Policy Statement 2009

Pol icy

Statements

of the

Phi l ippine

Pediatr ic

Society, Inc.

Pol icy

Statements

of the

Phi l ippine

Pediatr ic

Society, Inc.

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

Obesity in Children and Adolescents

Child Labor

Infant WalkersCaffeine and ChildrenMedical Certificate for school EntrantsPre-Operative Evaluation in Pediatric PatientsUndergoing Surgery and other Major Therapeutic orDiagnostic Procedures

Sports Clearance

SERIES 2009 VOL. 1 ISSUE

1

7

13

17

23

27

31

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Message

The Philippine Pediatric Society, Inc., a Specialty Division of thePhilippine Medical Association, has its membership composed ofhardcore advocates of children. Its medical concerns are far beyonddiagnosis and treatment. Child welfare, protection of theenvironment, caring about the future, growing and enjoying lifeand living humanely are among the many concerns of Pediatricians.

Pediatricians, therefore, are the closest allies of children startingfrom conception until they have become adults. The childs earlylife must be remembered as blissful years of youth, though hestruggles 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 isthat Pediatrician.

The PPS, through its officers and members of the board of Trusteescommends this output of the committee headed by Dr. CarmencitaDavid Padilla on the series of Policy Statements. Short of being alegal document, this publication should be adopted as a doctrine ofreference for all child advocates.

Mabuhay ang Filipino.

Victor S. Doctor, MDPresident

Philippine Pediatric Society, Inc.

PPS Policy StatementsOFFICIAL PUBLICATION OF THE

PHILIPPINE PEDIATRIC SOCIETY,INC.Carmencita D. Padilla, MD, MAHPS

Editor-in-Chief

Cynthia Cuayo-Juico, MDIrma R. Makalinao, MD

Co-chairpersons

Jocelyn J. Yambao-Franco, MDJoel S. Elises, MD

Salvacion R. Gatchalian, MDGenesis C. Rivera, MD

Advisers

Nerissa M. Dando, MDJoselyn A. Eusebio, MD

Edilberto B. Garcia, Jr., MDRamon C. Severino, MD

Editorial Board

Maria Theresa H. Santos, MDGloria Nenita V. Velasco, MD

Research Associates

Philippine Pediatric Society, Inc.Board of Trustees

OFFICERS

Victor S. Doctor, MDPresident

Genesis C. Rivera, MDVice President

Melinda M. Atienza, MDSecretary

Ma. Noemi T. Salazar, MDAssistant Secretary

Milagros S. Bautista, MDTreasurer

May B. Montellano, MDAssistant Treasurer

Jocelyn J. Yambao-Franco, MDImmediate Past President

Fe V. Del Mundo, MDHonorary President

MEMBERSStephen C. Callang, MDJoselyn A. Eusebio, MD

Salvacion R. Gatchalian, MDAlexander O. Tuazon, MD

Florentina U. Ty, MDGrace Marilou L. Vega, MD

Ma. Victoria C. Villareal, MD

iii

PREFACE

More than 50% of the population are pediatric in age. The Philippine Pediatric Society remains committedto protect the Filipino children through its various services by the network of pediatricians throughout thecountry. Advocacy remains at the heart of the organization. Child advocacy is worth all the challenges anddifficulties that are experienced, for, in the end, it is ultimately for the benefit of the child. With this fourthvolume of Policy Statements, the Philippine Pediatric Society renews and strengthens its commitment tothe Filipino child.

The PPS policy statements have had a major impact on Philippine Health Policy Development since thefirst publication in 2003. A policy statement in the first issue, newborn screening, has been enacted intoRepublic Act 9288 or the Newborn Screening Law. The Newborn Screening Law mandates that everychild must be given the opportunity to be offered newborn screening. Today, 2 other policy statementshave been crafted into bills universal newborn hearing screening (Senate Bill No 2390 sponsored bySenators Miriam Defensor-Santiago, Pilar Juliana Cayetano, Loren Legarda and Manuel Lapid) and orphandisorders (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 itsMaternal-Newborn Health And Policy Strategy Framework. It is envisioned that the PPS policy statementswill 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 differentsubspecialties, and chapters, the committee presents 9 policy statements.

There are policy statements that have been withdrawn from this volume due to further review and informationfrom 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 policystatements were also jointly sponsored.

This issue presents policy statements on:

Obesity in Children and Adolescents, jointly sponsored with the Society of Adolescent Medicineof the Philippines, Inc;, the Philippine Society of Pediatric Metabolism & Endocrinology. Inc; andthe 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 HealthOfficers Association, the Philippine Society of Pediatric Cardiology and Department ofEducation;Pre-Operative Evaluaion in Pediatric Patients Undergoing Surgery and Other MajorTherapeutic or Diagnostic Procedures, jointly sponsored with the Philippine Society forPediatric Cardiology; the Child Neurology Society of the Philippines; the Philippine Society forPediatric Anesthesia; and the Philippine Society of Pediatric Surgeons;

iv

vSports 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 affectingour children; hence, a lot of areas need to be covered and a lot of work remains. The committee remainsunfazed and ever more ready to accept these challenges as it continues to research and work towards thisgoal in the hopes of protecting the future of Filipino children.

The Editors

1BACKGROUND

Being at risk for overweight is defined as a BMI between the85th and 95th percentile for age and gender, and beingoverweight is defined as a BMI at or above the 95th percentilefor age and gender. Disadvantages of using BMI include theinability to distinguish increased fat mass from increase fat-free mass and reference populations derived largely from non-Hispanic whites, potentially limiting its applicability tononwhite 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 isdefined as greater than the 95th percentile of the weight forlength. The definition is purely statistical, and the percentilevalues are age and gender specific. It is important to measurehead circumference because a very large head may alterweight-for-length ratio.3

The number of overweight children and adolescents has morethan doubled since the early 1970s. From 1999 to 2000, theprevalence of overweight (BMI 95th percentile for age andgender) for children aged 2 to 19 years ranged from 9.9% to15.5%. The prevalence increased with age and was higher inracial-ethnic minorities than in non-Hispanic whites. Forexample, Mexican American children were significantly moreoverweight (23.7%) than non-Hispanic white children (11.8%)

beginning at age 6.10 years. Representative national data areunavailable to estimate reliably the prevalence of overweightin Asian children and adolescents.4

In the Philippines, the sixth National Nutrition Surveyconducted by the Food and Nutrition Research Institute in2003 showed that among the 4,110 children aged 0-5 surveyed,1.4% were overweight (only 0.4% in 1998). Among childrenbetween ages 6-10, 1.3% were overweight (negligiblepercentage in 1998); and among 11-19-year-olds, 3.5% wereoverweight. These data showed that the number of overweightchildren increased between the years 1998 and 2003.5 Thesefigures were based on the old system of classification usingweight for age, not BMI.

The Department of Education, through the Health andNutrition Center (HNC), conducts nutritional assessment ofpublic school students twice within each school year. Thenutritional assessment of elementary students based on weight-for-height and body mass index (BMI) conducted towardsthe end of school year 2003-2004 showed that out of10,383,276 children assessed, 1,870,404 or 18.01% werebelow normal; 8,188,319 or 78.86% were normal; and 324,553or 3.13% were above normal. Nutritional assessment ofsecondary school students based on body mass indexconducted in March 2004 showed that out of 3,145,011students weighed, 12.59% were below normal, 84.50% werenormal, and 2.91% were above normal.6

Obesity in Children and the AdolescentsPhilippine 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 countriesthat experienced rapid economic and epidemiological transition in the past 20 years. The effect of thistransition 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 high-energy and high-fat foods in populations with reduced levels of physical activity. Obesity in childrenand adolescents is related to a lot of diseases and complications and studies have shown that it increasesthe risk of serious illnesses and death later in life, thus raising public health concerns. Prevention ofobesity in children and adolescents should be of primary concern. This policy statement presentsinformation on the prevailing obesity among children and adolescents and cites strategies for theprevention and early identification of obesity.

KEYWORDS: obesity epidemic, overweight, sedentary lifestyle, body mass index, diabetes, stroke,cancer, high-fat, high-calorie foodURL: http://www.pps.org.ph/policy_statements/obesity.pdf

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

PPS Policy Statements Series 2009 Vol. 1 No. 1

2In 2001, a local study was done among schoolchildren aged 8to 10 years from private and public schools in Manila whichshowed that undernutrition was much more prevalent amongpublic schoolchildren while overnutrition was much moreprevalent among private schoolchildren.7 The increasingprevalence of overweight among private school children wasalso seen in a study done by Chan-Cua. The study included1822 boys from Grade I-VII of a private school in Metro Manila.Weight:Height ratio (WHR) was used to assess overweight andobesity in the students. Based on the Philippine (FNRI-PPS)growth reference chart, 17% of the boys were overweight and47% were obese. Based on the National Center for HealthStatistics (NCHS) growth reference chart, 16% were assessedto be overweight and 41% obese. Obesity was also assessedbased on BMI. A striking 47% had BMI of >20. Majority of theboys assessed came from the middle and upper socioeconomicclasses with Chinese ancestry, which could be considered ahigh risk population.8

Genes are important in determining a persons susceptibilityto weight gain, but energy balance is determined by calorieintake and physical activity. Some forces thought to underliethis epidemic are economic growth, modernization,urbanization and globalization of food markets.3

Pathologic obesity is associated with endocrine or neurologicdisorders or is due to iatrogenic causes, e.g. medications.3

Obesity, at first glance, may seem to be a problem of theindividual himself, but we must also recognize that it as aproblem rooted in neighborhoods and schools, modes oftransportation, local food availability, food advertising tochildren and governmental policies.9

Food intake and activity in young children are strongly influencedby parents. During early childhood, the more parents encouragechildren to eat certain foods, the less likely they are to do so. Thus,foods that have been forbidden in childhood may be overconsumedwhen children finally have access to them later on.10 Social supportfrom parents, siblings and other members of the communitycorrelates 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 increasedrisk for obesity during childhood and later in life.11

The rise in consumption of fast food may be relevant to thechildhood obesity epidemic. Fast food incorporates all of thepotentially adverse dietary factors, such as saturated and transfat, high glycemic index, high energy density, and large portionsize. A large fast food meal (double cheeseburger, French fries,soft drink, dessert) could contain 2200 kcal, which, at 85 kcalper mile, would require a full marathon to burn off.11 Familylife has changed a lot over the past years, with trends towardseating out and greater access to television than before. It is

said that children consume more energy when meals are eatenin restaurants than at home, possibly because restaurants tendto serve larger portions of energy dense foods.11

Todays youth are considered the most inactive generation inhistory. This is caused in part by reductions in school physicaleducation programs and unavailable or unsafe communityrecreational facilities.12 According to the World HealthOrganization, nearly two-thirds of children in both developedand developing countries are insufficiently active, with seriousimplications on their future health.13

In the 1998 Asian Conference on Early and ChildhoodNutrition, the Food and Nutrition Research Institute reportedthat the most common leisure activities of Filipino childrenaged 8 to 10 were playing computer games, reading, andwatching television.14 Another survey of children aged 8 to10 years in Manila conducted by FNRI showed that only oneout of four children participated in actual physical exerciseeveryday. Three out of four spent their time playing computergames, watching television, and reading. It was also reportedthat children had physical education lessons only once or twicea week.15

Television viewing is thought to promote weight gain byincreasing energy intake and displacing physical activity.Children seem to passively consume excessive amounts ofenergy-dense foods while watching television. Televisionadvertising could adversely affect dietary patterns at othertimes throughout the day and exposure to commercialsincreases the likelihood that children later select an advertisedfood when presented with options.11

Being severely overweight in childhood is associated withrelatively rare immediate morbidity from conditions, such aspseudotumor cerebri, slipped capital femoral epiphysis,steatohepatitis, cholelithiasis, and sleep apnea. Being overweightis also associated with a higher prevalence of intermediatemetabolic consequences, such as insulin resistance, elevated bloodlipids, increased blood pressure, and impaired glucose tolerance.These conditions, which are often asymptomatic, increase thelong-term risk for developing diabetes and heart disease inadulthood and are associated with persistent obesity intoadulthood. However, the recent emergence of medical conditionsthat are new to overweight children, such as type 2 diabetes,represents the increasing prevalence of more serious, shorter termmorbidity. Perhaps the most significant morbidities for overweightchildren and adolescents are psychosocial.3,5

Laboratory investigations directed at identifying co-morbiditiesof obesity may include thyroid functions, lipid profile, completechemistries and hepatic profile, and fasting glucose and insulin.An oral glucose tolerance test (OGTT) should be considered toexclude impaired glucose tolerance or T2DM in individuals athigh risk, e.g. family history of T2DM and/or metabolicsyndrome, after 10 years of age. Determination of serum orurinary cortisol

PPS Policy Statement Obesity in Children and the Adolescents

3levels should be reserved to exclude the presence of Cushingssyndrome in obese individuals who have appropriate historicalinformation and/or physical findings.

Infants who are hypoglycemic or require very frequentfeedings as well as infants with dysmorphic features requirefurther evaluation. Examples include persistenthyperinsulinemic hypoglycemia of infancy (OMIM no. 61820)and BWS with hypoglycemia, or PWS and BBS withdysmorphism.3

Recommendations

1. The PPS recognizes that the battle against childhoodobesity in the Philippines is both difficult and laborious.Thus, in addition to the abovementioned policies, it isthe 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 strongrelationship between exclusivity and duration ofbreastfeeding to reduction of childhood obesity. Theseevidences showed the advantages of breastfeeding,especially if exclusive, and noted that the favorableeffects are more prominent in adolescence. Plausiblemechanisms why breastfeeding lowers obesity riskinclude learned self-regulation of energy intake,metabolic programming in early life and inherentproperties of breast milk.20,21 Metabolic programmingwill lead to higher plasma insulin in bottle/formulafed infants resulting to stimulation in fat depositionand early development of adipocytes. Breast milk, onthe other hand, contains bioactive factors whichmodulate epidermal growth and tumor necrosis factorsthat inhibit adipocyte differentiation.

ii. Nutritiona. Home-cooked meals should be encouraged as

opposed to eating out in restaurants.b. Avoidance of fast food

iii. Physical activitya. Engage in regular exercise.b. Minimize viewing of television.c. Encourage family support.

2. To solve the problem of obesity, however, a cooperativeeffort among various individuals and groups of peoplefrom all segments of society is of prime importance. Eachone has a role in preventing childhood obesity andensuring that our children become healthy, well-nourishedadults.

Roles of Government and Community Leaders

1. Community leaders should make safe communityfacilities available for childrens physical activities.

2. The government, through its agencies, should intensifyinformation campaigns on proper nutrition and healthylifestyle.

3. The government should regulate marketing and promotionof food products to children.

4. The government, through the Department of Education, shouldmonitor the strict implementation of the DECS MemorandumNo. 373 s. 1996: Encouraging the Sale and Consumption ofHealthy and Nutritious Foods in the Schools.

5. The government should support researches on overweightand obesity of Filipino children and adolescents.

6. The government should give due recognition to foodmanufacturers and establishments that promote healthyfoods.

7. The government, through the Department of Health, shouldpush for the approval of the pending Administrative Orderregarding the mandatory labeling of nutrition facts andhealth claims on pre-packaged food.

8. The government should retrain health workers on the useof the Center for Disease Control percentile charts forclassification of overweight and obese.

Roles of Marketing, Media and Advertising Industry1. The media and advertising industry should intensify

information dissemination on the prevention and controlof childhood obesity and its harmful consequences.

2. The Ad Board should strengthen its commitment tosafeguard truth in food advertising.

3. The Ad Board should invite physicians from concernedmedical societies to serve as members of their technicalcommittee that screens advertisements.

Roles of School Administrators and Teachers1. 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 thatschool cafeterias provide healthy food and beverages.

4. School administrators and teachers should work togetherwith the school health personnel in monitoring thenutritional status of all pupils and students.

Roles of Parents and Primary Caregivers1. Parents should be role models for their children. Parents

should be mindful of their eating habits and physicalactivities.

2. Parents should introduce at around 6 months of age avariety of foods, including vegetables and fruits in the diet.

3. Parent should provide healthy food options (adequatecalories but low in saturated fat, low salt, low simplesugar). Meals consisting of nutritious foods prepared athome should be encouraged instead of consuming fastfood meals.

Obesity in Children and the Adolescents PPS Policy Statement

44. Parents should encourage and provide opportunities formore physical and sports activities and reduce sedentaryactivities (watching television, playing computer orvideo games).

5. Parents should give their children home preparednutritious foods as school snacks and meals.

6. Parents should discourage their children from buyingunhealthy food (soft drinks, candies, chips) in schoolcafeterias.

7. Parents should refrain from using food as reward fortheir children. Physical activity and quality time withparents should reward desired behavior instead.

8. Parents should read nutrition information on foodlabels.

Roles of Physicians1. Physicians should obtain a thorough dietary,

psychosocial and family history on the pediatric patient.Hypertension, dyslipidemias, tobacco use, and otherconditions that can be cardiovascular risk factors shouldbe identified and addressed.

2. Physicians should monitor height, weight, and BMIof children and adolescents at every clinic visit. Theyshould identify those at risk for overweight andobesity.

3. Physicians should advocate exclusive breastfeeding forat least 6 months and onwards; and propercomplementary feeding.

4. Physicians should educate the family on healthy eatingand regular exercise habits early in the childsdevelopment. Useful information may be madeavailable 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, MAHPSCo-chairpersons: Cynthia Cuayo-Juico, MD and Irma R.Makalinao, MDMembers: Nerissa M. Dando, MD; Joselyn A. Eusebio,MD*; Edilberto B. Garcia, Jr., MD; Ramon C. Severino,MDAdvisers: Joel S. Elises, MD; Genesis C. Rivera, MD;Jocelyn J. Yambao-Franco, MDCouncil on Community Service and Child AdvocacyDirectors: Salvacion Gatchalian, MD; Roberto Espos, Jr.,MD; Gregorio Cardona, Jr., MDResearch Associates: Lady Christine Ong Sio, MD; MariaCorazon Martin, MD; Tiffany Tanganco, MD; Aizel de laPaz, MD; Domiline Coniconde, MD; Emmanuel Arca, MD;Gloria Nenita Velasco, MD; Maria Theresa Santos, MD

*Lead ReviewerPANEL OF EXPERT REVIEWERS

Society of Adolescent Medicine of the Philippines, Inc.Rosa Ma. Nancho, MDErlinda Cuisia-Cruz, MDAlicia Berbano-Tamesis, MD

Philippine Society of Pediatric Metabolism andEndocrinology, Inc.Sioksoan Chan-Cua, MDSusana Campos, MD

Nutrition Foundation of the PhilippinesRodolfo Florentino, MD, PhD

Philippine Society of Pediatric Gastroenterology andNutritionRandy P. Urtula, MDJuliet Sio-Aguilar, MDMary Jean Guno, MDGrace Battad, MDPaciencia Macalino, MDAurora Genuino, MDRebecca Castro, MD

PPS Committee on Nutrition and Promotion of BreastfeedingMary Jean Guno, MDRandy Urtula, MD

PPS Obesity Working GroupGrace Uy, MDSusan Jimenez, MDGrace Battad, MDSioksoan Chan-Cua, MDGemma Dimaano, RD

ACKNOWLEDGEMENTS

Participants of the Round Table Discussion on Obesity inChildren and Adolescents (01 October 2004):

Ma. Theresa Bacud Health Education Promotion OfficerIII, Health and Nutrition Center, Department of EducationJane Mari Cabulisan, MD Medical Specialist II, NationalCenter for Disease Prevention and Control, Department ofHealthFrances Prescilla Cuevas Chief, Health Program Officer,National Center for Disease Prevention and Control,Department of Health Sioksoan Chan-Cua, MD Director, Philippine Associationfor the Study of Overweight and Obesity; President,Philippine Society of Pediatric Metabolism andEndocrinology, Inc.

PPS Policy Statement Obesity in Children and the Adolescents

5Obesity in Children and the Adolescents PPS Policy Statement

Cristina Dablo, MD Division Chief, Medical Officer VII,Healthy Lifestyle Division, National Center for DiseasePrevention and Control, Department of Health Aurora Gamponia, MD Secretary, Philippine Society ofPediatric CardiologyMa. Rhodora Garcia-De Leon, MD President, PhilippineSociety of Pediatric CardiologyMerlita Nolido Chief Education Program Specialist,Bureau of Elementary Education, Department of EducationAntonia Siy Senior Counselor, Center for FamilyMinistries FoundationFlorentino Solon, MD President and Executive Director,Nutrition Center of PhilippinesAlicia Berbano-Tamesis, MD Founding President, Societyof Adolescent Medicine of the Philippines, Inc.Maria Lourdes Vega Chief, Nutrition Information andEducation Division, National Nutrition CouncilVirgie Velasco Performance Officer, Kapisanan ng mgaBrodkaster ng PilipinasEstrella Paje-Villar, MD President, Philippine PediatricSocietySalvacion Gatchalian, MD Director, Council on CommunityService and Child Advocacy, Philippine Pediatric Society, Inc.Carmencita David-Padilla, MD Chairperson, Committeeon Policy Statements, Philippine Pediatric Society, Inc.Cynthia Cuayo-Juico, MD Co-chairperson, Committee onPolicy Statements, Philippine Pediatric Society, Inc.Nerissa Dando, MD Member, Committee on PolicyStatements, Philippine Pediatric Society, Inc.Joselyn Eusebio, MD Member, Committee on PolicyStatements, Philippine Pediatric Society, Inc.Edilberto Garcia Jr., MD Member, Committee on PolicyStatements, Philippine Pediatric Society, Inc.Irma Makalinao, MD Member, Committee on PolicyStatements, Philippine Pediatric Society, Inc.Ramon Severino, MD Member, Committee on PolicyStatements, Philippine Pediatric Society, Inc.Aizel de la Paz, MD Research Associate, Committee onPolicy Statements, Philippine Pediatric Society, Inc.Tiffany Tanganco, MD Research Associate, Committeeon Policy Statements, Philippine Pediatric Society, Inc.

Participants of the Round Table Discussion on Obesity inChildren and Adolescents (11 October 2005):

Lorna Abad, MD Member, Philippine Society of PediatricMetabolism & Endocrinology, Inc.Sofia Amarra, PhD - Senior Science Research Specialist,Food and Nutrition Research InstituteNerissa Babaran - Nutrition Officer IV, National NutritionCouncilJane Mari Cabulisan, MD Medical Specialist II, NationalCenter for Disease Prevention and Control, Department ofHealth

Sioksoan Chan-Cua, MD Director, Philippine Associationfor the Study of Overweight and Obesity; President,Philippine Society of Pediatric Metabolism andEndocrinology, Inc.Sylvia Estrada, MD Member, Philippine Society ofPediatric Metabolism & Endocrinology, Inc.Ma. Rhodora Garcia-De Leon, MD President, PhilippineSociety of Pediatric CardiologyRosa Maria Nancho, MD President, Society of AdolescentMedicine of the Philippines, Inc.Thelma Navarrez, MD - Director II, Health and NutritionDivision, Department of EducationJuliet Sio-Aguilar Member, Philippine Society of PediatricGastroenterology and Nutrition, Inc.Edison Ty, MD - Board Member, Philippine Society ofPediatric CardiologyRandy Urtula, MD President, Philippine Society ofPediatric Gastroenterology and Nutrition, Inc.Grace Uy, MD - Chair, Obesity Working Group, PhilippinePediatric Society, Inc. CommitteeFelicidad Velandria - Treasurer - Philippine Association ofNutrition, Inc.Estrella Paje-Villar, MD President, Philippine PediatricSocietyJocelyn Yambao-Franco, MD Vice-President, PhilippinePediatric SocietyCarmencita David-Padilla, MD Chairperson, Committeeon Policy Statements, Philippine Pediatric Society, Inc.Nerissa Dando, MD Member, Committee on PolicyStatements, Philippine Pediatric Society, Inc.Emmanuel Arca, MD Research Associate, Committee onPolicy Statements, Philippine Pediatric Society, Inc.Domiline Coniconde, MD Research Associate, Committeeon Policy Statements, Philippine Pediatric Society, Inc.

The Committee on Policy Statements recognizes thecontribution of the following:

Center for Family Ministries FoundationDepartment of Education Bureau of Elementary EducationDepartment of Education Health and Nutrition CenterDepartment of Health National Center for DiseasePrevention and ControlDepartment of Science and Technology - Food and NutritionResearch InstituteKapisanan ng mga Brodkaster ng Pilipinas National Nutrition Council Nutrition Information andEducation DivisionNutrition Center of PhilippinesPhilippine Association for the Study of Overweight andObesityPhilippine Association of Nutrition, Inc.Philippine Society of Pediatric Cardiology

6PPS Policy Statement Obesity in Children and the Adolescents

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

REFERENCES

1. Kuczmarski RJ, Ogden CL, Guo SS et al. 2000 CDCGrowth Charts for the United States: methods anddevelopment. Vital Health Stat 11. 2002; (246): 1-90.

2. Centers for Disease Control and Prevention. BMI forchildren and teens. Atlanta, GA: Centers for DiseaseControl and Prevention; 2003. Available atwww.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm.Accessed September 24, 2006.

3. Obesity Consensus Working Group. The Journal ofClinical Endocrinology & Metabolism. Mar 2005;90(3): 1871-1887.

4. Ogden CL, Carroll MD, Flegal KM. Epidemiologictrends in overweight and obesity. Endocrinol MetabClin North Am. 2003; 32: 741-760.

5. Screening and Interventions for Overweight in Childrenand Adolescents: Recommendation Statement. USPreventive Services Task Force. Pediatrics 2005; 116:205-209.

6. Lobstein T, Baur L, Uauy R. Obesity in children andyoung people: a crisis in public health. Obes Rev. 2004;5(suppl 1):4-104.

7. Must A, Strauss RS. Risks and consequences ofchildhood and adolescent obesity. Int J Obes RelatMetab Disord. 1999;23(suppl 2):S2-S11.

8. Zametkin AJ, Zoon CK, Klein HW, Munson S.Psychiatric aspects of child and adolescent obesity: areview of the past 10 years. J Am Acad Child AdolescPsychiatry. 2004; 43; 134-150.

9. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH.Prevalence of a metabolic syndrome phenotype inadolescents: findings from the third National Health and

Nutrition Examination Survey, 1988-1994. Arch PediatrAdolesc Med. 2003; 157: 821-827.

10. The 6th National Nutrition Surveys: Initial Results. Foodand Nutrition Research Institute. Available at http://www.fnri.dost.gov.ph/nns/6thnns.pdf. Accessed onOctober 6, 2004.

11. Department of Education Health and Nutrition Center.Integrated School Health and Nutrition Program Q &A (Questions and Answers). September 2004. Availableat the Department of Education.

12. Florentino R. A study of overweight and obesity amongschool children in Manila. Paper read at the 2nd Asia-Oceania Conference on Obesity (MASO 2003),Renaissance Hotel, Kuala Lumpur, Malaysia,September 8, 2003.

13. Chan-Cua S, Cuayo-Juico C, et al. Prevalence ofoverweight among boys in a Metro Manila private gradeschool. Journal of ASEAN Federation of EndocrineSocieties. 1995:16-20.

14. Galvez MP, Frieden TR, Landrigan PJ. Obesity in the21st century. Environmental Health Perspectives.2003;111(13):A684-5.

15. Dietz WH. The obesity epidemic in young children.Br Med J 2001;322:313-4.

16. Ebbeling CB, Pawlak DB, Ludwig DS. Childhoodobesity: public-health crisis, common sense cure. TheLancet 360:473-82.

17. American Obesity Association Fact Sheets. Available ath 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.

18. Ebbeling CB, Pawlak DB, Ludwig DS. Childhoodobesity: public-health crisis, common sense cure. TheLancet 360:473-82.

19. Why childhood obesity levels are rising. Available athttp://www.tinajuanfitness.info/articles/art120799.html.Accessed on December 5, 2003.

20. More Filipino kids becoming obese. Available at http://www.inq7.net.lif/2003/nov/13/lif_32-1.htm. Accessedon April 23, 2004.

DISCLAIMER:The publication of the Policy Statements of the Philippines Pediatric Society is part of an advocacy for the provisionof quality health care to children. The recommendations contained in this publication do not dictate an exclusivecourse 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 andadvice of physicians. Nuances and peculiarities in individual cases or particular communities may entail differencesin the specific approach. All information is based on the current state of knowledge. Changes may be made in thispublication at any time.

7BACKGROUND

The Convention on the Rights of the Child outlines the rightsof every child. Children have the right to life, an adequatestandard 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. Inspite of this, childrens rights continue to be violated in theform of child labor.1

An estimated 246 million children around the world engagein child labor, of which roughly three-quarters work inhazardous situations or conditions, such as mines, workingwith chemicals and pesticides in the agricultural sector, orworking with dangerous machinery. They are found in homesas 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 exploitationand abuse, working as domestic servants or unpaid householdhelp under horrific circumstances. They are either trafficked(1.2 million), forced into debt bondage or other forms ofslavery (5.7 million), prostitution and pornography (1.8million), participating in armed conflict (0.3 million), or otherillicit activities (0.6 million). The Asian and Pacific regionshave 127.3 million child laborers, representing 19 percent ofchildren, the largest in the 5 to 14 age group.2

A National Statistics Offices Survey on Children in 2001recorded a total of 24.9 million Filipino children, of which 4.0million were economically active, i.e., one out of six (6) childrenworked. Most working children came from Southern Tagalog,followed by Central Visayas and Eastern Visayas. They werecomposed of children aged 10-14 years old and 15-17 yearsold, consisting of more males than females, and majority (7 outof 10) resided in rural areas. More than 50 percent were engagedin agriculture, hunting, and forestry, while others were inwholesale and retail, repair of motor vehicles and personal andhousehold goods, in private households with employed persons,fishing, and manufacturing. Most were unpaid workers in theirown household-operated farm or business, while one-fifth werefound in private establishments and in private households. Threeout of 5 children were not paid. Roughly 25 percent of workingchildren 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. Physicalenvironment hazards were the most common, of which 44.4percent were exposed. Around 237,000 (9.9%) were exposedto physical, chemical, and biologically hazardousenvironments. Physical hazards included temperature orhumidity (most common), slip/trip fall hazards, noise,radiation/ultraviolet/microwave, pressure. Children inagriculture, hunting, and forestry were greatly exposed tophysical hazards. One out of 5 children was exposed tochemical elements (such as silica and saw dust and

Child LaborPhilippine Pediatric Society, Inc.

Child labor is very prevalent specially in developing countries like the Philippines. This putsthe children at risk for abuse and exploitation, exposes them to hazardous environments andalso compromises their health. This policy statement discusses the impact of child labor inchildren, the various laws that have been enacted to quell this problem and recommendationsfor parents, physicians and the government on how to protect our children from child laborand uphold the rights of a child.

Keywords: child labor, child abuse, exploitation, childrens rightURL: http://www.pps.org.ph/policy_statements/child_labor.pdf



8mist/fumes). Almost 1 in 5 working children was in danger ofbiological infections, fungal and bacterial being the mostcommon. Unfortunately, of the more than 2.4 million workingchildren who used tools/ equipment in their work, only about683,000 (35.3%) were provided with safety/protective device/equipment. Approximately 23 percent of working childrenincurred injuries while at work, such as cuts, wounds and/orpunctures, contusions/bruises/hematoma, and abrasions.2

Although 7 in every 10 working children attended school, 1.2million (44.8%) encountered problems, including difficultyin catching up with the lesson, high cost of school supplies/books/transportation, far distance of the school from theirresidence, unsupportive teachers, and lack of time for studying.Not surprisingly, 2 in every 5 working children stopped ordropped out of school. Reasons for dropping out includedloss of interest and high cost of schooling.2

Because of the conditions that child laborers are forced towork in, which are intensive and unhygienic, these childrentend to be underweight and undernourished. They are alsoexposed to a variety of chemical, biological, and physicalhazards.6 Possible long-term repercussions of child laborinclude inhibited development of a countrys human resources,reduction of lifetime earnings of individuals, and loweredlevels of productivity.6

The ILO Convention No. (ILOC) 138 sets minimum agesabove which work can be allowed as necessary or even auseful part of young peoples lives.7,8 ILO Convention No.182 identifies the different worst forms of child labor. It alsosets policies for the elimination of child labor - the worst formsto be eliminated immediately while other forms should berestricted in time by establishing minimum age laws and otherlegal frameworks that protect children from exploitation.9,10

Republic Act (RA) 9231, more popularly known as the Anti-Child Labor Law, amended some provisions of RA 7610. TheAct provides for the elimination of the worst forms of child laborand affords stronger protection for the working child. It has thefollowing salient features: 1. it prohibits the engagement of achild in worst forms of child labor; 2. provides for the workinghours of a working child aged below 15 and those aged 15 butbelow 18; 3. determines ownership, usage and administration ofthe working childs income; 4. provides for the setting up of atrust fund to preserve part of the working childs income; 5.provides stiffer penalties against acts of child labor, particularlyits worst forms, penalizes parents and legal guardians who violatethe provisions of the Act with a fine or community service; and6. 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, forcedlabor, recruitment of children in armed conflict.

2) Child for prostitution, pornography3) Child for illegal activities/illicit activities4) 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 childb) Exposes child to abusesc) Is performed underground, underwater or dangerous

heightsd) Involves use of dangerous machineries, equipment

or toolse) Exposes child to physical danger like dangerous feats

of balancing, physical strength, or manual transportof heavy loads

f) Is performed in an unhealthy environment exposingthe child to hazardous working conditions, elementsor substances, co-agents, or processes

g) Is performed under particularly difficult conditionsh) 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 yearsold. Children between 15 and 18 years old may be employed inundertakings not hazardous or deleterious in nature, i.e. anykind of work in which the employee is not exposed to any riskthat constitutes an imminent danger to his or her life and limb,safety, and health. A child below 15 years old is not permittedto work in any public or private establishment, with twoexceptions: children working directly under the soleresponsibility of his or her parents or guardians or legal guardian(where only members of the employers 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 wherethe childs employment or participation in public entertainmentor information through cinema, theater, radio or television isessential. These are subject to conditions and provisions asdetermined by the Department of Labor and Employment(DOLE).1 Children of any age, however, are strictly prohibitedfrom performing for advertisements that promote alcoholicbeverages, tobacco, and violence.5

Still, children below 15 are not allowed to work more than 4hours per day, 5 days per week. Children between 15 and 18are allowed to work in non-hazardous circumstances, for notmore than 8 hours per day and not more than 40 hours perweek. 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 workingchild shall belong to him/her in ownership and shall be set

PPS Policy Statement Child Labor

9aside primarily for his/her support, education or skillsacquisition and secondarily to the collective needs of thefamily. Not more than twenty percent (20%) of the childsincome may be used for the collective needs of the family.

A trust fund must be established to preserve part of the workingchilds income. The parent or legal guardian of a workingchild below 18 years of age shall set up a trust fund for atleast thirty percent (30%) of the earnings of the child whosewages and salaries from work and other income amount to atleast two hundred pesos (P200,000.00) annually, for whichhe/she shall render a semi-annual accounting of the fund tothe Department of Labor and Employment. The child shallhave full control over the trust fund upon reaching the age ofmajority.

In addition, the Act provides for maximal penalties forviolators (e.g. employers, subcontractors or others facilitatingthe employment of children in any of the worst forms of childlabor) and sets penalties for involving children in hazardouswork. It also allows children, parents, or other concernedcitizens to file complaints. RA 9231 holds parents liable incase of violation of the said Act and provides penalties forthem such as payment of a fine of not less than Ten ThousandPesos (P10,000) but not more than One Hundred ThousandPesos (P100,000), or be required to render community servicefor not less than thirty (30) days but not more than one (1)year, or both such fine and community services at the discretionof the court. The maximum length of community service shallbe imposed on parents who have violated the provisions ofthis Act three (3) times.11

Child labor refers to any work performed by a child that:1. Subjects the child to economic exploitation, or2. Is likely to be hazardous for the child, or3. Interferes with the childs education, or4. Is harmful to the childs health or physical, mental,

spiritual, moral, or social development.

It is a situation wherein children are compelled to work on aregular basis. In addition, it refers to work where children areseparated from their families and where children are forcedto lead prematurely adult lives.4 As opposed to child labor,child work childrens or adolescents participation in economicactivity that does not negatively affect their health anddevelopment 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 hasdeveloped and implemented a national program for theelimination of the worst forms of child labor. The PhilippineTime-Bound Program Against Child Labor, launched in 2002,emphasizes combining sectoral, thematic, and area-basedapproaches in combating child labor. In support of the

program, the ILO-International Programme on the Eliminationof Child Labor (IPEC) has implemented a project that involvesstrengthening the enabling environment for the eliminationof the worst forms of child labor and direct action for childlaborers, their families, and communities.7

The Philippine Program Against Child Labor is the flagshipprogram for combating the worst forms of child labor in thecountry5 and involves several agencies (such as theDepartment of Labor and Employment, Department of Justice,Department of Social Welfare and Development (DSWD),Department of Health), the police, and non-governmentorganizations. The Bureau of Working Conditions isresponsible for conducting labor inspections and formonitoring the use of child labor.11 The Department of Laborand Employment is the lead agency in the implementation ofthe Philippine Program Against Child Labor (formerlyNational Program Against Child Labor). Other programpartners include the employers group, such as the EmployersConfederation of the Philippines and workers organizations,such as the Federation of Free Workers and the Trade UnionCongress of the Philippines.

The multi-agency program Sagip Batang Manggagawa allowsfor the rescue of child laborers and the placement of thesechildren in DSWD-managed centers or institutions where theyundergo rehabilitation prior to reintegration. The agencysConditional Cash Transfer provides money to families in needon the condition that human capital investments be made, e.g.sending their children to school and bringing them regularlyto health centers. Receipt of money is contingent on enrollmentand regular attendance of at least 85 percent of school days.12

The Philippine Pediatric Society, Inc. is in support of theelimination of the worst forms of child labor and of protectingchildren in the employable age.

RECOMMENDATIONS

Roles of the National Government1. The national government should continue to enhance

existing legislation that will help in the elimination ofthe worst forms of child labor in the country.

2. The national government should ensure child-friendly andchild-sensitive enforcement of existing anti-child laborlegislation.

3. The national government should include child laborconcerns in the following areas:

a. National Developmentb. Social Policiesc. Labor market policies

4. The national government should enhance education(through information dissemination and developinganalytical skills, critical thinking, and decision making)

Child Labor PPS Policy Statement

10

and other training policies that respond to the needs ofworking children and those who are at risk.

5. The national government should provide opportunitiesfor specialized training of inspectors of child labor.

6. The national government should increase socialspending and budget allocation to basic social services.

7. The national government should enjoin the participationof private groups, business sectors, and civicorganizations.

Roles of the Local Government1. Local governments should develop local laws or

ordinances that are in support of the nationalgovernments effort at eliminating the worst forms ofchild labor.

2. Local governments should provide mechanisms forimproving implementation of national legislation.

3. Local governments should set up mechanisms fordetecting, monitoring, reporting, and providing actionagainst the worst forms of child labor.

4. Local governments should provide social support andeconomic opportunities (through training of adults,micro-finance, other credit schemes, establishment ofsustainable small industries, and alternative livelihoodprograms) to families who are vulnerable to the worstforms of child labor.

5. Local governments should enforce and implement thelaw.

6. Local governments should provide educational andtraining opportunities and alternatives to children whoare at risk of and engage in child labor.

7. Local governments should encourage communityinvolvement and social mobilization through localadvocacy for the prevention of child labor.

8. Local governments should provide free rescue andpsychosocial recovery and social reintegration servicesto child laborers.

9. Local governments should provide litigation servicesto victims of child labor and child economicexploitation.

Roles of the Physician and other Health Workers1. 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 traininglaws and other information relevant to child labor.

3. The physician should detect and report to the properauthorities any child suspected of engaging in child labor.

4. The physician should counsel the parents of child/children suspected of engaging in child labor regardingthe immediate hazards and long-term consequences ofchild labor.

5. The physician should provide free medical services to

children engaged in child labor.6. The physician should conduct free annual or semi-

annual medical check-ups for identified child laborersand other members of their families.

Roles of the Parents1. The parents should ensure that their child/children does

not/do not engage in unacceptable (according to RA9231) forms of child labor.

Document prepared by the Committee on PolicyStatements

Chairperson: Carmencita D. Padilla, MD, MAHPSCo-chairpersons: Cynthia Cuayo-Juico, MD; IrmaMakalinao, MDMembers: Nerissa Dando, MD; Joselyn Eusebio, MD;Edilberto Garcia, Jr., MD; Ramon Severino MDAdvisers: Joel Elises, MD; Salvacion Gatchalian, MD;Genesis Rivera, MD; Jocelyn Yambao-Franco, MDResearch Associates: Maria Theresa H. Santos, MD; GloriaNenita V. Velasco, MD

EXPERT REVIEWERS

Department of Labor and Employment Bureau of Womenand Young WorkersChita G. Cilindro (Director)

Department of Health National Center for DiseasePrevention and ControlYolando E. Oliveros, MD, MPH (Director IV)

Department of Social Welfare and DevelopmentGemma Gabuya (Social Welfare Officer V)

Round Table Discussion Participants

16 October 2007

Department of Labor and Employment Bureau of Womenand Young Workers - Chita G. Cilindro (Director)

Department of Labor and Employment - Ruby Dimaano

Department of Health National Center for DiseasePrevention and Control, Family Health Office RodolfoAlbornoz, MD (Medical Specialist III)

Department of Social Welfare and Development NicamilK. Sanchez (Social Welfare Officer IV)

Liga ng mga Barangay sa Pilipinas Rudenio Eduave(Director for Organizational Development)

PPS Policy Statement Child Labor

11

Child Labor PPS Policy Statement

ACKNOWLEDGEMENTS

The committee would like to acknowledge the followingfor their contribution:Department of Labor and Employment Bureau of Womenand Young Workers - Chita G. Cilindro (Director)Department of Labor and Employment - Ruby DimaanoDepartment of Health National Center for DiseasePrevention and Control - Yolando E. Oliveros, MD, MPH(Director IV)Department of Health National Center for DiseasePrevention and Control, Family Health Office RodolfoAlbornoz, MD (Medical Specialist III)Department of Social Welfare and Development - GemmaGabuya (Social Welfare Officer V)Department of Social Welfare and Development NicamilK. Sanchez (Social Welfare Officer IV)Liga ng mga Barangay sa Pilipinas Rudenio Eduave(Director for Organizational Development)

REFERENCES

1. DOLE Primer. Labor in the Philippines. Available athttp://www.dole.gov.ph/primers/rightswyw.htm

2. UNICEF Fact Sheet.3. 2001 National Statistics Office Survey on Working

Children4. 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. VisayanDaily Star. 31 March 2006. Available at http://www.v i sayanda i lys t a r. com/2006 /March /31 /topstory7.htm.

6. World Children Organization. Available at http://world_children.org/WCO%20web%20images/homepage/phil_cond1.htm.

7. Sardaa MC. Combating Child Labor in thePhilippines. Prepared for Asian Development BankInstitutes Seminar on Social Protection for the Poor inAsia and Latin America. 25 October 2002, Manila.

8. ILO Convention No. 138. Available at http://ohchr.org/english/law/pdf/ageconvention.pdf. Accessed onSeptember 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 sugarcaneplantations in the Philippines. Terre des HommesNetherlands. 2005.

11. Republic Act 9231. An Act Providing for theElimination of the Worst Forms of Child Labor andAffording Stronger Protection for the Working Child,Amending for this Purpose Republic Act No. 7610. AsAmended, Otherwise Known as the Special Protectionof Children Against Child Abuse, Exploitation, andDiscrimination Act. Available at http://www.ops.gov.ph/records/ra_no9231.htm. Accessed onSeptember 11, 2007.

12. Reactions to the Policy Statement Child Labor draftedby the Philippine Pediatric Society, Inc. Department ofSocial Welfare and Development. October 2007.


13

BACKGROUND

Infant walkers are commonly used mobile infant carriers today.They allow a pre-ambulatory infant to sit in a suspended seatattached to a circular rim standing on wheels. The device givesthe infant precocious locomotion.1-3 Walkers are sometimesequipped with a plastic table or hanging toys that keep theinfant entertained while seated. Some are equipped with abraking mechanism whereas others are foldable and can beeasily stowed.1

Walkers are employed by parents for various reasons: to keeptheir infant preoccupied while they are doing other things, tohold their children during feeding, to keep their children quietand happy, to aid the infant in strengthening their legs and tohelp infants walk at an earlier age.1,2,4-6 However, recent studieshave shown that infant walkers are not beneficial to childrenand 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 caneven delay their motor and mental development.1,2-9 One studyshowed that walker-experienced infants scored lower onBayley scales of mental and motor development compared tonon-walker experienced.1,3 Another study showed that walkerexperienced infants had abnormal Denver DevelopmentalScreening Test Results9 while another study showed that

walker assisted infants initially had abnormal gait when theystarted walking independently.1 Aside from delayed motordevelopment, contractures of the calf muscles and motordevelopment mimicking spastic diaparesis may also appear.2,8

Moreover, walkers make infants more prone to accidentssuch as falls, burns, poisonings, submersions, suffocationand even death.1,4-6,10-21 All of these accidents are attributedto the increased range and speed of infants when riding thewalker.

Falls. Inside a walker, the speed of the infant can reach upto 3 feet/sec, and even with a guardian present, this speedmay be too fast to catch a falling child. The speed andacceleration endowed to an infant when riding a walker maycause fatal injury from falls even at low heights. Literaturehas shown that falls from stairs occur in 75 96% ofcases.1,4,5,12,18-20 Some of these are severe, some cause facialinjuries, majority cause head injuries and rarely, fatalities.1,4-6,10-20

Although some stairs are gated and some walkers areequipped with braking mechanisms that stop the carriagewhen there are changes in elevation, it has been found thatthese are not enough to sufficiently decrease the frequencyof falls in infants.1

Burns and Poisonings. Infants riding a walker may be moreprone to both burn injuries and poisoning due to increased

Infant WalkersPhilippine Pediatric Society, Inc.

Infant walkers are commonly employed by parents nowadays. Recent studies have foundthat infant walkers may put children at risk for accidents and minor injuries as well as causea delay in motor development. This policy presents the advantages and disadvantages ofinfant walker use as well as recommendations for its use.

Keywords: infant walkers, accidents, minor injuriesURL: http://www.pps.org.ph/policy_statements/infant_walkers.pdf



14

access to the kitchen and other dangerous areas in the house.16-21

Reported burn injuries were contact and scald burns, somesevere enough to require resuscitation and skin grafting. Ithas been reported that the incidence of thermal injuryassociated with baby walker use remains at high levels despiteincreased safety measures.17,18,21

Submersions and Suffocations. Despite the swimming poolbeing fenced-in, there have been reports of submersion anddrowning of infants on walkers. There was also a report ofsubmersion in a toilet bowl by an infant riding a walker.Likewise, there was also a report of infant suffocation whileinside the walker when the infants neck was caught in betweenthe walker tray.1

Minor Injuries. These injuries include pinch injuries to theinfants fingers and toes, abrasions, contusions, lacerations,extremity fractures and other soft tissue injuries.1,4-6,12,17-20

Many countries have realized the danger that walkers pose totheir children and, thus, started creating policies that will helpcurb this rising problem. Such policies includerecommendations of stationary walkers and playpens asalternative to mobile infant walkers, guidelines that regulatethe manufacture of safer walkers, withdrawal of mobilewalkers from the market and banning of walkerproduction.2,4,6,18 In 1997, the American Society for Testingand Materials (ASTM) created voluntary guidelines andstandards on the manufacture of infant walkers.4 Some of theseinclude a braking mechanism for the walker and a requirementthat the walkers width be greater than 36 inches (the widthof an average door).1 Likewise, New South Wales, Australiahas set the 2000 baby walker regulation, which required aspecified level of stability and a gripping mechanism to stopthe walker at the edge of the step.22 All of these moves werenoted to decrease the number of infant walker-relatedinjuries.4,22

Another means employed is the education of doctors, nurses,midwives and other health personnel regarding the dangersof walker use which they then share with the parents andguardians of the children.2,5,6,10,21-28 This was done in the UnitedKingdom, Singapore, US, Canada and other developedcountries. It was found that parental knowledge of the dangersassociated with baby walkers may be effective in reducingbaby walker possession and use.10,23-26,28 However, this onlylimited the frequency of baby walker-related accidents to someextent and many still believe that banning walkers from themarket and recalling existing walkers would be moreeffective.3,7,8,18,21,22,27,28

In the Philippines, there is very little awareness on the adverseeffects of walker use. Many still employ infant walkers withthe belief that these aid their children to walk earlier and faster

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

RECOMMENDATIONS

Roles of the Government1. 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 thatinforms the public of the disadvantages of infant walkersand discourages its use.

3. The government should aid in the education of doctors,midwives and other health personnel on the disadvantagesof infant walker use.

4. The government should ban the use of walkers in hospitalsand approved child care facilities.

5. The government should initiate and support researchesregarding the benefits, disadvantages and safety of infantwalker use in the Philippine setting.

Roles of Physicians and Health Care Personnel1. 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 anddisadvantages of infant walker use.

3. Physicians and health care personnel should make surethat walkers are not used in their clinics and other childhealth care facilities.

Roles of Parents1. 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.

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

PPS Policy Statement Infant Walkers

15

EXPERT REVIEWER

Lead reviewer: Joselyn A. Eusebio, MDexpert reviewer: Philippine Pediatric Society Committee on____

Rommel Crisenio M. Lobo, MD

REFERENCES

1. Injuries associated with infant walkers. AmericanAcademy of Pediatrics: Committee on Injury and PoisonPrevention. Pediatrics. Vol. 108, No. 3. September 2001.Pp. 790 792.

2. Hadzagic Catibusic F, Gavrankapetanovic I, ZubcevicS, Meholjic A, Rekic A, Sunjic M. Infant walkers: theprevalence of use. Medicine Archives. Vol. 58, No. 3.2004. Pp. 189 190.

3. Siegel AC, Burrows RV. Effects of baby walkers onmotor and mental development in human infants. Journalof Developmental and Behavioral Pediatrics. Vol. 20, No.5. October 1999. Pp. 355 361.

4. Shields BJ, Smith GA. Success in the prevention ofinfant walker related injuries: an analysis of nationaldata, 1990 2001. Pediatrics. Vol. 117, No. 3. March2006. Pp. e452 459.

5. Santos Serrano L, Paricio Talavero JM, Salom Perez A,Grieco Burucua M, Martin Ruano J, Benlloch MuncharazMJ, Llobat Estelles T, Beseler Soto B. Patterns of use ,popular beliefs and proneness to accidents of a babywalker. Bases for health information campaign. An EspPediatrica. Vol. 44, No. 4. April 1996. Pp. 337 340.

6. Al-Nouri L, Al-Isami S. Baby walker injuries. Annals ofTropical Pediatrics. Vol. 26, No. 1. March 2006. Pp. 67 71.

7. Burrows P, Griffiths P. Do baby walkers delay the onsetof walking in young children? British Journal ofCommunity Nursing. Vol. 7, No. 11. November 2002.Pp. 581 586.

8. Engelbert RH, van Empelen R, Scheurer ND, HeldersPJ, van Nieuwenhuizen O. Influence of infant walkerson 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 preventionwith infant walkers and strollers.

11. Deaths associated with infant carriers United States,1986 1991. MMWR Morbidity and Mortality WeeklyReport. 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

fall injuries among infants: a study in Greece. Archivesof Pediatric and Adolescent Medicine. Vol. 158, No. 10.October 2004. Pp. 1002 1006.

13. Watson WL, Ozanne Smith J. The use of child safetyrestraints with nursery furniture. Journal of PediatricChild Health. Vol. 29, No. 3. June 1993. Pp 228 232.

14. Leblanc JC, Pless IB, King WJ, Bawden H, Bernard Bonnin AC, Klassen T, Tenenbein M. Home and safetymeasures and the risk of unintentional injury amongyoung children: a multicenter case control study.CMAJ. Vol. 175, No. 8. October 10, 2006. Pp. 883 887.

15. Emanuelson I. How safe are childcare products, toysand playground equipment? A Swedish analysis of mildbrain injuries at home and during leisure time 1998 1999. Injury Control and Safety Promotion. Vol. 10, No.3. September 2003. Pp. 139 144.

16. Mroz LS, Krenzelok EP. Examining the contribution ofinfant walkers to childhood poisoning. Vet HumToxicology. Vol. 42, No. 1. February 2000. pp. 39 40.

17. Cassell OC, Hubble M, Milling MA, Dickson WA. Babywalkers still a major cause of infant burns. Burns. Vol.23, No. 5. August 1997. Pp. 451 453.

18. Smith GA, Bowman MJ, Luria Jw, Shields BJ. Babywalker related injuries continue despite warning labelsand public education. Pediatrics. Vol. 100, No. 2. August1997. P. E1.

19. Claydon SM. Fatal extradural hemorrhage following afall from a baby bouncer. Pediatric Emergency Care.Vol. 12, No. 6. December 1996. Pp. 432 434.

20. Petridou E, Simou E. Skondras C, Pistevos G, Lagos P,Papoutsakis G. Hazards of baby walkers in a Europeancontext. Injury Prevention. Vol. 2, No. 2. June 1996.Pp. 118 120.

21. Sendut IH, Tan KK, Rivara F. Baby walker associatedscalding injuries seen at University Hospital KualaLumpur. Medical Journal Malaysia. Vol. 50, No. 2. June1995. Pp. 192 193.

22. Thompson PG. Injury caused by baby walkers: thepredicted outcomes of mandatory regulations. MedicalJournal of Australia. Vol. 177, No. 3. August 5, 2002. Pp.147 148.

23. Kendrick D, Illingworth R, Woods A, Watts K, CollierJ, Dewey M, Hapgood R, Chen CM. Promoting childsafety in primary care: a cluster randomized controlledtrial to reduce baby walker use. British Journal ofGeneral Practice. Vol. 55, No. 517. August 2005. pp.579 580.

24. Tan NC, Lim NM, Gu K. Effectiveness of nursecounselling in discouraging the use of the infant walker.Asia Pacific Journal of Public Health. Vol. 16, No. 2. 2004.Pp. 104 108.

25. Rhodes K, Kendrick D, Collier J. Baby walkers:pediatricians knowledge, attitudes, and healthpromotion. Archives of Diseases in Childhood. Vol. 88,No. 12. December 2003. Pp. 1084 1085.

Infant Walkers PPS Policy Statement

26. Conners GP, Veenema TG, Kavanagh CA, Ricci J,Callahan CM. Still falling: a community wide infantwalker injury prevention initiative. Patient EducCouns. Vol. 46, No. 3. March 2002. Pp. 169 173.

PPS Policy Statement Infant Walkers

27. Kendrick D, Marsh P. Babywalkers: prevalence of useand relationship with other safety practices. InjuryPrevention. Vol. 4, No. 4. December 1998. Pp. 295 298.

28. Morrison CD, Stanwick RS, Tenenbein M. Infantwalker injuries persist in Canada after sales haveceased. Pediatric Emergency Care. Vol. 12, No. 3. June1996. Pp. 180 182.


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BACKGROUND

Caffeine has been used as early as the Stone Age when ancientpeoples discovered that chewing seeds, bark, and leaves of certainplants eased fatigue, stimulated awareness, and elevated mood.1,2For thousands of years, it has been used in a variety of formssuch as coffee, tea, chocolate, yerba mat, and guarana berriesamong others.3 Caffeine is the most widely consumedpsychoactive substance, its consumption being estimated at120,000 tons per annum.1 It has also been added to a variety ofcarbonated and energy drinks and medicines, such asdecongestants, analgesics, stimulants, and appetite suppressants.4(See Appendix) Childrens exposure to caffeine is largely viacarbonated drinks, chocolate, tea, and coffee (especially inurbanized areas) through the deluge of coffee franchises.

In a study on beverage caffeine intake in young children inCanada and USA, it was determined that American childrenconsumed more caffeinated beverages at 56% compared toCanadian children at 36%. Canadian children consumedapproximately half the amount of caffeine (7 vs. 14 mg/day).It was concluded, however, that caffeine intake fromcaffeinated beverages remained well within safe levels forconsumption by young children.5

Caffeine is a xanthine derivative and its effects are mediatedthrough its action on the cerebral cortex and brain stem of the

central nervous system. Caffeines effects are dose-related andmost of its undesirable effects are at greater doses. At dosesof 100-200 mg, caffeine may increase alertness andwakefulness, promote faster and clearer flow of thought andbetter general body coordination, and may produce loss offine motor control and result in dizziness. 6,7 However dosesof more than 500-600 mg can cause restlessness, anxiety,irritability, muscle tremors, sleeplessness, headaches, nausea,diarrhea or other gastrointestinal problems, and abnormal heartrhythms.8 Caffeine stimulates the heart, dilates vessels, causesbronchial relaxation, and increases gastric acid production.7Its other metabolic effects include releasing fatty acids fromadipose (fatty) tissue and affecting the kidneys (resulting inincreased urination) which could lead to dehydration.9 It isimportant to note that caffeine also fits the definition of anaddictive substance, with withdrawal symptoms, an increasein tolerance over time, and physical cravings.7

Caffeine poisoning from consuming excessive amounts hasoccurred in other countries.10,11 The symptoms of caffeinepoisoning in infants include very tense muscles alternatingwith overly relaxed muscles, rapid, deep breathing, nauseaand/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 untouchedarea. A recent study done in Harding University, Arkansas,

Caffeine and ChildrenPhilippine 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 buthas effects on other body systems. Its consumption is widespread due to its easy accessibilityand availability through sodas, chocolate, and coffee, owing to the spread of coffeeestablishments 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 PediatricSociety, Inc. recommends limiting caffeine consumption by children.

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



17

USA was the first to investigate the effects of caffeine on bothcardiovascular and metabolic responses to exercise in healthyboys and girls. The study was done on 52 seven to nine-yearold boys and girls, each randomly receiving a placebo and acaffeinated drink twice each on four separate days. The resultsrevealed that caffeine acutely elevated both resting andexercise blood pressure, but acutely reduced heart rate in boysand girls given a moderate to high dose of caffeine an hourbefore exercise. Caffeine was found to have no effect onmetabolism, and there were no significant differences foundbetween boys and girls.13

In the United States, a report by the National Center forAddiction and Substance Abuse at Columbia University foundthat young women aged 8 to 22 who drank coffee were morelikely to smoke and drink alcohol, and to do so at an earlierage than non-coffee drinkers and their male counterparts. Thestudy called caffeine a little known risk factor for substanceabuse and warned that the glamorizing of addictive substanceshad contributed to this problem.14 In a study done on caffeinedependence in 36 adolescents, it was determined that therewas no significant difference in the amount of caffeineconsumed daily by caffeine dependent versus non-dependentteenagers.15

In a study done on 275 students in Italy in 2006, the prevalenceand related disability of multiple addictions were assessed. Inthis population, behavioral addictions were multiple, a sourceof disability, and were related to substance. However, whetherthis is a temporary phenomenon among adolescents or areliable marker for the future development of substance abuseneeds to be clarified.16

There has also been concern on the possible negative effectsof caffeine on bone growth of children. A cohort studyconducted by Lloyd et al. was done to determine whetherdietary caffeine consumed by American white females betweenages 12 to 18 affected total body bone mineral gain duringages 12 to 18 or affected hip bone density measured at age18. It was determined that dietary caffeine intake at levelspresently consumed by American white, teenage women wasnot correlated with adolescent total bone mineral gain or hipbone density at age 18.17

A meta-analysis was conducted by Hughes and Hale on thebehavioral effects of caffeine and other methylxanthines onchildren. Acute exposure to or intake of high doses (>3 mg/kg) of caffeine in children who consumed little caffeineproduced negative subjective effects (e.g. nervousness,jitteriness, stomachaches, and nausea). Caffeine appeared toslightly improve vigilance performance and decreased reactiontime in healthy children who habitually consumed caffeine.18The acute effects of caffeine on learning, performance, andanxiety were investigated in 21 children through a double-

blind placebo-controlled crossover design. In the small samplesize, there was an indication that caffeine enhancedperformance on a test of attention and on a motor task. Theparticipants reported feeling less sluggish but somewhatmore anxious.19

Cases of rare reactions to caffeine intake including tics20 andurticaria21 have been documented.

Aside from the undesirable effects that children mayexperience with excessive caffeine ingestion, there are otherconcerns that adults need to be aware of. Excessive intake ofcarbonated drinks may lead to obesity, nutritional deficiencies,and dental caries.22 Caffeine addiction may also put patientsat risk for tooth wear, such as attrition, erosion, and abrasion.23In addition, there are certain medications that interactnegatively with caffeine. The antibiotics ciprofloxacin andnorfloxacin may increase the length of time caffeine remainsin the body and may amplify its effects. Theophylline has somecaffeine-like effects and its concentration may increase in theblood when taken with caffeine-containing food or beverages.Ephedra (or ma-huang), an herbal dietary supplement, hasalready been banned due to health concerns in the USA butmay still be present in herbal teas. Its ingestion in combinationwith caffeine may be risky.8

In a 2008 retrospective assessment done in the Virginia AdultTwin Study of Psychiatric and Substance Use Disorders, itwas concluded that individual differences in psychoactivesubstance use (in this case alcohol, caffeine, cannabis, andnicotine), in terms of initiation and early patterns of use, werestrongly influenced by social and familial environmentalfactors while later use was more strongly influenced by geneticfactors.24 This underscores the importance that parents andschools play in prevention and cessation counseling.

However, other beverages that contain caffeine, such as teaand coffee, may have other beneficial effects. The beneficialeffects of coffee are a direct result of its higher caffeine content.Its regular intake may reduce the risk of Parkinsons disease,type 2 diabetes25, colon cancer, liver cirrhosis, hepatocellularcarcinoma26, and gallstones.27,28 It may also serve as a powerfulaid in enhancing athletic endurance and performance and helpmanage asthma and headaches. Furthermore, coffee containsantioxidants (e.g. chlorogenic acid and tocopherols) andminerals, such as magnesium, that may improve insulinsensitivity and glucose metabolism. Lastly, trigonelline incoffee has anti-bacterial and anti-adhesive properties that mayhelp prevent dental caries.27

To what extent an individual will be affected will depend onhis/her sensitivity to the substance and his/her sensitivity, inturn, will depend on body mass, history of caffeine use, andstress. Those with lower body masses (e.g. children) willexperience the effects of caffeine sooner than those with

PPS Policy Statement Caffeine and Children

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19

higher body masses (e.g. adults). Those with regular caffeineintake will be less susceptible to experiencing caffeinesnegative effects than those with irregular caffeine intake.And all types of stress can increase a persons sensitivity tocaffeine, e.g. psychological stress or heat stress. Age,smoking habits, drug or hormone use, and other healthconditions (e.g. anxiety disorders) are additional factors thatneed to be considered.8

In the USA, there are no specific guidelines for limitingcaffeine intake. Moderate coffee drinking of 1-2 cups per daydoes not seem to be harmful according to the American HeartAssociation.9 Health Canada, however, has the followingrecommendations for maximum caffeine intake levels forchildren:

Children* 4 - 6 years 45 mg/day7 - 9 years 62.5 mg/day10 - 12 years 85 mg/day

* Using the recommended intake of 2.5 milligrams perkilogram of body weight per day and based on average bodyweights of children (Health and Welfare Canada, 1990), basedon behavioral effects. 29

In the Philippines, caffeine is considered a miscellaneous foodadditive in cola type beverages and its maximum level of useis limited to 200 ppm.30 At present, there are no existingspecific guidelines on limiting caffeine intake for children.

RECOMMENDATIONS

Roles of the Government1. The government should implement laws that mandate

labeling of all food, beverage, and medicines thatcontain caffeine and the level of caffeine found in theseproducts.

2. The government should strengthen and implementprograms to promote healthy diet and alternativeoptions to intake of caffeine-containing foods andbeverages.

3. Increase awareness of the public, through the Departmentof Health and DOH accredited hospitals, includingschools on the effects of caffeine in children.

4. To encourage the coffee selling establishments to includea warning or caution (posters, signs) on the negativeeffects of caffeine on children.

Roles of Food, Beverage, and Medicine Manufacturers1. Food, beverage, and medicine manufacturers should

properly label their products that contain caffeine and thelevels at which it is found in the product.

Note : Labeling may not be enough. It should include :Caffeine may be habit forming, may cause increasein heart rate, insomnia, or even NOTRECOMMENDED FOR CHILDREN orCONTRAINDICATED IN CHILDREN WITHMEDICAL CONDITIONS, OR CONSULT YOURDOCTORS ON THE SAFETY OF CAFFEINE INCHILDREN.

Roles of Physicians1. Physicians should educate parents and caregivers on the

effects of caffeine, the products that contain them, andways in which its intake could be reduced and/oravoided.

2. Physicians should educate parents and caregivers on foodand beverage products that are energy rich butnutritionally dense (e.g. fresh fruit juices, milk, etc.) inplace of softdrinks and energy drinks.

3. Physicians should be vigilant in prescribing medicationsthat have adverse drug interactions with caffeine-containing food and beverages, especially if theirpediatric patients are consuming diets containing suchitems.

Roles of Parents1. 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 childrens diets.3. Parents should encourage their children to consume food

and beverage products that are energy rich butnutritionally dense (e.g. fresh fruit juices, milk, etc.).

4. Parents should inquire with their childrens primaryphysician if any of their childs medications (whetherprescription or over-the-counter) contain caffeine and thelevel at which it is found in the medication.

5. Parent should aim to reduce/avoid administeringmedication containing caffeine to their children unlessotherwise strongly indicated by their childs pediatrician/attending physician.

6. Parents should set examples in the moderate intake ofcoffee.

Document prepared by the Committee on PolicyStatementsChairperson: Carmencita D. Padilla, MD, MAHPSCo-chairpersons: Cynthia Cuayo-Juico, MD; Irma Makalinao,MDMembers: Nerissa Dando, MD; Joselyn Eusebio, MD;Edilberto Garcia, MD; Ramon Severino, MDAdvisers: Joel Elises, MD; Salvacion Gatchalian, MD;Genesis Rivera, MD; Jocelyn Yambao-Franco, MDResearch Associates: Maria Theresa H. Santos, MD; GloriaNenita V. Velasco, MD

Caffeine and Children PPS Policy Statement

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ACKNOWLEDGEMENTS

The Committee on Policy Statements recognizes thecontribution of the following:

Dr. Mario Capanzana -- Officer in Charge, Food andNutrition Research Institutex

REFERENCES1. 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 onMay 7, 2007.

3. National Cancer Institute. Caffeine. National CancerInstitute Drug Dictionary. National Institutes of Health.Available at http://www.cancer.gov/Templates/drugdictionary.aspx?CdrID=40817. Accessed on May11, 2007.

4. National Cancer Institute. Caffeine. National CancerInstitute Dictionary of Cancer Terms. National Institutesof Health. Available at http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=454809. Accessed onMay 11, 2007.

5. Knight CA, Knight I, Mitchell DC. Abstract. Beveragecaffeine intakes in young children in Canada and theUS. 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. Accessedon 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: AHARecommendation. 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. 150No. 12. Page 860.

11. Walsh I, Wasserman GS, Mestad P, Lanman RC.Abstract. Near-fatal caffeine intoxication treated withperitoneal dialysis. Pediatric emergency care.December 1987. Vol. 3 No. 4. Pages 244-249.

12. Psychology Today Staff. Caffeine. Psychology Today.2002 October 10. Available at http://w w w . m e d i c i n e n e t . c o m / s c r i p t / m a i n /art.asp?articlekey=38065. Accessed on May 11, 2007.

13. Turley KR, Gerst JW. Abstract. Effects of caffeine onphysiological responses to exercise in young boys andgirls. Medicine and Science in Sports and Exercise.2006 March. Vol. 38 No.3. Pages 520-526.

14. Needham C. Sweet but dark: coffee consumption andteen girls. Available at http://www.jrn.columbia.edu/studentwork/cns/2003-06-03/320.asp. Accessed on June8, 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. 66No. 1. Pages 1-6.

16. Pallanti S, Bernardi S, Quercioli L. Abstract. TheShorter PROMIS Questionnaire and the InternetAddiction Scale in the assessment of multiple addictionsin a high school population: prevalence and relateddisability. CNS Spectr. 2006 Dec. Vol. 11 No. 12. Pages966-974.

17. Lloyd T, Rollings NJ, Kieselhorst K, Eggli DF,

Policy Statement 2009

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