Andrew Tagg. Back to School, Don't Forget the Bubbles, 2020. Available at:
It’s the first day of school here in Australia and parents and carers are waving their young children off with a kiss for their first day. When I first saw the size of school bags I was amazed. How can children carry so much? Surely they will just fall over and lie on their backs waving their little legs in the air like distressed turtles? What on earth are they carrying in there that needs the Bag of Holding?*
What’s the problem?
Barbosa J, Marques MC, Izquierdo M, Neiva HP, Barbosa TM, Ramírez-Vélez R, Alonso-Martínez AM, García-Hermoso A, Aguado-Jimenez R, Marinho DA. Schoolbag weight carriage in Portuguese children and adolescents: a cross-sectional study comparing possible influencing factors. BMC pediatrics. 2019 Dec;19(1):157.
With reduced access to lockers, it seems that children are taking the weight of the world on their shoulders. Surprisingly, this Portuguese group found that Grade 5 children carried more than Grade 9 kids. This trend has been replicated in New Zealand with Grade 3 kids carrying around 7kg (13.2% of their body weight) and Grade 6 leavers bearing only 6.3Kg (10.3% body weight). Most school items have a set weight, no matter what grade you are in, but one might have thought that as the educational load increases over the years so might the weight of the textbooks. Perhaps an increase in the use of personal electronic devices and e-books accounts for some of this difference.
Surely carrying those giant bags can’t be good for the growing body? Neck, back, and shoulder pain are prevalent in adolescents and are closely linked by carrying heavy school bags. These effects take place when the bag weighs more than 10% of their body weight. In nearly every study girls carry more than boys. This makes sense as although they may carry exactly the same things in their rucksacks girls are generally lighter and so the weight of their bag, as a percentage of their total body weight, is higher.
Mandrekar S, Chavhan D, Shyam AK, Sancheti PK. Effects of carrying school bags on cervical and shoulder posture in static and dynamic conditions in adolescent students. International journal of adolescent medicine and health. 2019 Oct 30.
This group looked at how they carry their bags. Trying to be cool and swinging your bag over just one shoulder changes one’s static biomechanics. The head and neck move forward to compensate and the carrying shoulder rises. Then, because the centre of gravity is shifted the subject would tilt their torso away. Could this be the cause of the stereotypical teenage posture? It took just five minutes of bag wearing for any postural changes to become evident. It has also been suggested that a heavier bag weight is associated with an increased incidence of lower back pain in teens and this, in turn, is linked with an increased risk of lower back pain as an adult.
If they are not wearing their back slung over one shoulder they are wearing it slung low, rather than high and tight on their shoulders, and most of the biomechanic data suggests this puts a lower degree of stress on their lumbar spines than letting it ride high. The higher position also lends itself to more forward rotation of the pelvis and greater hip flexion. And, of course, wearing your bag on the front, instead of on the back, causes a whole new range of issues.
Whilst this post is focusing on just one potential downside of heavy school bags, Wierseema et al. found 247 children with injuries related to backpack use between 1999-2000. These were due to tripping over them (28%), getting hit by one (13%) or just trying to put them on (8%). Actually wearing the thing was associated with another 13% of complaints – specifically back pain.
There is also a condition called backpack palsy or, to be more accurate, backpack brachial plexus palsy. It is much more common in military recruits but can occur in children. Often unilateral, the paraesthesia, pain and sensory loss in addition to possible muscle wasting are due to neuropraxia of the brachial plexus.
Does it make a difference if teenagers take some of the rubbish out of their bags?
Rodríguez-Oviedo P, Santiago-Pérez MI, Pérez-Ríos M, Gómez-Fernández D, Fernández-Alonso A, Carreira-Núñez I, García-Pacios P, Ruano-Ravina A. Backpack weight and back pain reduction: effect of an intervention in adolescents. Pediatric research. 2018 Jul;84(1):34.
This Spanish group targetted teenagers with an educational intervention. This comprised of a one-hour session on posture, the effects of backpack weight and some healthy lifestyle advice. They found that the intervention arm of the trial did indeed have (statistically significant) lighter bags moving forward in the younger cohorts but not in the older ones.
Mathur H, Desai A, Khan SA. To determine the efficacy of addition of horizontal waist strap to the traditional double shoulder strap school backpack loading on cervical and shoulder posture in Indian school-going children. Int J Phys Med Rehabil. 2017;5(434):2.
If you want to reduce the usual bag-induced postural slump these authors, looking at 60 children, suggest that adding a waist strap to the usual two shoulder straps could make all the difference.
So what does this all mean?
As parents, we need to keep an eye on what our children are actually putting in their bags (compared to what they say they are putting in there). Perhaps we should weigh the bags as often as the children and limit the number of keyrings and Beanie Boos attached to the outside? Perhaps we need to further embrace technology and allow for the increased use of electronic devices coupled with a much, much older technology and let them use bags on wheels, similar to carry on luggage?
There have been a number of initiatives to make the wearing of school backpacks healthier. Sri Lanka introduced a National Healthy Schoolbag Campaign aimed at improving the lives of children. Large textbooks were split into smaller volumes to make it easier to carry just one small book around and a multidisciplinary schoolbag regulatory council was set up to liaise with industry partners to help regulate bags. In the US the “Pack it light, wear it right” initiative focussed on what the individual could do.
*If you really want to know what is in their bags you need to look inside. This wonderful paper from Archives suggests that the vast majority (96%) of parents had never checked the weight of their children’s bags and 34% had never even looked inside
Forjuoh SN, Little D, Schuchmann JA, Lane BL. Parental knowledge of school backpack weight and contents. Archives of disease in childhood. 2003 Jan 1;88(1):18-9.
Other Selected References:
American Academy of Pediatrics. How not to wear a school backpack. AAP Grand Rounds. 2008 Nov 1;20(5):58-9.
Brackley HM, Stevenson JM. Are children’s backpack weight limits enough?: A critical review of the relevant literature. Spine. 2004 Oct 1;29(19):2184-90.
Kim KE, Kim EJ. Incidence and risk factors for backpack palsy in young Korean soldiers. Journal of the Royal Army Medical Corps. 2016 Feb 1;162(1):35-8.
Goodgold S, Corcoran M, Gamache D, Gillis J, Guerin J, Coyle JQ. Backpack use in children. Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association. 2002;14(3):122-31.
Jayaratne K, Jacobs K, Fernando D. Global healthy backpack initiatives. Work. 2012 Jan 1;41(Supplement 1):5553-7.
Maurya S, Singh M, Bhandari PS, Bhatti TS. Backpack brachial plexus palsy. Indian Journal of Neurotrauma. 2009 Dec;6(02):153-4.
Rose K, Davies A, Pitt M, Ratnasinghe D, D’Argenzio L. Backpack palsy: A rare complication of backpack use in children and young adults–A new case report. european journal of paediatric neurology. 2016 Sep 1;20(5):750-3.
Talbott NR, Bhattacharya A, Davis KG, Shukla R, Levin L. School backpacks: it’s more than just a weight problem. Work. 2009 Jan 1;34(4):481-94.
Weir E. Avoiding the back-to-school backache. CMAJ: Canadian Medical Association journal= journal de l’Association medicale canadienne. 2002 Sep;167(6):669-.
Wiersema BM, Wall EJ, Foad SL. Acute backpack injuries in children. Pediatrics. 2003 Jan 1;111(1):163-6.