Category Archives: Children

Not Sleeping Well? Here’s My Advice.

This week, March 6 – 13, is National Sleep Awareness Week, so it’s a good time to review healthy sleep habits. I see a lot of adults and teens in my clinic who are chronically tired and have troubles sleeping — both falling asleep and staying asleep.

How Much is Enough?

According to the National Sleep Foundation’s research, here’s the amount of sleep we need:

  • Newborn (0-3 months): 14-17 hours
  • Infant (3-12 months): 12-15 hours
  • Toddler (1-2 years): 11-14 hours
  • Preschool (3-5 years): 10-13 hours
  • School age (6-13 years): 9-11 hours
  • Teenager (14-17 years): 8-10 hours
  • Adult (18-64 years): 7-9 hours
  • Older adult (>65 years): 7-8 hours

One of the main problems with insufficient sleep is the daytime sleepiness, an obvious consequence of not sleeping enough. A fascinating series of tests in children showed that insufficient sleep and daytime sleepiness both lead to worse school performance. Most of these children went to bed at 9-9:30 am and almost all got up at 7 am, causing a daily sleep debt of 1/2-1 hour for many children. While that may seem like a small amount, like any debt, it must be paid back, and most children cannot recover all of this lost time by sleeping late on weekends.

One good bit of news from the same study describes how delaying school start times even by just a half hour can significantly improve sleep duration and daytime sleepiness. In their interventional study with six primary schools in Shanghai, delaying school openings from 7:30 to 8 or 8:30 gave the children almost an hour of extra sleep — and more importantly, less complaints of daytime sleepiness. This fits with studies in other parts of the world and supports the growing movement, led by pediatricians, to delay school opening times to 8:30 am. Just doing this could allow better sleep and improved test scores for all students!

Besides school performance, poor sleep also leads to an increased risk of overweight and obesity in children (as well as adults). A 2007 meta-analysis of 36 studies across the world showed a strong, independent association between short sleep duration and weight gain in children, which continues into adulthood.

For adults,  poor sleep can cause long-term problems with high blood pressure, depression, diabetes and obesity. It can also cause dangers such as sleeping behind the wheel or more errors at work (medical training and internships are notorious for this, as are night shift workers driving home).

My tips for sleeping well

Get all screens out of the bedroom. Technology is changing so quickly that it’s difficult for research to keep up. But it’s clear that many people are having a lot more sleeping troubles when using their iPads and cell phones at bedtime. It’s partly because their backlight alters our sleep hormones, but also it’s distracting us with answering text messages even after lights out. I think a great general rule, for adults and kids, is no screen time two hours before bedtime (that includes TV), and definitely get all screens out of your bedroom while you sleep.

Exercise often — but early. Exercise has been shown to improve sleep habits, but only if done at least four hours before bedtime. Otherwise, you still may have too much metabolic energy and will have trouble falling asleep. This is also a good tip for kids who are having sports practices late into the night.

Avoid alcohol and smoking before sleeping. Alcohol is a major cause of insomnia for many. Drinks will certainly make you sleepy, but your body will rebound and wake you up in the middle of the night. It’s far better to have only a drink or two, at least 2 hours before bedtime. Smoking causes the same problems; that initial relaxation quickly wears off and the nicotine stays in your system for hours.

Caffeine is another major cause of poor sleep. As we get older, we cannot handle the triple-shot cappuccinos which we had in college, and it’s very common to have poor sleep with any caffeine drinking after lunchtime. So if you’re having light sleep, definitely take a look at your caffeine habits first; any tea, sodas or coffee after lunch may be keeping you awake. If you must have your afternoon coffee, at least try to switch to decaf.

Other tips include not staying in bed if you can’t sleep. If you can’t fall asleep, after 20 minutes of trying you should get up and try to relax in another room. Staying longer in bed generally makes you more anxious, making it even harder to fall back asleep.

Take a nap. Napping, even if only 20-30 minutes when needed, has been shown to have great benefit for short term memory and concentration. As I get older, I definitely lag more in the afternoon, and a 15 minute power nap at lunch really helps me get through a busy clinic afternoon (as does a lighter lunch).

What about natural medicines and non-prescription pills? Many people use over the counter pills such as Tylenol PM. It does work well, in the short term, for many people — but I strongly advise not taking it regularly, as the Tylenol component is totally unnecessary and can cause liver problems if taken chronically. If you must use this medicine, please buy only the active ingredient, diphenhydramine (Benadryl) separately and only use that. As for natural medicines, melatonin works for some types of insomnia but is rarely very effective. Others may consider an herbal capsule with valerian and other compounds such as passionflower, hops or lemon balm.

 

 

Don’t Skip Breakfast! Here’s Why.

Did you know that the U.S. Center for Disease Control predicts that one third of all Americans will have diabetes by the year 2050? This scary statistic is not just an American phenomenon; many Western countries’ modernized diets have led to a diabetes epidemic. The main culprits are what you would expect: obesity and an unhealthy diet. These lifestyle patterns are set as children, and are very difficult to change later on.

So what steps can we take to prevent this? As we recognize National School Breakfast Week, one crucial step is to always have breakfast. Most of the 20-30% of children and teens skipping breakfast may think it’s no big deal, but the long-term consequences of skipping breakfast can be serious enough to warrant a big family discussion. We all know instinctively that eating breakfast is important, and research can help parents convince their kids to eat breakfast — as well as eat it themselves!

Most kids are very focused on the present, and they just won’t be motivated with any talk about health risks decades down the line.  But they’re much more open to data showing how breakfast-skippers not only gain more weight, but they also do worse in school. So if you have an overachiever child who runs out the door in the morning without breakfast, show them the studies showing that breakfast skippers perform worse in school exams.

And here’s an important tip for parents whose child is terrified of gaining weight and skips breakfast: children who skip breakfast actually end up more obese than those who eat breakfast! The main reason for this is mostly because breakfast-skippers get very hungry by lunchtime and end up binge-eating more, usually with less healthy mid-morning snacks and bigger lunch portions. Also, because their metabolism is in a partial fasting mode without breakfast, the body stores more energy from foods as fat, instead of just breaking it down to glucose for your brain and muscles.

Adults also don’t get a pass for skipping breakfast, as they get the same slow weight gain as kids do. The importance of eating breakfast was impressively covered in the Childhood Determinants of Adult Health Study. In this fascinating study from Australia, researchers asked 2,000 school children about their breakfast habits, then followed up with them 20 years later and assessed their health. The results were striking; those kids who skipped breakfast all those years had a larger waist — by 2 inches! These same kids as adults also had higher insulin levels, which leads to more diabetes. They also had higher total cholesterol and the “bad” cholesterol, LDL — both of which cause clogging of the arteries and lead eventually to heart attacks and strokes. Another long term study, this time from Japan, followed 82,000 people for 15 years and found that the breakfast-skippers have a 14% increased risk of heart disease and 18% higher risk of strokes.

And for those of you worried about diabetes, or told you are prediabetic, it’s very important to follow the usual advice to have small, frequent meals instead of one or two large meals. Another excellent study, the Health Professionals Follow-Up Study, followed 29,000 American men for 16 years, and found that the breakfast skippers had a 21% increased risk of developing diabetes.

The type of breakfast is also important. The main research suggests what is obvious to parents — that simple sugars in sweetened cereals are much less healthy than high-fiber, more complex whole-grain cereals as well as fruits, nuts, and dairy products. Those quick energy bursts from the sugary cereals give kids a quick “high” which just as quickly wears off, and their brains and body are dragging along come lunchtime.

My advice for those of you who skip breakfast because “I have no time”: at least try to have a cup of yogurt with some fresh berries and cereal in the morning. You can throw it in your bag, along with a banana, and eat it on the way to school or work. Yogurt by itself is a superfood with its calcium and probiotics, and daily yogurt actually helps you to keep your weight stable. And blueberries are packed with healthy antioxidants and fiber.

So, the next time your kids are trying to run out the door before breakfast, sit them down in front of a bowl of Wheaties with yogurt and tell them how breakfast helps with better grades as well as better health — now, and in their futures.

Rubber Ducky You’re The One — To Cause Diabetes and Cancer?

My boys are now both over two years old, but they still like the occasional chew on their toys, which are mostly made of plastic. Rubber duckies, Lego men, Brio trains — it’s still a ton of fun to put in their mouths if it makes mommy and daddy really mad. I choose my battles with them, but I try to stop them partly because I’m worried about the chemicals in the plastic. Surely, microscopic parts of that plastic must be getting into their systems? One set of bath toys was very typical, made in China but exported to America, from a company vowing they are “safe and dependable”, with standards that “meet and exceed” US laws. What exactly does that mean? What are these laws? Should I be worried? And just how well can I or any parent protect our children from all environmental harms?

When I think about our modern world’s reliance on chemicals and plastics, I’m reminded of what Donald Rumsfeld called the “known unknowns” – we know that we understand almost nothing about the safety of the 80,000 consumer chemicals created since World War II, because they’ve never been required to be tested on humans. As the WHO states in their 2012 report State of The Science of Endocrine Disrupting Chemicals, “the vast majority of chemicals in current commercial use have not been tested at all.

bathtoy

The chief concern is that some of these chemicals are endocrine disruptors, which are chemicals whose molecular structure is similar to our natural hormones. With this mimicry, they can bind to the same receptors that our natural hormones do, thus altering our normal endocrine activities which control  just about every aspect of our health. We are mostly worried about children because these endocrine disruptors could cause permanent damage during our most sensitive growth spurts: while still developing in the womb, and later during puberty. The most notorious example of an endocrine disruptor is diethylstilbestrol (DES), a synthetic estrogen which was given to many pregnant women in the decades after World War II as a treatment to prevent birth complications. But slowly it became clear that many newborn girls of these mothers were getting a rare vaginal cancer, and DES was banned and declared a carcinogenic — but even right now many of these same “DES daughters” are continuing to have reproductive health problems both for themselves as well as in their own children, which means some endocrine disruptors can permanently alter our DNA, affecting generations.

The US Endocrine Society published an even more damning document, their 2015 Scientific Statement on Endocrine-Disrupting Chemicals, which concludes that

…there is strong mechanistic, experimental, animal, and epidemiological evidence for endocrine disruption, namely: obesity and diabetes, female reproduction, male reproduction, hormone-sensitive cancers in females, prostate cancer, thyroid, and neurodevelopment and neuroendocrine systems.

The prestigious JAMA Pediatrics published their own review of endocrine disruptors in 2012, essentially agreeing with the WHO’s assessment that while hard data on humans isn’t very strong, there’s enough concerning data to conclude that “efforts to reduce EDC exposure as a precaution among pregnant women and children are warranted.” Chemicals such as BPA, PVC and phthalates are most often mentioned as causing harm in boys and girls, associated with infertility, obesity, cancers and neurodevelopmental problems such as behavioral issues and a lower IQ.

Plastic ID Codes and Properties. Source: tinyurl.com/o487x9o
Plastic ID Codes and Properties. Click to enlarge. Source: tinyurl.com/o487x9o

So what can we all do to protect ourselves? After all, everything we touch almost literally has plastic as part of it. I’ve found a few consumer groups and blogs that offer helpful advice for worried parents. My favorite is The Soft Landing blog, which has a very useful collection of safer product shopping guides. The Pediatric Environmental Health Specialty Unit also offers similar advice. Here’s a small summary of what most are advising:

  • Try to buy products (especially for babies) that are free of BPA, phthalates and PVC (The Soft Landing website has great blog lists).
  • Switch all your plastic food containers to glass.
  • With the Plastic Coding System, avoid numbers 3, 6 and 7 and try to use numbers 1,2,4 or 5.
  • Consider buying organic produce to reduce exposure to pesticides..
  • If you must use plastic cling wrap, only use PE wrap; minimize contact of cling wrap plastic with the food; and try not to microwave with the plastic on it. Especially don’t let the plastic sit on top of liquids, whether cold or hot.
  • Reduce indoor dust exposure by cleaning carpets and dusty surfaces regularly using a vacuum cleaner with a high-efficiency particulate air (HEPA) filter.
  • Always immediately transfer your restaurant leftovers into glass containers at home, and never reheat your leftovers or eat directly from takeaway plastic containers.

We’ve put most of these into practice in our home, so I feel a bit less stressed about this issue.  And the boys’ bath toys? While The Soft Landing blog reassuringly listed them on their list of safer bath toys, their own company rep emailed me to confirm they are “BPA-free, phthalate-free, and non-phthalate PVC”. So I am letting them munch away — for now. Choose your battles…

Obesity in Childhood: How Can We Stop the Pandemic?

obesity in childhoodIt’s no secret that children all over the world are putting on too much weight; in the US, an astonishing 1/3 of children are overweight or obese.  Being overweight as a child can lead to many diseases as an adult, including heart disease, diabetes, arthritis, high blood pressure, and some cancers. Also, overweight kids have lower self-esteem and higher risks for depression. So what can parents, or society really do to stop this epidemic? And how can family doctors and pediatricians help?

The first step parents should take is to find out where your child fits on a Body Mass Index (BMI) chart. Your doctor should be doing this at the well-child exams, but you can easily find childhood BMI calculators online (such as this one) and find out yourself. A child above 85% is considered overweight, and above 95% is obese. Many parents are surprised at finding their child is officially overweight or obese, which is why these objective BMI standards are important for tracking, as well as assessing progress.

There are quite a few weight loss approaches that most doctors can agree on; one major agreement is that diets almost never help, at any age. Any diet plan designed for quick weight loss is almost guaranteed to long-term failure, and many people frequently end up even heavier than before. The healthiest option is always slow and steady weight loss. One pound a week of weight loss for many children, from very conscious changes in diet and exercise routines, is appropriate.

Another major approach involves cutting back on TV time. The American Academy of Pediatrics just published a major policy statement stating that “the evidence linking excessive TV viewing and obesity is persuasive“. They specifically recommend a ban on junk- and fast-food advertising in all children’s TV programs, and they set specific limits of TV time for age groups. They also detail multiple studies showing how having a TV in the bedroom is another independent risk factor for obesity, both as a child and later as adults. They also recommended that “pediatricians need to ask 2 questions about media use at every visit: 1. How much screen time is being spent per day? and 2. Is there a TV set or Internet connection in the child’s bedroom?”

One approach I mentioned before was to have a good breakfast. Many studies have shown that eating a nutritious breakfast is crucial for a child’s physical growth and school performance, and that breakfast-skippers actually end up more overweight, both in childhood and later as adults.

Of course, the main treatments for obesity are the obvious: more exercise and eating proper foods in moderate amounts. It’s important that there be a family effort to help your overweight child lose weight. Parents also need to lead by example; it’s much harder for a child to lose weight if their parents are also overweight and don’t exercise. As for diet recommendations, the most obvious choices to eliminate are sodas and fruit drinks. Sodas truly have almost no redeeming value, especially for children. Any child drinking a daily soda is adding extra pounds of fat each year, and they are also increasing their risk for diabetes as well as teeth problems. Most fruit juices are also quite poor substitutes for natural fruits and should be used at a minimum. For exercise, most kids should be getting 60 minutes a day, but this can be broken up into multiple sessions. The key is finding something they love to do. And don’t forget that any exercise is better than nothing!

Another effort involves reviewing the foods at school. I recently heard the great news that milk producers in America reformulated their flavored milk to have 1/3 less sugars and calories. Many (but not all) nutritionists consider this a positive step, as schools that totally eliminated flavored milk encountered a large drop in milk drinking, which raises the risk of kids not getting enough nutrients such as calcium. What does your school do?

Parents who want to learn more about childhood obesity and how to fight it can find excellent resources at the website healthychildren.org, which is officially run by the American Academy of Pediatrics. And at familydoctor.org, the American Academy of Family Medicine also offers many tips on weight loss for all ages.

Curing a Cough: What’s the Best Medicine?

Coughing from a cold or flu is probably the most frustrating symptom we can have — for children, their parents, and even the doctor treating them. Why? Because there’s honestly very little that we can do to treat it. That’s a hard pill to swallow, and it’s especially humbling for me as a family physician. But it’s also very frustrating for me as a father of two toddlers, as they just started daycare and are fighting new viruses every week. As we comfort them at two in the morning with a hacking cough, I’ll face same question from my wife as from parents in my clinic: “which cough syrup should we use?”

First, it’s important to note that a cough is generally a good thing. It’s our body’s natural attempt to get germs and toxins out of our bodies, so it’s not such a healthy idea to suppress the cough too much. Of course, a cough can become too severe, or painful, and lack of sleep isn’t good for anyone’s immune system. So in terms of that, I think it’s reasonable to try something safe. But it’s clear that no matter what you use, nothing makes a cough completely go away for more than a couple of hours. And it’s also important to note from the graph below that the cough is always the last symptom to get better, and may linger even for a couple of weeks.

a graphical image and time line for cold symptoms

Having said that, I’d like to help you cut through the confusion at your pharmacy and make this simple: don’t bother with almost any of the OTC cough syrups. First, try some honey.

Your pharmacy shelves have a bewildering assortment of cough and cold medicines. It’s confusing for me as well, even with my training! Overdosing is quite a problem, especially for children. In fact, drug makers in 2008 voluntarily changed their warning labels (with a gentle push from the FDA), pulling off the shelves all cough medicines used for children under two years old, and changing warning labels to say “do not use in children under 4 years of age” (you can read the FDA statement here). The American Academy of Pediatrics is even more strict: no OTC cough medicines for any child under 6 years old, and caution from ages 6 to 12. The major concern has been the number of overdoses, even deaths, in children taking too much of these medicines — especially acetaminophen, otherwise known as Tylenol, which is added for pain and fever relief. In a proper dose it works wonderfully, but in high doses it causes liver failure.

Not only are these medicines potentially dangerous, they also barely work anyway. For example, the decongestant phenylephrine, which is now in almost every combination medicine, is no better than placebo in the best research results. In other words, there’s a good reason your runny nose isn’t getting better — it’s because the medicine doesn’t work. This medicine a couple of years ago replaced the far more effective drug pseudoephedrine — but this is now only behind the pharmacy counter, because people were buying pseudoephedrine-containing pills in bulk and cooking it down to make methamphetamine. So if you really want sinus relief, you have to ask the pharmacist for pseudoephedrine. It’s still OTC, so you don’t need a prescription from your doctor, but you’re only allowed two boxes.

The bright side to all this is that the most useful cough syrup may be in your home right now. It’s honey! A Cochrane database review from 2014 showed that honey helped better than dextromethorphan and also diphenhydramine for cough frequency, severity and quality of sleep, for children and their parents, with minimal side effects.

My advice for a cough in different age groups is as follows:

Age one and under: no OTC syrups are safe, including honey, which carries the risk of botulism. The best advice is to take care of the cause of the cough, often from post-nasal drip, by using nasal saline drops or spray. A bedroom humidifier can also help if the room is too dry, especially in cold winter nights. Probiotics also can be helpful, as a growing number of studies are showing their effectiveness in reducing duration of a cold, less severe symptoms, and less time away from school or work. The best research is on bifidobacteria and Lactobacillus GG probiotics. Also, don’t forget to get the annual flu shot for any child over 6 months of age. If they’re younger, they’re vulnerable to get the flu — which is why it’s even more important that all caretakers and family members get the annual flu shot, so they won’t pass along the flu virus to the baby. Coughing can also cause pain from a sore throat or rib inflammation, so if your baby is fussy but has no fever, they may be in pain, so don’t be afraid to give them ibuprofen or acetaminophen syrups for comfort (and better sleep).

Ages 1-6: I think honey or honey-based herbal mixtures (not homeopathic) should be the first choice for a cough. Probiotics should also be used during the illness. Taking care of nasal congestion often can help decrease a cough, again including the safe remedy of nasal saline rinsing. As a second choice of syrups, a cough syrup containing only dextromethorphan could also help a bit, as was shown in that Cochrane review from 2014. This medicine is the “DM” part of many labels.

Ages 6-12: Again, honey-based syrup is not only the most effective but also the safest choice. At this age, the risk-benefit ratio of other treatments becomes more favorable, including my favorite nasal decongestant combination: pseudoephedrine pills and oxymetazoline nasal spray. Probiotics during the illness also are helpful. But don’t forget that many doctors would still be hesitant to recommend any OTC medicines until 12 years of age. Also, while the oxymetazoline nasal spray works rapidly for nasal congestion, never take it for more than 5 days in a row, otherwise you can develop rebound nasal congestion and could become dependent on it (we call it “Afrin addiction”).

Ages 12 and up: We’re finally at the “adult” age where most OTC medicines at least are safe to use, whether or not they’re effective. I would still stick with honey syrup, and the decongestants as I mentioned above. Again, don’t forget about probiotics. Also, don’t forget about common sense items such as a healthy amount of sleep, as well as foods full of antioxidants, and light exercise to boost your immune system. In terms of natural medicines, elderberry syrup has some evidence to help decrease symptoms of the flu.

Ages 65 and older: Here we start getting cautious again with OTC medicines, as many might have unwanted side effect combinations with the prescribed medicines for chronic diseases that many elderly people take. As we get older, we can’t fight off infections as well as we could when younger. So it’s important not to get sick in the first place — with the annual flu vaccine, as well as the pneumonia vaccines. If you do get a cold, some OTC medicines may cause more side effects in the elderly, such as dangerously high blood pressure from pseudoephedrine, or confusion, urinary retention and lethargy from diphenhydramine. I would focus on honey or dextromethorphan syrups, and nasal saline spray for a decongestant.

Which OTC medicines don’t work at all, at any age? I would advise not to use any homeopathic remedies, such as Oscillococcinum or Zicam, which may seem appealing to many but literally have no evidence of effectiveness, as you would expect from a product which by definition has zero molecules of any active drug. The FTC recently issued an enforcement requiring homeopathic labels to state ” (1) There is no scientific evidence that the product works and (2) the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts.” And it’s also dangerous to assume that homeopathic medicines are safer, as noted by this winter’s warnings by the FDA against homeopathic teething tablets, which tests show may have toxic amounts of belladonna, and which could be related to ten deaths of infants. Clearly this is a case where the risks far outweigh benefits.

For more information about treating the common cold, you can read my family practice academy’s parent handout about treating the common cold in children ; and more articles about the common cold at my wellness blog at MyFamily Health Guide.

 

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Digital Media and Children: Not All Screens Are Equal

 

I knew it was inevitable, but I was hoping to delay it a bit longer: my son Alex has discovered the digital world. Almost two years old, he’s increasingly fascinated with mommy and daddy’s smartphones, tablets, and laptop computers. As I help him drag Curious George toys on an iPad app to complete a puzzle, I feel a pang of guilt knowing I’m breaking a taboo to have no screen time of any type for any child under two (and two hours maximum total screen time for older children), policies long recommended by the American Academy of Pediatrics (AAP) and the Obama administration, among others.

Am I already ruining his chances to go Ivy League?

This hard and fast two-hour policy, beaten into parents’ brains by their pediatricians, troubles me and many others partly because it was last updated in 2011 before the astounding boom of tablets, smartphones and touch screens among both kids and adults. The policy warnings had focused very reasonably on TV and its clear long-term harms to healthy development in kids under two—especially harmful when passively watching non-interactive, non-educational TV.

But such traditional passive TV watching, while still the dominant form of media consumption for most children, is rapidly becoming meaningless for many. Clearly, an interactive video game that parents and toddlers are playing together or watching family vacation videos on a smartphone can have huge value compared to zombie-like staring at an episode of Spongebob or China’s popular Pleasant Goat (喜羊羊) cartoons—these kinds of shows are shown in studies to harm a young child’s executive functioning, a prefrontal brain skill set including memory, attention, and setting goals.

Not all screens are equal, and guidelines need to be updated to reflect these differences.

The policy also doesn’t reflect the reality on the ground: a recent survey of parents by Common Sense Media shows that toddlers under two are spending almost one hour a day using screen media anyway. This is why, in my own efforts to offer better advice to my patients as well as myself and my wife, I set out to find the most recent research that focuses on digital media with young children.

Teachers are an obvious source to assess what’s working for children’s education. In a Joan Ganz Cooney Center 2013 survey of 694 American teachers of kindergarten to eighth grade, most teachers (74%) reported they were already using digital games as part of their classroom teaching. A great majority (78%) thought that digital games were improving student mastery of basic curriculum (especially math), and 71% agreed that they helped with extra-curricular skills such as critical thinking, collaboration and communicating. Only 21% thought that digital games in classrooms led to behavioral issues.

We often, and by default, assume that video games are inherently antisocial and couldn’t truly be healthy for our society. But much research has shown that many of these games are quite the opposite, actually helping to foster social skills such as empathy, caring, and sharing. I encountered the term “prosocial” quite often in the new research, and I think it’s a powerfully evocative word to help understand digital media’s positive potential.

An impressive study published last August in Pediatrics, surveyed 5,000 children ages 10 to 15 and found that those who played video games up to one hour a day had higher levels of life satisfaction, prosocial behavior, and behavioral control compared to those who played no games. The study also showed that playing too much (more than three hours a day) had the opposite effects. Another main point was that both positive and negative effects were actually quite small.

It’s also helpful, and important, to distinguish between types of screen time. Passive TV watching is clearly the worst type of screen time. An excellent review published last year in British Medical Journal surveyed 11,000 mothers in the UK and compared whether TV and electronic game use in five-year-old children led to behavioral issues when they reached seven. They found that excessive TV (or DVD) watching (over three hours) led to worsening social behavior, conduct, and hyperactivity, compared to light TV watching, under one hour a day. And light video game playing also showed improved social behavior compared to no playing.

I still generally agree with most of the AAP’s family media plan advice, especially no TV ever in bedrooms and no screens at certain times of the day, including during meals, and screen time limits depending on age. With children under two, I definitely believe that screen time should never be spent alone: kids always benefit more from any activity when parents are playing along.

Even more practical advice about which digital media may be helpful or not is in the outstanding website from non-profit Common Sense Media. The site has a handy list of best apps for preschoolers, along with very practical ratings including quality, learning potential, positive role models, ease of play, and consumerism. This is where I discovered highly rated apps like Busy Shapes, which I’ve played with Alex and has positive developmental benefit—but still probably isn’t nearly as beneficial as an old fashioned wooden puzzle set. I tried the e-book version of Dr Seuss’ My ABC Book, but he ignored the lovely rhymes and kept tapping to hear the noises (some, but not all, research does show that e-books are often inferior—as children who focus on the distracting technology absorb and understand less of the story).

For all the redeeming qualities of interactive screen time, however, what is clear to me after all my research is that even a highly-rated app or video games could never be as stimulating or educational as actual 3D games. Stacking, matching, reading books—all of these flat 2D-screens just can’t compare to a pile of crayons, wooden blocks and Legos. But I’ve also decided that Alex, at 21 months, can continue to dabble in some digital media. My wife and I haven’t watched traditional TV in many years and only use it for DVD or ad-free TV shows, and we always keep the kids away from this passive exposure. In all cases, we still limit total time to far below one hour a day, and almost none of it is ever unsupervised.

I think we’re doing a pretty good job in this new digital world. Screens are an ever-rapidly essential and inescapable part of modern and future life, and with a bit of evidence-based guidance, our kids will be just fine.

 

© 2014 Richard Saint Cyr, as first published on Quartz