ࡱ> %` +WbjbjNN f,,N>RRR$v,,,PN-L-lvUp.:L.b.b.b.Z5Z5Z5ooooooo$rh]uoRC44|CCob.b.|pFFFCb.b.oFCoFFFd6hb.. *O,yD(gpiD%p0UpguEuhhuRhZ5t9.F<?3Z5Z5Z5ooOFjZ5Z5Z5UpCCCCvvvD,Dvvv,vvv  11 August, 2009 Submission to the New Zealand Food Safety Authority on Proposed Amendment to the New Zealand Folic Acid Standard: NZFSA Public Discussion Paper; no.10/09 Prepared by Dr Rosemary Marks, President PSNZ in consultation with the membership of PSNZ on behalf of Paediatric Society of New Zealand. Comments on sections 1, 2, 3 and 5 and other issues. Introduction The Paediatric Society of New Zealand is a multidisciplinary organisation with a membership of more than 450 child health professionals. The aims and objectives of the Society are to stimulate interest in and to promote the scientific study of child health and Paediatrics in New Zealand, and to engage in all activities which, in the opinion of the Society, may be necessary from time to time in the interests of child health, and to engage in the following activities which promote the welfare of New Zealand children: Encourage and promote the study and advancement of the science and practice of paediatrics, child health nursing and other professional practices involved with child health Generally to promote the health and welfare of children in New Zealand consistent with the United Nations Convention on the Rights of a Child. Advocate for children on all issues related to their health at a local, regional and national level. Provide information to the public of New Zealand on all matters that concern the health and welfare of children. Advance public education and awareness of the science and practice of paediatrics, child health and welfare of children. Maintenance of the highest possible level of the scientific and ethical practice in the health care of children in New Zealand. Section 1 We note that the New Zealand (Mandatory Fortification of Bread with Folic Acid) Food Standard 2007 is due to come into effect on 27 September 2009, two years following New Zealand signing the standard under the joint agreement with Australia. We note that a public relations campaign was embarked on by industry interests, only four months prior to the implementation date. We submit that the timing of this public relations campaign was designed to minimise the opportunity for the scientific arguments in favour of folic acid fortification to be presented to the public and to maximise public anxiety. We also submit that there has been deliberate misinformation, in particular on the following points An allegation that folic acid fortification is unnecessary as the incidence of neural tube defects has reduced. While it is true that the incidence of liveborn infants with neural tube defects has decreased, the overall incidence is not significantly changed, with a large proportion of fetuses with neural tube defects being terminated. This is in line with data from other countries including Australia.1 Folic acid has been characterised in the mass media as a medication and compared with active drugs such as diazepam (Valium). This has been a deliberate attempt to incite public anxiety. Folic acid is in fact the synthetic form of Vitamin B9 which is an essential nutrient vital to normal function. It has been claimed that even with fortification, pregnant women would need to consume 11 slices of bread each day. This would be true, if the only food consumed was bread. While there may be some women living in poverty whose dietary intake consists largely of bread, the majority of New Zealand women take a mixed diet. Section 2 The discussion document states Adults get about 250 micrograms of folate from food each day, which is well below the recommended intake. This is misleading. Results from the 1997 Nutrition Survey2 were that the median daily intake from food for the New Zealand adult population was 242 micrograms. The median intake for males was 278 micrograms, while the median intake for females was 212 micrograms. Females living in the most deprived areas (quartile IV) had median intake of only 201 micrograms. As noted below these women are those at highest risk. Yeung at al3 have demonstrated that very high folate concentrations in blood are associated with taking folic acid supplements, not with consuming foods fortified with folic acid. The discussion paper states that the recommended intake for New Zealand adults is 400 micrograms of folate per day. It is stated that adults get about 250 micrograms per day from food. This implies that most if not all New Zealand adults are folate deficient and will benefit from folic acid fortification. Therefore there will be no detrimental excesses or imbalances. Bread is an effective vehicle for delivering vitamins. It is consumed by most people on a daily basis. Neural Tube Defects PSNZ agrees that adequate intake of folate in the periconceptional period (4 weeks prior to conception and 12 weeks after conception) is proven to reduce the risk of neural tube defects. PSNZ notes that the general public has limited understanding of the nature and impact of Neural tube defects on the affected individuals and their families. Mandatory folic acid fortification is clearly the most effective public health strategy to address the problem of reducing the risk and therefore incidence of neural tube defects. If almost all women in New Zealand planned their pregnancies and consulted a Health Professional prior to embarking on unprotected sexual activity and took appropriate folic acid supplements consistently while trying to become pregnant, then mandatory fortification would not be necessary. However, more than half of all pregnancies in New Zealand are unplanned. Unplanned pregnancies occur in the more disadvantaged sectors of the community, especially younger women including teenagers, and women in low socioeconomic groups. These women are more likely to have a diet low in naturally folate rich foods and less likely to be taking folic acid supplements. Therefore a public health approach is necessary to reach these women. More than a third of all infants presenting to the Starship neurosurgical unit for initial surgery for meningomyelocoele over the last 7 years (2002 2008) were Maori. Maori are disproportionately represented in many adverse health outcomes that reflect social disadvantage. Costs of fortification PSNZ notes the estimate that the cost of fortification is estimated to be between 3 and 5 cents per loaf. This would appear to be high compared with data from the US baking industry of 25 cents per person per year. We acknowledge that economies of scale may be possible in the USA. The costs to industry are noted. These would be passed on to consumers as an increase in price. The increase in price is minimal compared with the price increase over the last 24 months which have resulted from the wide fluctuations in the price of oil. Costs of care for children with neural tube defects Outcome for children with neural tube defects varies with the severity and location of the lesion. However the majority require multiple episodes of surgery and have significant needs for equipment and disability support services. Many are unable to join the workforce. A survey in South Australia in the mid 1990s found that only 22% of adults with meningomyelocoele were in full employment.1 PSNZ notes that the costs of public health services for people with neural tube defects are based on the 1997 paper by Singh and Elliott4, and are now out of date. There have been significant increases in the cost of delivering health services as a result of the adoption of new technologies (e.g. MRI scanning), and changes in human resource management resulting in higher costs. PSNZ also notes that the treatment of children and adults with neural tube defects has impacts on healthcare resources for other healthcare users. Many children with meningomyelocoele will require a ventriculoperitoneal shunt insertion for hydrocephalus. Half of all shunts fail within two years and require replacement. Each child with meningomyelocoele will require an average of 5 shunt revisions.5 There are significant resource issues in the provision of neurosurgical services in New Zealand. Financial resource is only part of the issue. There are not enough paediatric neurosurgeons to meet demand. Mandatory fortification with folic acid, by reducing the number of infants born with neural tube defects, will ensure that other children requiring neurosurgical intervention can receive more timely surgery. Iodine PSNZ notes the intention to proceed with iodine fortification and endorses this decision. It is not clear why the baking industry has not objected to this requirement. Section 3: Problem Definition As noted above the cost burden on industry would be passed on to consumers as price increases. Consumers have been very tolerant of price increases and are unlikely to reduce consumption of a staple foodstuff. The concern about even distribution of folic acid is noted. As folic acid is water soluble, significant difficulties with uneven distribution would be surprising. It is noted that a number of other additives are added to bread during manufacture and uneven distribution of these additives does not appear to be of concern. It is surprising that the baking industry has raised these concerns so close to the implementation date. One would expect that in a well managed industry the necessary equipment would already be in place. Section 5: Options PSNZ supports the adoption of option 5.1 with mandatory fortification of bread with folic acid being implemented as planned on 27 September 2009 in accordance with the New Zealand (Mandatory Fortification of Bread with Folic Acid) Food Standard 2007. PSNZ is absolutely opposed to the adoption of option 5.3. The preferred option for PSNZ would be mandatory fortification of flour with folic acid. Over 50 countries already have mandatory fortification of the food supply with folic acid, and many of those countries have mandatory fortification of flour. A further option that has been discussed in other jurisdictions is to proceed with mandatory fortification with folic acid, and at the same time restrict the sale of supplements containing high levels of synthetic folic acid. Other issues Health risks of mandatory fortification with folic acid There has been much discussion in the media from those opposing mandatory fortification with folic acid regarding potential health risks. Our evaluation of the evidence is that there is no high level evidence of risk. We support the collection of data in relation to these potential risks, and the continuing monitoring and evaluation of the international literature on this subject. Colorectal cancer Epidemiological studies have demonstrated an inverse relationship between higher dietary folate intakes and the incidence of colorectal cancer. In other words, individuals with high levels of folate in their diets are less likely to get colorectal cancer. However there is also evidence that suggests that adults with very high folate/folic acid intakes, particularly those who take high dose folic acid supplements may have increased growth of early cancerous or precancerous lesions. Data from the USA shows a steady decline in the incidence of colorectal cancer since the mid 1980s. From 1995 there is a modest reversal of this decline. From March 1996, voluntary fortification with folic acid was permitted. In 1998, fortification with folic acid became mandatory. At this point the incidence started to decline again resuming the previous trajectory seen prior to 1995. It has been postulated that the apparent increase in incidence in the mid 1990s results from increased diagnosis as a result of more widespread screening for colorectal cancer and increased rates of colonoscopy. The trends in colorectal cancer incidence in the USA cannot be explained by folic acid fortification of food and do not support the hypothesis that mandatory fortification with folic acid causes colorectal cancer.6,7,8 Prostate cancer Information from the American Cancer Society Prevention Study II Nutrition Cohort showed no significant association between folate intake and subsequent prostate cancer. However there was a non-significant association with those with the highest folate intake having a decreased risk of advanced prostate cancer.9 Figueiredo and colleagues have also reported finding nonsignificant associations with an inverse relationship between dietary folate intake and risk of prostate cancer. However men who received folic acid supplements had a higher incidence of prostate cancer that those who took placebo.10 Breast cancer In 2004 authors from Aberdeen reported long term follow up of a cohort of women who had participated in a double blind trial of folic acid supplementation for periconceptional prevention of Neural Tube Defects as showing an increased incidence of breast cancer. This association was not statistically significant and the authors did not claim a causal relationship. However there was substantial media coverage in the UK at the time of the report.11 A large epidemiological study from Sweden showed that high intake of dietary folate was associated with a lower incidence of postmenopausal breast cancer.12 Other cancers Yang et al13 have analysed all cancer mortality in the USA in a large cohort of people whose dietary folate intake was known. Mortality was highest in the quintile with the lowest folate intakes. There was no association detected with high dietary folate intakes and mortality from cancer. This is further evidence that folate may be protective against at least some cancers. Masking Vitamin B12 deficiency Concern has been raised that that mandatory fortification with folic acid could mask vitamin B12 deficiency, leading to delays in appropriate treatment for vitamin B12 deficient individuals. Deficiency of both B12 and folate can cause a megaloblastic anaemia in which red blood cells are larger than normal, while deficiency of B12 also causes neurological symptoms. If megaloblastic anaemia (or other symptoms suggestive of vitamin deficiency) is found then the cause needs to be identified by appropriate medical evaluation and laboratory investigations, which would include measurement of blood levels of both vitamins. Geriatricians do not regard this as a significant issue and would not recommend against folate supplementation. Economic issues International studies have examined the cost benefits of mandatory fortification with folic acid and concluded that there are significant savings resulting from this public health strategy.14,15 In a period of economic recession when public spending needs to be constrained, can we afford not to proceed with mandatory fortification with folic acid? In summary: The Paediatric Society of New Zealand recommends: That mandatory fortification of bread with folic acid be implemented as planned on 27 September 2009 in accordance with the New Zealand (Mandatory Fortification of Bread with Folic Acid) Food Standard 2007. That a public education campaign be carried out with the goals of Raising the level of awareness of the nature and impact of Neural Tube Defects on affected individuals and their families Increasing the understanding of the negative economic effects on the Health Services in New Zealand, and the implications for availability of funds for other Health Services Correcting the misinformation that folic acid is a medication that is being added to bread, and ensuring the public understand that fortification with folic acid replenishes an essential vitamin that has been removed during processing Reassuring the public that folic acid is safe and that there is no clear evidence that folic acid fortification at the proposed level causes cancer, and that it may indeed be protective against some cancers That there are early indications of other possible health benefits. That an updated assessment of the actual and complete economic impact of Neural Tube Defects be carried out. This should include assessment on the impact of Neural Tube Defects on other health consumers. That information systems which provide accurate information on the true incidence of Neural Tube Defects in New Zealand be developed. Data should be anonymised and collated by region. That robust information systems for monitoring other potential health benefits and risks be established including the rates of Congenital heart disease Cardiovascular disease Cerebrovascular accidents secondary to acquired cerebrovascular disease Colorectal, breast and prostate cancers. If the decision is made to defer implementation of the New Zealand (Mandatory Fortification of Bread with Folic Acid) Food Standard 2007, our recommendations 2-5 must be actioned as public education will still be required and data will be needed to for the review in 2011. As the eminent Australian Paediatric Neurosurgeon, Donald Simpson said in 1998: Antenatal diagnosis is not antenatal prevention: it is a second best. 1 Glossary FolateFolate is the naturally occurring form of vitamin B9, and occurs in a range of foods, especially grains, leafy vegetables and some fruitsFolic acidFolic acid is the synthetic form of vitamin B9Neural tube defectNeural tube defects occur when closure of the neural tube in the embryonic stage does not occur completely. Defects may occur at any level in the brain and spinal cord.  References Donald Simpson. Spina bifida: an unfinished story. Journal of Clinical Neurosdence 1998, 5 (3) : 251-256 Ministry of Health. 1999. NZ Food NZ people:Key Results of the 1997 Nutrition Survey. Wellington, New Zealand.  HYPERLINK "http://www.moh.govt.nz/moh.nsf/ea6005dc347e7bd44c2566a40079ae6f/8f1dbeb1e0e1c70c4c2567d80009b770?OpenDocument" http://www.moh.govt.nz/moh.nsf/ea6005dc347e7bd44c2566a40079ae6f/8f1dbeb1e0e1c70c4c2567d80009b770?OpenDocument Yeung L et al. Contributions of Total Daily Intake of Folic Acid to Serum Folate Concentrations. JAMA. 2008;300(21):2486-2487. Singh S, Elliott RB. 1997. Prevention of Spina Bifida in New Zealand. Auckland: University of Auckland (unpublished) Personal communication. Mr Andrew Law, Clinical Director, Paediatric Neurosurgery, Starship Childrens Hospital, Auckland. Bayston R et al. Folic acid fortification and cancer risk.  HYPERLINK "http://proquest.umi.com/pqdlink?RQT=318&pmid=28154&TS=1248770592&clientId=65833&VInst=PROD&VName=PQD&VType=PQD" The Lancet:  HYPERLINK "http://proquest.umi.com/pqdlink?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=28154&pcid=38028581&SrchMode=3&aid=1" 2007; 370 (9604):2004 RA Hubner and RS Houlston, Folate and colorectal cancer prevention. British Journal of Cancer (2009) 100, 233 239 Mason et al. A Temporal Association between Folic Acid Fortification and an Increase in Colorectal Cancer Rates May Be Illuminating Important Biological Principles: A Hypothesis. Cancer Epidemiol Biomarkers Prev. 2007;16(7):1325-1329 Stevens VL et al. Folate Nutrition and Prostate Cancer Incidence in a Large Cohort of US Men. Am J Epidemiol 2006;163:989996 Figueiredo JC et al. Folic Acid and Risk of Prostate Cancer: Results From a Randomized Clinical Trial. J Natl Cancer Inst 2009;101: 432 435 Charles D et al. Taking folate in pregnancy and risk of maternal breast cancer. BMJ 2004;329:1375-6. Ericson U et al. High folate intake is associated with lower breast cancer incidence in postmenopausal women in the Malm Diet and Cancer cohort. Am J Clin Nutr 2007;86:43443. Yang Q et al. Serum Folate and Cancer Mortality Among U.S. Adults: Findings from the Third National Health and Nutritional Examination Survey Linked Mortality File. Cancer Epidemiol Biomarkers Prev 2009;18(5):143947) Jentink J et al. Economic evaluation of folic acid food fortification in The Netherlands. European Journal of Public Health 2008; 18(3):270274 Llanos A et al. Cost-effectiveness of a folic acid fortification program in Chile. Health Policy 83 (2007) 295303     THE PAEDIATRIC SOCIETY OF NEW ZEALAND Secretariat: Email:Denise Tringham P O Box 22 234 Wellington 6441 Tel: (04) 938 4827 Fax: (04) 976 4827 psnz@paradise.net.nz   PAGE \* MERGEFORMAT 6 Health of our children: Wealth of our nation FIJ 6 7 m n z   ŷحߤxk\PAh9/ h!B*CJ^JphhtB*CJ^Jphh9/ htB*CJ^Jphh9/ htB*CJph h9/ htB*CJ\^JphhhtB*phh&htCJ ht5CJhq*htaJhthq*5aJhq*hq*5CJ$^JaJ$hq*hq*5^JaJ ht5aJ hq*5aJhtht5aJ hW^JhthtCJhthWJ8 m n {   3 ) #$ & F$ ddd*$-DM [$\$a$gdt 7$8$H$gdq*gdtgd64VV*Wa'ijkuvXz$ d*$7$8$H$^a$gdI$ d*$7$8$H$^a$gd! & F%gd!$ & F% d*$7$8$H$a$gdt 7$8$H$gdtgdt$$ ddd*$-DM [$\$^a$gd!krsu;=WXY34ƸƴƦƕvƸg[OhIB*CJ^JphhFB*CJ^JphhI{htB*CJ^JphhtCJH*^JhtCJ^Jht5B*CJ^Jph hyht5B*CJ^Jphht6B*CJ^Jphh!htB*CJH*^JphhtB*CJ^Jphh~htB*CJ^Jphh~htCJ^Jh~htCJhyht5CJXY34Hxy01E F _ w"x""8$9$%%((()) 7$8$H$gdF 7$8$H$gdt4GH)VY0E F \ ] ^ _ !!x""""6$7$$$J&N&G'H'ԷԷԷԫԫԚԎԂqcUUԫUhtB*CJH*^JphhF5B*CJ^Jph hFhF5B*CJ^JphhVB*CJ^Jphh}B*CJ^Jph hFht5B*CJ^JphhFB*CJ^Jphht6B*CJ^Jphh>htB*CJ^JphhtB*CJ^JphhhtB*CJ^Jph hht5B*CJ^Jph!H'((())),,,,,---@..///00<3?366ȷȷsbsVHhtB*CJH*^Jphhq*B*CJ^Jph hOjht5B*CJ^Jphht5B*CJ^Jphh_gB*CJ^Jphh}sB*CJ^Jphh}shtB*CJ^JphhBhtB*CJ^Jph hyht5B*CJ^Jphh}B*CJ^Jph hoho5B*CJ^Jphho5B*CJ^JphhtB*CJ^Jph)))**++,,,,----..////011133 7$8$H$^gdt 7$8$H$gd_g 7$8$H$gdt366688%9&949::;;;==<=@@@-@AAAAAAA 7$8$H$gdt 7$8$H$^gdt6688888"9$9%92:::::;;;;;===(>7>n>w>>>>>>>'??@@@-@@@AAAAAA㟑㺑uho5B*CJ^Jphh}5B*CJ^Jphht5B*CJ^Jphh}B*CJ^JphhtE-htB*CJ^Jphh^htB*CJ^JphhoB*CJ^JphhtB*CJH*^JphhtB*CJ^Jph h^htB*CJH*^Jph-AAAAABBB_C DDE FFF d*$7$8$H$^gd" & F& d*$7$8$H$gd" & F& d*$7$8$H$gd" d*$7$8$H$gdq*$ & F& d*$7$8$H$a$gdt 7$8$H$gdtAAAABB FFFFGGJJRJSJ_J`JaJbJcJdJmJKK㺬vgYJYhthtB*CJ^Jphht5B*CJ^Jphh+htB*CJ^JphhtB*CJH*^Jph h` 5htB*CJH*^Jphh~Ght6CJ^Jht6CJ^JaJh~Ght6CJ^JaJ h~Ght6B*CJ^Jphhq*B*CJ^Jphh}B*CJ^JphhtB*CJ^Jph h0dht5B*CJ^JphFFGGH-HDHHHHIIJcJdJmJ 7$8$H$gdt 7$8$H$gd" & F& d*$7$8$H$gd" d*$7$8$H$^gd" & F& d*$7$8$H$gd"$ d*$7$8$H$^a$gd}mJtJJJ K9K:KMKKITkd`$$Ifl0,"(p t644 layttTkd$$Ifl0,"(p t644 laytt $7$8$H$IfgdtKKKKKKLLqLMPNNBOPQQ$ & F' d*$a$gdtgdt 7$8$H$gdtTkd$$Ifl0,"(p t644 layttKKKLLqLLLLL_M`MaMMMMMMMNNONPNƳr_TE_h^htB*CJ^Jphfffh^htCJ^J%h,htB*CJ^JmH phsH h,ht0JCJ^J#j h,htCJU^Jjh,htCJU^JhtCJ^Jh,htCJ^J%h^htB*CJ^JmH phsH htB*CJ^JmH phsH ht5B*CJ^Jphhq*5B*CJ^Jphh}5B*CJ^JphPNNBOROSO}O~OOOPPP PPPPPPQQݻv^^I^>2h^htCJ]^Jh^htCJ^J)h^ht0JB*CJ^JmH phsH .jh^htB*CJU^JmH phsH ,h^ht0JB*CJ\^JmH phsH (h^htB*CJ\^JmH phsH 1jh^htB*CJU\^JmH phsH h^htB*CJ\^Jph# h^htB*CJ]^Jph# %h^htB*CJ^JmH phsH h^htB*CJ^JphQ|R SqS"TTUUVVVVVVV V V V VVVVVVVgdq*dgdt$ & F' d*$a$gdtQUVVVV V VVVVVV;V*@ E0 Heading 3g$\R" b2> Y!r"B%(*-0R3"68;>bA2DGI@& 56CJ4@4 E0 Heading 4$@&8@8 E0 Heading 5$@&5<@< E0 Heading 6$@&5CJ<@< E0 Heading 7 $@&a$5<@< E0 Heading 8 $@&a$5DA@D Default Paragraph FontRi@R 0 Table Normal4 l4a (k( 0No List ZOZ nM Char Char15*5@CJ KH OJPJQJ\^JaJ tH \\ nM Char Char14,56@CJOJPJQJ\]^JaJtH VV nM Char Char13&5@CJOJPJQJ\^JaJtH V!V nM Char Char12&5@CJOJPJQJ\^JaJtH \1\ nM Char Char11,56@CJOJPJQJ\]^JaJtH NAN nM Char Char105@OJPJQJ\^JtH NQN nM Char Char9 @CJOJPJQJ^JaJtH TaT nM Char Char8&6@CJOJPJQJ]^JaJtH :O: E0Addressa$ 5mH sH 8@8 E0Header !CJBOB nM0 Char Char7@OJQJaJtH 8 @8 E0Footer !CJFOF ${:0 Char Char6@OJQJ^JmH sH :U@: E0 Hyperlink>*B*^JphJVJ E0FollowedHyperlink>*B* ^Jph@B@ E0 Body Text p@ 1$BB nM0 Char Char5@OJQJaJtH B>@B !E0Title  p@ 1$a$5CJ0XOX nM Char Char4*5@CJ KHOJPJQJ\^JaJ tH 2P"2 #E0 Body Text 2"B1B "nM0 Char Char3@OJQJaJtH LCBL %E0Body Text Indent$0^`BQB $nM0 Char Char2@OJQJaJtH 6Qb6 'E0 Body Text 3&a$FqF &nM0 Char Char1@CJOJQJaJtH ,W@, E0Strong5^JDOD E0 No Spacing)CJ_HmH sH tH RYR +@0 Document Map*M CJOJQJ^J<< *nM0 Char Char@CJaJtH jj t Table Grid7:V,0,026:+O026:@ +O.J8mn{3)a ' i j k u v XY34Hxy01EF_wx89 !!!!""##$$$$%%%%&&''''()))++...00%1&1412233355<5888-899999999999:::_; <<= >>>>??@-@D@@@@AABcBdBmBtBBB C9C:CMCCCCCCCDDqDEPFFBGHII|J KqK"LLMMNNNNNNN N N N NNNNNNNN@AB*W.D`EE}GGHHHH+OXXX!\(""# AA@t  !\(  h CE%"  3"?  @ABCqELFSS?-;lbn2qk\D@ORQ8Q* gw  W <b14\5q<O>B 1 8w1N/ : f 1  y?  u M  4  `6U:LsNA_cknkAehS)8Z' sZ' *b?@R`CE%"  @AB CnExFf%Ip,0A  K *   8 h  L  D kk nPn&k X>@`4B "B2    #$B2   | b  3 #" ? b  3 #" ? 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Submissions

The Paediatric Society believes all children and youth should, by right, attain optimal physical, mental and social health and wellbeing.  By working as a coordinated national network of health professionals the Society dedicates its efforts and resources to making official submissions to both Government and Non-Government organisations on issues that will impact on the health and wellbeing of children and young people.

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