opinion Children & Diving — Recommendations & Considerations

Text by Konstantinos Alexiou less powerful stature compared to narrower and more horizontal than Photos courtesy of Hj. Syed Abd adults. Their lack of strength and later in life. By the age of 12, the Rahman of Kids Scuba Malaysia endurance has an impact on their Eustachian tubes develop into their ability to cope with the heavy and adult-like form, making equalization Is it safe? When are young bulky diving gear while kitting up of the in the middle ear too young? The topic of chil- prior to the dive and when swim- easier and more effective. However, ming underwater. Children have a normal Eustachian tube function dren and diving has been larger ratio of surface area to body does not guarantee that a young and will remain controversial mass; therefore, they are more diver will reliably perform a Valsalva and highly emotional. The prone than adults are to heat loss in manoeuvre. [1, 4]. following article intends to cold environments. Increased drop One of the most common medi- in their core (hypo- cal conditions in childhood is asth- provide a review of current thermia) may occur in underwater ma. This serious lung disorder has recommendations regarding activities because of the high ther- reached epidemic proportions to medical issues and fitness as mal conductivity of the water [4]. children and it is a major concern— well as important considera- and long subject of controversy— Physiological differences. Children within the diving community [1]. tions related to the involve- are under physical and physiologi- There is an argument that asthma ment of children in under- cal development; simply put, they may put a child at an increased risk water activities. are still growing. of pulmonary and other Their growth plates (epiphyseal life-threatening complications. As The participation of children in plates) are active until the late Mitchell [3] suggests, children with a underwater activities is not some- teens or early 20s where the epiphy- history of asthma should refrain from thing new. It started growing in the ses “close” and bone elongation diving activities until puberty. mid-1980s. For many years now, stops. At an age when children are the Confédération Mondiale des It has been suggested that inert eligible for an Open Water div- Activités Subaquatiques (CMAS) gas bubbles tend to form in the ing course, they should have their and the Professional Association of epiphyseal tissue causing decom- medical fitness re-evaluated by a Diving Instructors (PADI) have intro- pression illness (DCI). Such an injury dive physician. Similar attention is duced formal training programmes to the epiphyses may impair the required when a child suffers from and guidelines for teaching children process of bone growth. According hay fever, since this illness may as young as eight [5]. Today, PADI to Dr [4], it is not wise predispose them to aural and sinus alone certifies more than 10,000 to draw any solid conclusion regard- barotrauma. young divers per year between the ing this theory, as there is insufficient ages of 10-14 [1]. evidence and no clinical reports of Psychological differences. Medical apparent epiphyseal damage dur- and physiological factors are vital How children differ from ing . factors and need to be thoroughly adults Another concern is the equaliza- considered before a child attends a Physical differences. Children are tion. Up until the age of around diving course. usually of smaller size and have a eight, the Eustachian tubes are However, psychological and Children in Malaysia take part in PADI Seal Team course offered by Kids Scuba near Kuala Lumpur

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Children practice underwater skills, guided by an instructor, in a PADI Seal Team course with Kids Scuba near Kuala LumpurK behavioral issues are also impor- ing with this issue. Therefore, DAN of a total of 705 cases. tant. They determine how a child concluded, “any recommenda- will learn and gain skills, as well as tions made would be based on • Susceptibility to toxicity: the quality of their social interac- theoretical considerations taking Clinical experience suggests no tion and emotional development. into account what is known about particular difference in susceptibil- Sometimes, physical growth does normal growth and development, ity of children down to age eight not equate with emotional matu- and the empirical evidence that to either pulmonary or Central rity. Psychosocial and cognitive exists where children younger than Nervous System (CNS) oxygen tox- factors need to be accessed dur- 12 have scuba dived”. icity. ing the child’s dive training pro- cess [3]. Main issues to be addressed by • Epiphyseal damage due to DCI: DAN [7] are: There is no published evidence Medical statement suggesting that the physis , or (DAN) con- • Evidence of increased inci- growth plate in bones, is more ducted a search of 4,600 biomedi- dence of Patent Foramen Ovale susceptible to decompression cal journals going back to 1966 in (PFO) in children: One study was sickness (DCS) in children com- an attempt to locate studies on made on the age distribution of pared to adults. Depth and time how the physiological differences PFO. They found an increased restrictions should be imposed by between adults and otherwise incidence of PFO in the 10- to training organizations to increase healthy children alter the child’s 20-year-old group compared safety. capability and risks associated to other groups. However, this with diving. The Medline data- incidence was based only on six • Susceptibility to pulmonary baro- base revealed no papers deal- cases (three with existing PFO) out trauma: Children at the age of

46 X-RAY MAG : 68 : 2015 EDITORIAL FEATURES TRAVEL NEWS WRECKS EQUIPMENT BOOKS SCIENCE & ECOLOGY TECH EDUCATION PROFILES PHOTO & VIDEO PORTFOLIO Children enjoy learning about with Hj. Syed Abd Rahman, founder and PADI Master Scuba opinion Diver Trainer of Kids Scuba Malyasia, one of the world’s largest children’s diving clubs and winner of the PADI Youth Diver Education Award (right); Children practice diving skills in the pool during a PADI Seal Team course with Kids Scuba near Kuala Lumpur (below). For more information, visit: www.kidsscuba.com eight or younger are at a theoreti- • Susceptibility to ear baro- emboli (VGE) and DCS: No pub- cal increased risk of pulmonary trauma: Due to the physiological lished data on the post-dive VGE barotrauma, because their pul- characteristics of the Eustachian incidence and DCS occurrence monary alveoli are still multiplying, tubes in children (see above), in children compared to adults is pulmonary elasticity is increased, ear infections and barotraumas available. In addition, if children and chest wall compliance are common in diving based on get DCS, the severity level of their increased. It is strongly recom- a study conducted by Dr Guy injury compared to adults had mended that children younger Vandenhoven [6]. not been ascertained. Depth and than eight should not scuba dive. time restrictions should be intro- • Exposure to cold environment: duced by training organizations • Are children more likely to have As previously noted, children will to enhance safety. an asthma episode while diving? cool faster in the water. They Cold conditions, physical exer- should not become hypothermic • Physical ability to cope with tion, salt-water aspiration, and underwater. Proper thermal pro- emergencies: As mentioned due to an asthma attack tection and hydration before, dur- before, children have less strength when underwater are risk factors. ing and after diving minimize the and stamina than adults do. In However, there is no sufficient evi- likelihood of . addition, they present with char- dence to accept or reject these acteristic behavioral responses, hypotheses. • Susceptibility to venous gas including evidence of anxiety or panic. However, appropri- high-risk . Most of these otolaryngological issues during ents, doctors and diving instruc- ate human factor studies deaths were accidental in nature the course and the dives, all with tors show common sense and have not been carried out. and theoretically could be avoid- complete recovery. extreme caution.  able if diving was conducted Epidemiology of div- safely [2]. Conclusion REFERENCES: ing incidents/acci- CMAS has run youth diving Children’s physical, physiological, [1] BRYLSKE A: THE NEXT GENERATION: WHAT YOU NEED TO KNOW ABOUT KID DIVERS. IN: THE COMPLETE DIVER: THE dents in youths programs for years and now pathophysiological and psycho- HISTORY, SCIENCE AND PRACTICE OF SCUBA DIVING. DIVE DAN collected data on has records of close to a million logical characteristics influence TRAINING LLC, UNITED STATES, 2012. P. 155-161. 1,248 diving fatalities exposures without serious injury. their performance during diving. [2] CARUSO JL, UGUCCIONI DM, ELLIS JE, DOVENBARGER JA, BENNETT PB. DIVING FATALITIES INVOLVING CHILDREN AND for the years 1989-2002. In addition, PADI issued 122,298 In light of this fact, children should ADOLESCENTS: 1989-2002. UNDERSEA AND HYPERB MED. 2004; Twenty-four (1.9 percent) Junior Open Water (JOW) certifi- not be considered as small adults. 31(3): 329. deaths involved divers 17 cations between 1988 and 1998, It is essential that education and [3] CVITANOVICH A, LANGTON P: CHILDREN AND DIVING: A years of age or younger and is aware of only one fatal training must be focused and PAEDIATRIC PERSPECTIVE. SPUMS J 2003; 33: 74-75. (range 10-17). Every case accident involving a JOW diver adapted to the individual child. [4] MITCHELL S: CHILDREN IN DIVING: HOW YOUNG IS TOO was determined to be [4]. As the number of children YOUNG? SPUMS J 2003; 33: 81-83. an accidental death. Finally, Vandenhoven [6] et below the age of 12 increases, [5] RICHARDSON D: CHILDREN AND DIVING: THE RECREATION- and/or air embo- al., conducted a study of 234 more empirical and clinical data AL-DIVING TRAINING PERSPECTIVE. SPUMS J 2003; 33: 83-89. lism was the cause of children divers (ages 6-13) with will be gathered and our under- [6] VANDENHOVEN G, COLLARD F, SCHAMP E: CHILDREN AND DIVING: MEDICAL ASPECTS. EIGHT YEARS’ SPORTS MEDICAL death in the vast majority a follow-up of eight years. They standing of children’s capacity FOLLOW-UP OF THE FIRST SCUBA DIVING CLUB FOR CHILDREN of mishaps. It is important did not record any significant during diving will further increase. IN BELGIUM. SPUMS J 2003; 33: 70-73. to note that several of the incident in 2,216 dives in the sea Children and scuba diving is a [7] DAN MEDICAL STAFF: YOUNG DIVERS. HTTP://WWW.DANAP. ORG/DAN_DIVING_SAFETY/DAN_DOC/PDFS/YOUNG2.PDF young divers lacked formal and recorded only one case of controversial topic where there is [ACCESSED 02/06/2015] diving training and many hypoxic syncope during breath- no absolute truth. This magnifies died while performing a hold diving and some other minor even more the need that par-

47 X-RAY MAG : 68 : 2015 EDITORIAL FEATURES TRAVEL NEWS WRECKS EQUIPMENT BOOKS SCIENCE & ECOLOGY TECH EDUCATION PROFILES PHOTO & VIDEO PORTFOLIO THIS PAGE: Scenes from Kids Scuba “A Day Photos courtesy of Hj. Syed Abd for Sharing” in Kuala news Rahman and Kids Scuba Malaysia Lumpur, Malaysia

Edited by Catherine Kids Scuba Holds Day for Sharing GS Lim The “A Day for Sharing” pool pro- Tioman at the end of gram ended with a group photo session March 2015. and the presentation of certificates. During the open Participating children and teenagers water component of also received backpacks full of basic school necessities, while the teachers and coordinators PADI Master Scuba Diver Trainer and founder from each home were present- of Kids Scuba, Hj. Syed Abd Rahman, talks with ed with gifts for their orphan- children about diving and the marine environ- ages, courtesy of Kids Scuba. ment (above); Rahman with four boys gradu- After the course, four orphan ating with Open Water Certifications (left inset); Day for Sharing participants (below) boys aged 18 to 21 were selected for a special program: the Zero to Hero program by was followed by boat dives to Soyak PADI, which gives participants and Renggis Islands in the Tioman Island training from the open water Marine Park, assisted by divermaster course to certi- Khairul Azizi. fication level. As part of this At the end of the 3-day and 2-night intensive program, there were dive trip, the final evening saw the boys weekly confined water sessions graduate with their PADI Open Water in the pool, in which the boys— certificates and receive their tempo- Fadhel, Shakir Ashraff, Daniel rary certification cards after successfully the course, the boys dived with the Kids completing the PADI Scuba team and B & J Diving Center, course. The boys’ next dive trip was con- a PADI 5-Star, IDC center in Kg Salang ducted at Tenggol Island in Terengganu on Tioman. The boys took part in shore where they continued their training in the and jetty dives at the Salang Jetty. This Advanced Open Water Course.  Every spring, Kids Scuba, a PADI swimming and snorkelling skills, as 5-star in Malaysia, well as an opportunity to discover the thrills of scuba diving. hosts an event to share the PADI Master Scuba Diver Trainer underwater experience with and founder of Kids Scuba, Hj. children and teenagers from Syed Abd Rahman, started the orphanages in Kuala Lumpur. day off by introducing the Kids Scuba Team and instructors to the The event was held this year at participants and teachers attend- the Maybank Training Academy ing the program. Everyone was swimming pool in Bangi, about then treated to a local breakfast, 30 minutes from Kuala Lumpur. before the participants were divid- ed into four groups. During the four-hour program, Kids Scuba hosted 46 underprivileged the four groups were rotated amongst and Kamal—were trained by the Kids kids and teenagers from two orphanage the activities, so everyone had a chance Scuba team under the direct supervi- homes for a one-day pool experience to learn and enjoy all the different skills. sion of Hj. Syed Abd Rahman. Then, with entitled “A Day for Sharing”. Included in During lunch, there were lots of smiling PADI’s support, the boys sat and com- the Discover Scuba program was educa- faces as participants shared their under- pleted their knowledge review, quiz and tion about the marine environment, basic water experiences with each other. exam before going on their island trip to

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