
continuous noise: 80-85dB for max 8 hrs
impulsive noise: 140 dB at any 1 exposure
 Transient threshold shifts
o change in hearing threshold of an average of 10db at 2000-4000Hz in either ear
o initially only high frequencies (3000-16,000Hz) are affected
 Methods to minimize noise:
o engineering control
o administrative and work practice control
o personal hearing protection
 Philippines: permissible noise level: 90 dB for 8 hr period

RECREATIONAL NOISE
  noise derived from leisure activities
 portable music player sound is too loud when:
o set higher than 60% of maximum
o cannot hear conversation around
o people can hear one's music
o find onself shouting
 60% / 30 minutes rule for music player
 IPOD:
time limit volume
no time limit 0-50%
18 hrs 60%
4.6hrs 70%
<18 mins (supraural earphones) full
5 mins (stock earphones) full
3 mins (isolator) full

o no time limit: 0-50% volume

o 18 hrs: 60% volume
o 4.6hrs: 70% volume
o

FETAL AND NEONATAL NOISE

 max average day-night sound level
o waking hrs: 55 dB , night time: 45 dB
o hospital: daytime: 45 dB, night time: 35 dB
 23-26th week of life fetus can perceive, store and react to auditory information
 higher frequency hearing develops later therefore more vulnerable
 cochlea000target organ of noise
 > 85-90dB noise to pregnant women assctd w/
o birth defects
o low birth wt
o IUGR
o prematurity
o SGA
o antepartum fetal death
o atypical brain devt
o high frequency hearing loss
FIREWORKS RELATED INJURIES
 legal to use:
o baby rocket
o bawang
o small triangle
o pulling of strings
o paper caps
o el diablo
o Judah's belt
o sky rocket
o sparklers
o luces
o fountains
o jumbo reular and special
 o mabuhay
o roman candle
o tropillo
o airwolf
o whistle device
o butterfly
 Campaigns:
 Oplan Iwas Paputok
 Oplan Torotot
 FOURmula Kontra paputok
1. better use pots, pans and horns
2. never pick up firecrackers that fail to explode
3. immediately wash wounds with soap and water
4. never fire guns

DENTAL CARIES--FLOURIDE
early dental caries: (≤71months old): decay,missing,filled tooth surface
Severe early dental caries: (3-5yrs):
≥ 1 decayed,missing,filled tooth in anterior maxillary teeth or
Decay,missing,filled tooth score: ≥ 4 (age 3), ≥ 5 (age 4), ≥ 6 (age 5)

Tootpaste:
≤ 3: smear
3-6: half pea size
>6: pea size

Fluoride varnish: 500mcg/ml every 6 months

MEDIA
* 8 years old are developmentally unable to understand the difference between advertising and
regular programming

DRINKING WATER
Groundwater----- substantial source of municipal water
Chlorination--------most effective means for the disinfection of public water supply

RETINOPATHY OF PREMATURITY
 ROP-->>
o Refractive errors
o Amblyopia
o Strabismus
o Blindness (due to retinal detachment)
 Retina--thin layer tissue covering back of eye
 Retinal vascular devt: 15-18 weeks AOG
 Retinal vessel devt begin at optic nerve-->>periphery
  Vessel reach
o nasal ora serrata by 3rd trimester
o temporal periphery by 40 weeks
 Stressors temp arrest devt-->>ischemia, avascular periph
o Resumes at 30-34 weeks gestation
o primitive vessels continue devt w/o forward progress
o -->> ridge (grows in depth and height)
 may regress w/ resumption of normal growth (indicate regression of ROP)
o alternately, may have abnormal growth-->>
o fibrovascular tissue in vitreous cavity
 VEGF (vascular endothelial growth factor)
 stimulated by hypoxia and ischemia
 PLUS DISEASE
o inflammation of eye with retinal vessel engorgement and tortuosity of posterior pole
vessels
o may resolve w/o intervention
o may lead to vessel contraction & scar formation-->>
o macular displacement
o always precedes partial or complete retinal detachment
 3 components to determine extent of disease
o Zone
o Stage
o (+)/(-) plus disease
 ZONE
Zone 1 most posterior area (2x distance frm optic nerve head to fovea
Zone 2 outside zone 1
Zone 3 temporal side

 STAGE
Stage 1 demarcation line separate avascular atneriorly from vascular posteriorly
Stage 2 intraretinal ridge: demarcation line increased in volume
Stage 3 ridge w/ extra-retinal fibrovascular proliferation
Stage 4 partial retinal detachment
Stage 5 Total retinal detachment

 Prematurity---primary risk for developing ROP

 Severity of ROP and prematurity directly proportional
 < 28 weeks AOG---greatest risk of developing ROP
 Treatment
o Cryotherapy
 prevent further progress disease by destroying cells that release angiogenic
factors
o Laser phtocoagulation
 destroy cells that lead to diseae progression
o Retinal reattachment
 Complications
 1. MYOPIA---occurs in 80% infants w/ ROP
2. STRABISMUS (crossed eyes) --23-47%
3. AMBLYOPIA (lazy eyes)
4. decrease visual acuity, macular ectopia (displaced ocular muscles), nystagmus, retinal
breaks, cataract, microcornea, angle-closure glaucoma, macular degeneration
 NO Corrective lenses worn-->>
o visual field confined to 2-3inches
o delay fine motor development
 Eye patching--for strabismus and amblyopia
 RECOMMENDATION:
o ROP cause blindness and decreased visual acuity
o Pathogenesis:
1. initial disruption in aborization of the retinal vasculature
2. subsequent hyperproliferation of retinal vessels

o Risk factors ROP:

 low gestational age
 low birth weight
o Classification:
 Zone
 Stage
 +/- Plus disease

o Eye findings:
 Prethreshold ROP
 eye finding that are likely to progress rapidly to threshold ROP
 a. Zone I, Stage 1-2 w/o plus disease
 b. Zone II ROP with any:
o Stage 2 + PLUS disease
o Stage 3 - plus disease
o Stage 3 + PLUS disease but not extensive for ablative surgery
 Threshold ROP
 ROP in either
o Zone I or II involving
o 5 contiguous or 8 discontinuous clock hours of
o stage 3 (extraretinal)
o + PLUS disease
 basis for surgical intervention
 risk of 50% retinal detachment
o Screen:
 BW ≤1500g or 32 weeks
 between 1500-2000g with unstable course
 1st exam:
 4 weeks chronologic age or
 31-33st post conceptual age (AOG + Chron age)
 exam
 weekly for prethreshold ROP
 2 week interval less severe ROP in Zone II
  Zone III only involve---repeat 2-3weeks
o Treatment
 (+) Threshold ROP: tx w/n 72 hrs
 Surgical intervention:
 peripheral retinal ablation w/ cryotx or laser
 scleral buckling (repair ret. detachment)
 vitrectomy (release ret. traction)
o Follow-up:
 1 yr-----2 1/2 yr-----4 yrs old
REPRODUCTIVE HEALTH EDUCATION AMONG ADOLESCENT
 Sex education four primary goals
o 1. information,
o 2. attitudes, values, insights,
o 3. relationships and interpersonal skills,
o 4. responsibility
o Four distinct groups
 delayers--not anticipate having sex in next yr
 anticipators--anticipate sex in next yr
 singles--had one sexual partner
 multiples---2 or more partners
 Phil:
o Adolescent and Youth Health and Development Program
 increase knowledge and awareness on fertility, sexuality and sexual health to
80%
o Population Awareness and Sex Education (PASE)
 for the out of school youth
 address early marriage and unemployment of out of school youth
 Population Education (POPED) curriculum's Four general competencies:
1. appreciation of relationship bet parenthood & family soidarity and stability
2. valuing importance of gender equality essential to devt
3. accept reproductive health as human right
4. appreciate importance to maintain balance between and among
population, resources, environment, sustainable devt
 8 subjects integrate Sex Ed:
o Aralin panlipunan I
o Araling panlipunan II
o Filipino I
o English I
o English IV
o Science II
o Health education I
o Technology and livelihood education II

HOUSEHOLD PRODUCTS POISONING

 child poisoning commonly occur at home
 < 6 years old----- greatest risk for home poisoning due to their hand-to-mouth exploratory
activities.
 Products: kerosine, insecticides, rat killers, moth balls, bleaching agents
 Acid and alkali:
o most common non-accidental poisoning
o ready availability
o Acid:
 toilet bowl cleaner (hydrochloric acid)
 neutralizer (sulfuric acid, nitric acid)
 disinfectant (phenol)
o Alkali:
 all-purpose cleaner (sodium hydroxide)
 cuticle remover (potassium hydroxide)
 cold-wave preparations (thioglycolate salts)
 laundry cleaner and bleaching (sodium hypochlorite)
 fabric softener ( ammonium compounds)
 Household cleaning products
o Gastrointestinal symptoms: nausea, vomiting, diarrhea
o Death dose: 1-3grams
 Ingestion of ACIDs:
o Oral: burning pain in mouth/pharynx, salivation, hyperemic, edematous mucosa,
ulcerations buccal mucosa and pharynx
o ocular: mydriasis, hyperemic conjunctivae
o Gi: nausea, vomiting, abdominal pain, upper GI bleeding, abdominal rigidity,
pancreatitis
o Esophagus: hemorrhagic esophagitis, slough of mucosa
o stomach: ulcerations
o dermal: erythema, blisters, cutaneous purpura, bruising
o CNS: depression, drowsiness, weakness, coma, death
 Ingestion of ALKALI:
o dysphagia, odynophagia, spontaneous vomiting, abdominal pain, drooling,
erythema/ulceration of oropharynx, hematemesis, shock, respiratory distress
 #1: Household cleaning agents
o most common ingested poison in pediatric age group
o includes: chlorine, decalcifier, hydrochloric acid, sodium hypochlorite, phenol
 #2: hydrocarbon
o kerosene
o diesel
o lighter fluid
o paint thinner
 #3 Seeds
 Medications
o Ferrous sulfate
o Paracetamol
o Isoniazid
o Acetylsalicylic acid or aspirin
 0-1yr:
o #1 kerosene
o #2 sodium hypochlorite
 2-3yr:
 o kerosene
o watusi
 4-5,6-9,10-13:
o seeds
 14-16,17-19
o sodium hypochlorite
 Hydrocarbons ingested:
o pulmo: cough, gag, choke, aspiration pneumonitis, respi distress, pleural eff
o cardiac: myocardiac sensitization, dysrhythmias
o neuro: cns depression, behavior change, coma, siezures, neuropathy
o GI: nausea, vomit, hematemesis, ulceration
o hepatic: centrilobular necrosis
o renal: acute renal failure, distal tubular acidosis
o hema: DIC
o derma: folliculitis, cellulitis, abscess, fascitis
 Prevention
o child-resistant closures
o safer medications
 PGH Poison Center for Manila:
o 524-1078, 521-8450 loc 2311
o Information:
 child's condition
 name product and ingredient
 quantity taken
 time of poisonin
 contact info
 age child
 wt child
MEDICINAL POISONING
 < 6 yrs old ---mostly occurring
 Pain relievers----most common poison exposures in these children.(second to household
products)
 Most common: paracetamol, isoniazid, ferrous, aspirin
 Most of the essential drugs list are also poisons when in large doses
 OTC:
o analgesics, antipyretics--among the most common OTC
o antihistamines, decongestants, vitamins, cough syrups, cold remedies, mild cortisone
creams, GI meds
 ANALGESICS
o inhibit synthesis of prostaglandin in CNS and block peripheral pain impulse generation
 ANTI-PYRETIC
o inhibit hypothalamic heat-regulatory center
 PARACETAMOL
o analgesic and antipyretic
o weak anti-inflammatory
o rapid and almost complete absorbed from GI tract
o 90% metabolized by Liver
 (convert into sulfate/glucoronide)
 in <12yrs old: Sulfation--major pathway
o susceptibility to hepatotoxic effects includes
 age
 diet
 nutrition
 metabolic state
o Toxic dose: 150mg/kg
o most commonly used self-poisoning due to availability
o Acute paracetamol toxicity:
 Phase I (30mins to 24 hrs)
 nausea, malaise, pallor, vomiting, diaphoresis
 Phase II (24 - 72hrs)
 RUQ pain---hepatic damage
 Blood chem and Renal function--abnromal
 Phase III (72 - 96hrs)
 hepatic necrosis and encephalopahty
 coagulation defects, jaundice, renal failure, mycocardial pathology
 liver biopsy: centrilobular necrosis
 nausea, vomiting may reappear
 Death
o related to hepatic failure
o preceded by anuria and coma
 Phase IV (4days - 2 weeks)
 complete resolution
 NSAIDS (non-steroidal anti-inflammatory drugs)
o rapidly absorbed from GI tract
o Cross blood brain barrier
 o methyl salicylate: 1-2 tsp (5-10ml) can be lethal to child
o Earliest signs and symptoms:
 nausea, vomiting, diaphoresis, tinnitus
o CNS:
 deafness, vertigo, hallucinations, agitation, hyperactivity, delirium, stupor,
lethary, coma, cerebral edema, convulsions
o GI:
 nausea, vomiting, hemorrhagic gastritis, decreased motility, pylorospasm
o Hepatic
 abnormal liver enzymes, altered glucose metabolism
o Metabolic
 hyperthermia, hypo/hyperglycemia, hypoglycorrhachia, ketonemia, ketonuria
o Pulmonary
 hypernea, tachypnea, respiratory alkalosis, acute lung injury
o Renal
 tubular changes, proteinuria, NaCl and water retention, hypouricemia
 IRON
o Children's MV: 10-18mg elemental iron/tab
o Prenatal MV: 65mg elemental iron/tab
o Toxic dose: 10-20mg/kg elemental iron
o Five clinical stages toxicity:
 1st stage
 nausea, vomiting, abdominal pain, diarrhea
 hematemesis, melena, hematochezia
 2nd stage (6-24hrs)
 latent stage
 resolution GI sx
 before overt systemic toxicity
 3rd stage
 Shock stage
 hypovolemia, vasodilation, poor urine output, decreased tissue perfusion,
metabolic acidosis
 4th stage (2-3days)
 Hepatic failure
o uptake of iron by reticuloendothelial system in liver-->> oxidative
damage
o 5th stage (2-8weeks)
 Rare
 gastric outlet obstruction sec to strictures and scarring
 ISONIAZID
o ingest toxic amount-->>recurrent seizures,profound metabolic acidosis, coma, death
o toxic dose:
 30mg/kg --->> seizure
 80-150mg/kg--- fatal
o 1st S/Sx appear 30mins-2hrs:
 nausea, vomiting, slurred speech, dizziness, tachycardia and urinary retention--
>>
 stupor, coma, recurrent grand mal seizures
 o Seizures
 refractory to anticonvulsant tx
 pyridoxine (Vit B6)
 eliminate seizure
 correct metabolic acidosis
o suspect in px with refractory seizure and metabolic acidosis

WATUSI POISONING
 Watusi
o matchstick-like pyrotechinic device
o made of:
 yellow phosphorus
 potassium chlorate
 potassium nitrate
 trinitrotoluene
 S/Sx:
o Vomiting---almost always present in acute phosphorous poisoning
o Severe GI:
 burning throat pain
 garlic odor breath and exreta
 high suggest Phosphorus poisoning
 Shock-->> Death in 24-48hrs
 Tx:
o 4-6 egg whites
 prevent further absorption of phosphate
o Normal saline solution
o directed toward Ca and Vit K
o N-acetylcysteine
 correct anticipated liver injury
o Alkaline soap (Perla, ivory)
 for dermal exposure
 Manifestation:
o hypocalcemia, hypoprothrombinemia, metabolic acidosis, mucosal injury esophagus

LEAD
 elevated blood lead levels (BLL):
o ≥ 10mg/dL:
 1 venous blood specimen or
 2 capillary blood specimens w/n 12 hrs
 absorbed by ingestion or inhalation
 95% lead found in erythrocytes
o bringing lead to bones
 long after exposure lead poses threat by release of stored lead from bones
 neurotoxic damage
 Lead encephalopathy
o ≥ 70mg/dL
o lethargy, abdominal cramps, anorexia, irritability-->>
o vomiting, clumsiness, ataxia, alternate hyperirritability and stupor
 o coma and seizures

HEALTHY AND UNHEALTHY FOODS FOR SCHOOL CHILDREN

 Unhealthy food----too salty, sweet, oily or fatty
 Nonnutritious foods---not contribute to nutiretnst tat body needs
 Undernutrition has decreased while overweight has increased between the years
 Health and nutrition center under DepEd:
o planning
o policy formulation
o staff development
o research, monitoring and evaluation
o coordination
o Programs:
 School milk project
 Breakfast feeding program
 Teacher-child-parent approach
 Applied nutrition program
 Alay tanim at pangkabuhayan
o Revitalizing supplementary feeding as primary intervention to undernutrition among
school children
o Encouraging sale and consumption of healthy and nutritious foods in schools
 RENIs (Recommended energy and nutrient intakes
o energy, protein, calcium, phosphorus, iron, iodine, zinc, selenium, magnesium,
manganese, fluoride, vitamins A, B12, C, D, E, K, thiamin, riboflavin, niacin, folate,
pyridoxine, water and electorlytes (Na,K, Cl).
o desirable proportions of protein, fats and carbohydrates and fiber
SOFTDRINKS IN SCHOOL
 12 oz soda:
o 10 tsp sugar
o 150 calories
 risk for:
o Dental caries (due to sugar content)
 Enamel erosion (due to acidity)
 Dentin hypersensitivity (due to acidity)
o Obesity
 risk 1.6x each addtl can or glass soda
o Poor nutrient intake
 soda negative associated to achieve adequate:
 Vitamin A (in all age)
 Calcium (<12 yrs)
 Magnesium (≥ 6yrs)
 AAP: recommends elimination of sweetened drinks in schools
 Memorandum No. 372:
 o Revitalizing Supplementary Feeding as Primary Intervention to Undernutrition Among
School Children
 Main objective of school canteens: improve nutritional status of school children
by making safe, cheap but nutritious food available to them.
 Prohibits chips and soft drinks
 Memorandum No. 373:
o Encouraging the Sale and Consumption of Healthy and Nutritious Foods in Schools
 refrain from selling food and beverages that do not contribute to health and
nutritional well being of students
 encouraged to sell fresh fruits and vegetables, root crops and cereals, meat and
poutlry, milk/dairy products, soup and native delicacies

BREASTFEEDING
 Exclusive breastfeeding: fist 6months-->2 years (24months)
 Breast milk: supply essential amino acids for growth and protection
 Advantages
1. boost infant's host defense
- bioactive components-lysozymes, immunoglobulins, hormone and growth factors,
immune modulators, anti-inflammatory & cellular components
2. aid in GI function
- feeding-related problems (constipation, diarrhea, colic) minimized
3. protective against several disease
- reduces prevelance and morbidity of respi illness and infection
- protects from UTI, otitis media, bacteremia, bacterial meningitis, botulism, NEC
- lower risk for SIDS and IDDM (insulin-dependent DM)
4. maternal-infant bonding
5. long-term cognitive and motor abilities
6. Maternal benefits: less risk breast and endometrial cancers, inc. wt loss, lactational
amenorrhea
7. Costs
 Bottle feeding:
o inc. Otitis media, H. infulenza bacteremia and meningitis; death from diarrhea
 Contraindications
1. Galactosemia in infant
2. maternal illegal drug use
3. anti-neoplastic
4. radiopharmaceutials
5. active TB (relative CI)
- allowed after 2 weeks tx (during 2wks: BM via cup or dropper)
6. HIV infection (relative CI)
 BABY-FRIENDLY HOSPITAL INITIATIVE 1992:
Every facility that provides maternity services and care for newborns:
1. written breast feeding policy
2. train all health care staff in skills to implement policy
3. inform all pregnant women (benefits & management of breastfeeding)
4. initiate breastfeeding w/n half an hour of birth
5. show how to breastfeed & maintain lactation
6. no food or drink other than breast milk
 7. practice rooming-in
8. breastfeeding on demand
9. no artificial teats or pacifier
10. breastfeeding support groups
 Republic Act (RA) No. 7600
o "The Rooming-In and Breastfeeding Act of 1992"
o advantages of breastfeeding

BREASTFEEDING IN THE WORKPLACE

International Labor Organization(ILO):
 compulsory maternity leave 6 weeks after delivery
 entitlement to further 6 months leave
House Bill No. 6661
 Act Promoting Breastfeeding by Establishing and Maintaining Lactation Stations in
Workplaces for Working Mothers, Providing for Penalties for violation thereof and for other
purposes (Breastfeeding Promotion Act)
 Mandatory Lactation stations in workplaces w/ >10 employees
Must Include:
1. Private and comfortable room (comfortable seats)
2. Storage for milk (Sufficient: small refrigerator, coolers/small ice chest w/ cold packs or
thermos)
3. Sink for hand-washing and cleaning equipment

COMPONENTS OF WORKPLACE BREASTFEEDING SUPPORT PROGRAM

ADEQUATE EXPANDED COMPREHENSIVE
Facilities
1. multipurpose space w/ electrical 1. BMBR only by BF mom 1. BMBR close to women's worksites
outlet
2. own breast pump (c/o employee) 2. 1 multi-user electric breast pump 2. + collection kits, addtl elec pump
3. table and chair 3. improved aesthetics 3. large room for several users
4. Sink, soap, water, paper towels. 4. items near the BMBR 4. items in the BMBR
if very far, extra time for cleaning
5. cold packs (c/o employee) 5. refrigerator for food near BMBR 5. small ref for storage milk in BMBR
Written Company Policy
1. 6-week unpaid maternity leave 1. 12-week unpaid maternity leave1 1. 6-14 week paid maternity leave 2
2. creative use of vacation days, 2. + allow part-time, job sharing, 2. + can bring child to work or on-site
personal time, sick days, holiday pay individual sched work hrs, day care available.
after birth compressed work week,
3. allow 2 breaks & lunch period in telecommuting.
8-hr work day to express milk 3. expanded unpaid breaks 3. paid nursing breaks
Workplace Education
1. policy communicated to all preg 1. all receive training on BF support 1. offered to partners of employees
policy (fathers)
2. have list of community resources 2. lactation care provider contracted 2. lactation care provider coordinate
for BF support on as needed basis BF support program
BMBR: Breastfeeding Mothers' Break Room
1
FMLA-The Family and Medical Leave Act
2
ILO- International Labor Organization
SCREENING FOR INBORN ERRORS OF METABOLISM
  5 disorders Newborn screening:
1. phenylketonuria
2. congenital adrenal hyperplasia
3. congenital hyperthyroidism
4. galactosemia
5. glucose-6-phosphate dehydrogenase
 Administrative Order No.1-A (2000): "Policies on Nationwide implementation of Newborn
Screening:
o newborn screening by 2004, shall be a part of standard newborn care

NEONATAL HEARING SCREENING

 Incidence of congenital hearing impairment: 1-3 per 1000 (well baby)
 high-risk infants rate: 2-4 per 100
 Risk indicators:
NEONATES (birth - 28 days)
o illness or condition requiring 48hr at NICU
o findings assctd with a syndrome known to include sensorineural or conductive hearing
loss
o family hx of permanent childhood sensorineural hearing loss
o ear and craniofacial abnormalities
o in utero infections (Toxoplasmosis, rubella, CMV, herpes)
INFANTS (29 days - 2 years)
o parental/caregiver concern re: hearing, speech, language, devt delay
o family hx of permanent childhood hearing loss
o findings assctd w/ syndrome known to include sensorineural or conductive hearing
loss, or eustachian tube dysfunction
o postnatal infections assct w/ SNHL (eg. bacterial meningitis)
o in utero infections (Toxoplasmosis, rubella, CMV, herpes)
o neonatal indicators: hyperbilirubinemia (rqr exchange transfusion) PPHPN (ass w
mech vent) and conditions reqr extracorporeal membrane oxygenation
o syndromes asstd w/ progressive hearing loss (osteopetrosis, neurofibromatosis,
Usher's syndrome)
o Neurodegenerative disorders (Hunter's sydnrome, sensorimotor neuropathies--
charcot-marie-tooth syndrome, friedrichs ataxia
o head trauma
o otitis media w/ effusion (recurrent or persistent) at least 3 months
 Philippines: hearing impairment--3rd leading cause of disability (deaf, partially deaf or poor
hearing ability)
 Hearing impairment:
detection 3 months
intervention/habilitation 6 months
* shown to prevent or reduce consequences
 Hearing impairment associated with Deficits:
o language devt
o academic performance
o personal & social maladjustments
o emotional difficulties
 AAP and JCIH (joint committe on infant hearing) 2000 statement:
 o early detection of and intervention for infants with hearing loss through integrated,
interdisciplinary state and national systems of universal newborn hearing screening,
evaluation and family-centered intervention
 AAP's 5 essential elements to effective universal newborn hearing screening program:
1. screening
2. tracking & follow-up
3. identification
4. intervention
5. evaluation
o Screening aim to screen minimum of 95% of entire newborn population to be effective
o false positive rate: <3%
o false negative rate: 0
 Recommended method for physiologic hearing screening:
o (EOAE) evoked otoacoustic emissions
o (ABR) auditory brainstem response

BLINDNESS PREVENTION AND VISION SCREENING

 Blindness---inability to count fingers at 3 meters
 Leading etiology:
o corneal opacity (by measles)
o xerophthalmia
o traditional eye medicine
 Leading causes(Phil.):
o Poor nutrition
o Measles
o Premature Birth
 Vitamin A deficiency---leading cause of childhood blindness
 Vitamin A capsules given to:
o 9-11months old
o 12-59 months
o sick and malnourished children
 Sick: pneumonia, chronic diarrhea, measles
 Phil DOH: Vision 20/20 program (1999): attain blindness prevalence rate of 50%
 AAP: eye exam at birth and well child visits
o Newborn: ocular abnormalities (corneal opacity, congenital cataract, ptosis)
o High risk eye problems: premature, FHx congenital cataracts, retinoblastoma,
metabolic/genetic diseases, developmental/neuro abnormalities
o Earliest possible age for visual acuity measurement: 3 years old
 WHO: "Prevention of Blindness and Deafness Program 2000"
o reduce preventable blindness in rural and underserved communities thru workshops
and local training activities and cataract intervention
o Phil: "Prevention of Blindness Program (1991):
Main components:
 cataract program
 primary eye care
 Vitamin A deficiency prevention and control

CHILD SAFETY IN PRIVATE MOTOR VEHICLES

  5-15yrs old range: traffic crashes----3rd leading overall cause of mortality
 Phil: 10-14yrs old: motor vehicle crashes----3rd leading overall cause of mortality
 (Manila)Vehicular accidents:
o 3-4x/week
o peak frequency: 3:00pm
o 18% of childhood injury deaths
 Passenger cars safety features:
o anti-lock brakes: reduce incidence of wheel locking and skidding
o crumple zone: at front of car, absorbs most of the impack in a collision
o airbags: inflate during a crash
o side-impact beams: cushion the blow of a side impact
o head restraints: prevent head from snapping back in rear-end crash
 Land Transportation and Traffic Code (RA4136)
o rules and regulations, to prevent occurrence of traffic accidents
 Republic Act 8750: (Seat Belts Use Act of 1999)
o mandates installation & use of seatbelts in front and rear seats
o Child below 6 yrs, prohibited from occupying the front seat of any moving motor
vehicle
o not require use of specialized seats or restraints for young children
 AAP:
o specialized child seats required for children weighing 60lbs (8 yrs old)
o however, mandatory use of child seats in developing countries not affordable, feasible
and sustainable
 AAP: adolescent drivers characteristics to explain greater risk for vehicle crash:
o lack of driving experience
o risk-taking behavior due to emotions, peer group pressure, others
o use of alcohol and other drugs
o low rate of safety belt use
o lack of experience in night-time driving

CHILD SAFETY IN PUBLIC MOTOR VEHICLES

 RA 8750: Seatbelts use act of 1999

CHILD PEDESTRIAN INJURY PREVENTION

 Manila: pedestrian injury is 51% of all road injuries.
 18.9 M children walk to school each day.
 5-12yrs old: traffic accidents 2nd most common type of accident in children
  UNICEF Criteria Safety Measures:
o speed limits
o seat belts
o cycle helmet and cycle lanes
o marked pedestrian crossings
o lighting and visibility measures
o safety education
o action against drunk driving

CHILD HELMET USE

 Among all road injuries, hospitalization from motorcycle crashes rank 2nd (11%) to
pedestrian-to-vehicle injuries (51%)
 motorcycle injuries:
o 44% - bone fractures
o 41% - head injury
o 7% - joint dislocation
o 1% - limb amputation
 Road injuries:
o 1st: pedestrian-to-vehicle injuries (51%)
 o 2nd: motorcycle crashes (11%)
o 5th: bicycle injuries (3%)
 Injuries from bicycle crashes:
o Majority: soft-tissue and muscluoskeletal trauma
o Majority of fatality: Head injuries
 Helmet use
o works by dissipating the sharp energy of a blow over a larger surface area
o reduce occurrence of brain injury by 63-88%
o reduce facial injuries to upper and mid areas by 65%
o provide equal protection from motor vehicle crashes (69%) & all other causes (68%)
o in 0-15yr old grp:
 decrease risk of head injury by factor of 0.4 and
 risk of concussion by factor of 0.6
o Phil:
 helmet use is mandatory and violators are charged a fine
 no laws or regulations require children to wear helmets
o Parents NOT allow children below 9 years old to ride as passengers on motorcycles

DROWNING
 Drowning: LEADING CAUSE of CHILD INJURY DEATH in the Philippines
 24% of child injury mortality
 1-4 yrs old: accidents:(submersion, suffocation, foreign bodies) 7th overall cause of mortality
o rate: 5.93 deaths per 100,000
 5-9 yrs old: accidents:(submersion, suffocation, foreign bodies) 4th
 10-14 yrs old: accidents:(submersion, suffocation, foreign bodies) 4th
 Phil: world record for deaths at sea; world record for worst single tragedy at sea
 Phil: most disaster prone country in the world
o typhoons, tropical storms and floods--most common mode of disaster
 Drowning:
o 2nd rank in injury mortality for both sexes ( 1st= vehicular accidents)
o male and female deaths 12.5 and 8.2 per 100,000 respectively
o 0-4 yrs old: at home or open water in urban setting
o 5yrs & older: natural bodies of water and public pools
o 15-19yrs old: alcohol factor
 Phil:
o average age of commercial fishing boats: 20 years
o average age of mostly second-hand fleet passenger ferries: 10 years

BURN INJURY
 less than 5 yrs old: majority of burn injuries at home
 Burn: 5th leading cause of childhood mortality
 Scalding--leading mechanism of injury
 Fire-related injuries:
o DOH: "Oplan: Iwas Paputok"--yearly program to avoid fire-related injuries
o R.A. 7183--reuglate & control the manufacture, sale, distribution and use of
firecrackers