Category Archives: Wellness

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.


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:
Plastic ID Codes and Properties. Click to enlarge. Source:

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, which is officially run by the American Academy of Pediatrics. And at, 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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Why I Became A Family Doctor

I am a family medicine doctor – but that is only a small part of who I am. Father, husband, photographer, social media guru, writer, singer — these are only a few of the many ways I define myself. But when I am on my deathbed, hopefully many decades from now, and looking back on my life, what will I list as my top accomplishments? What will resonate deep in my heart that I’ve lived a full life? Would it be my career? Actually, yes, this would be partly true. Of course my most satisfying moments will be a legacy of family and children, and I’m happily on that path. I am sure that I won’t find any more joy than surrounding myself with my wife, children and future generations. But regarding a career, I am extremely fortunate that I truly love my job and derive deep satisfaction from my 9-to-5 career. Very few people can say that about their job. Can you? And if you can’t say that, then perhaps you should do what I did – change your career path. It’s never too late.

Becoming a family medicine doctor was a second career for me, a life-changing decision that I made far after my undergraduate years at Columbia University. I never grew up thinking about becoming a doctor. My wonderful parents were very American in their approach to raising their four children – very hands off, letting us all figure out our career paths on our own, no matter how late we were in deciding. I almost wish my parents did have a bit more Chinese “tiger mom” strict parenting style and had guided me with a firmer hand while growing up. But now that’s neither here nor there, and I consider myself a much more well rounded person by becoming a doctor later in life.

Alex at my clinic

My desire to have a career helping people started during my high school days with two pivotal events. The first was my two year stint in Peer Ministry, where I and other students hosted weekend or overnight events and meetings with other teens, from schools across our state of Massachusetts. Our mission was mostly to help other teens cope with typical teenager struggles: parents, relationships, self esteem and the like. During these wonderfully open sessions, I blossomed into a self confident young man, finding deep satisfaction in helping others with their problems.

My second pivotal event occurred during my sophomore year of high school, during a student trip to the poor towns of West Virginia state, filled with old, abandoned coal mines. We helped rebuild homes and also assisted in teaching Bible school to a group of seven year old kids. They were too young to really understand Bible stories, but I had loads of fun dressing up as a cow and crawling around the gymnasium floor, with two dozen adorable kids happily crawling behind me, mooing and ringing their bells. I felt a deep emotional satisfaction bringing joy to those kids, and even right now I can still remember that feeling I had during that all too short week.  A child is a miracle of hope and happiness!

Ever since those two pivotal events in my life, I had tried to find a career that could recreate that deep emotional satisfaction from helping others. In high school I enjoyed and excelled at math and science and was considering becoming an engineer (not a doctor). I also was thinking that if I became skilled at these sciences, I could later become a professor and teach others. So I was thrilled that I got into Columbia University’s College of Engineering, and off I went to New York City. annual tailored health check New York City was an intense new world for me, but I definitely felt like a “country mouse in the city,” overwhelmed by the city’s intensity. It took me a while to find my groove, and I soon realized that my Columbia College friends were having a lot more fun than I was in Engineering. My liberal arts friends filled their days reading classic books, taking in the theatre, and discussing politics. How much more exciting for me! I decided to switch from the Engineering College to the Liberal Arts College, eventually graduating with a Bachelor of Arts in English. I especially loved my senior year, sitting on the great lawn in Central Park and reading Plato and Hunter Thompson in the glorious spring sunlight. It was there at Columbia that I honed my writing skills, mostly focusing on creative writing and drama. I especially loved my senior year when I wrote and acted with a hilarious and talented group of students for a comedy TV show. We called it “The Velveeta Players” because it was so cheesy! (Velveeta is a famous American brand of processed cheese).

I graduated from Columbia with an English degree and great enthusiasm for my future, but I still wasn’t sure which career path was best for me. I still loved the idea of teaching, but I didn’t feel like a master in any subject enough to teach. I loved to write and edit, but even a Columbia grad needed to start entry level in a publishing house, slowly climbing the career ladder. I moved back home, looking for editorial work in Boston, when my identical twin brother volunteered for a sleep research study at Harvard University School of Medicine, spending 35 days and nights there. He made quite a bit of money doing this, and the doctors were thrilled at the chance to perform sleep deprivation tests on identical twins. So I also volunteered, and we both spent 11 days and nights inside their lab, in separate rooms, completely isolated from all time cues from the outside world, with no windows, TV or radio (this was pre-internet). I was literally poked and prodded every couple hours, constantly monitored with machines and blood tests, saliva samples, video cameras, memory tests and mood scales. Every night they glued a dozen electrodes to my scalp and monitored my brain waves. I found out later that they had us on a 22 hour day, thus cutting away 2 hours a day from normal life and flipping our sleep cycles completely in a week. At the end, to reset us back to normal, they kept us upright in a bed, forcing us to stay awake for around 50 hours using any means possible; we played a lot of cards and sang silly songs. It was all quite surreal and strange and fascinating, and it was my first true foray into medicine. All the lab workers were medical students or doctors, and they loved their work and the science. I was hooked on medicine for the first time! But I still wasn’t ready to become a doctor. It took another year or so, after moving to wonderful San Francisco and still struggling to find a decent editing job, that I again found myself in the medical world. This time I was an editor and desktop publisher for a private medical company deep in the foggy cliffs of the Veterans Administration (VA) Hospital. Again I was surrounded by doctors and medical students doing fascinating research, loving their work, and getting paid well for it. And finally it clicked: I should become a doctor! Medicine was — and still is — the perfect mixture of my skills and desires: I could help people every day, in truly life-changing ways. And as a family doctor, I would never get bored, even forty years later, as every patient would be a new dilemma, with a new story.

I went back to school part time and aced my premedical classes, volunteering at Shriner’s Hospital for Children and other places to get more experience. I vividly remember my first real test: watching a person get open heart surgery. I’ll never forget the surreal sound of a saw cutting open his rib cage, or the smell of his burning flesh from a cautery gun stopping small bleeding, or looking down into his open chest, watching his heart beating. Many people would just pass out at that moment — but I thought, “wow, this is really cool!” Richard Saint Cyr portrait I eventually took the grueling and exhausting MCAT exam and soon got accepted into Saint Louis University’s School of Medicine. I had finally found my calling – and I remain thankful that I pursued this dream. In my life choices, my number one most important decision was asking Joanna to marry me; my second most important was deciding to become a doctor.

Many people ask me why I decided to become a family doctor and not specialize in something like cardiology or neurosurgery. I especially got this question while living in China because almost all doctors specialize there, and there really isn’t even a developed program for primary care doctors in China. Most Chinese people don’t realize that family medicine actually is a specialty, complete with extra training and our own medical exam and certification.

The classic American view of a doctor is of a small town doctor who the community knows and loves dearly, who has delivered generations of babies over their 40 years of practice. A good family doctor is deeply involved in their community’s health, their schools, their public safety. I always loved that classic American image of a doctor, and that’s what I strive for each day in my practice. I see people of all ages, from newborns to the elderly, and I follow them for years. It’s a deeply satisfying career, a true honor to deeply understand a patients’ health and history, and to do all I can to keep them thriving and healthy.


(this is an excerpt from my book translated into Chinese. I moved back to the USA last summer and now work at Swedish Bainbridge Island Primary Care Clinic in Washington state.) 

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

What’s The Best Bedtime For Kids?

A good night’s sleep is crucial for all of us, but especially for children. My Alex is now 17 months old and is pretty good with his routine, being put to bed at 8 pm and usually waking up around 7:30 am. Along with a nap or two, he easily gets his recommended 12 hours a day of sleep. But our upstairs neighbors’ toddlers are bouncing on our ceilings until at least 10 pm most nights. Many Chinese parents tell me their child goes to bed at 9, 10 or even 11 pm — much later than the typical children of my expat and American colleagues. What explains this cultural difference, but more importantly — is either one healthier for a child?

One study from 2005 confirmed my personal observations that Chinese children not only go to sleep later than American children, they also wake up earlier. This comparative survey showed that Chinese children in elementary school sleep a full hour less than American children (9.25 vs. 10.2 hours); more worrisome were the Chinese children’s complaints of daytime sleeping on big pumpkin

The main issue isn’t so much what time your child goes to bed: more importantly is their total amount of daily sleep, including naps (which very few children over five years take). Sleep research has shown that preschool-aged children need 11-12 hours, while school-aged children need at least 10 hours, and teens need 9-10 (infants need 16-18, and adults need 7-8). If your five year old is going to bed at 9:30 and waking up at 6:30 and already no longer takes naps, then their 9 hours a day of daily sleep isn’t enough for their long term health.

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 in China just published this year 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. Over time, this cumulative sleep deficit causes problems with attention spans, motivation, and also achievements on tests. Researchers hypothesize that the brain’s prefrontal cortex, which processes attention, creative processing, motivation, and abstract reasoning, is especially vulnerable to poor sleep. They conclude that “our results provide a cautionary tale for the practice in Chinese society that children spend a lot of time on studies even with the sacrifice of sleep time.”

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. One study of 500 adolescent twins in Anhui, China showed an association between less sleep and more weight gain. Another survey of over 4,000 children in rural northeast China found that obese children were more likely to have insufficient sleep (less than 7.5 hours, including naps). While this isn’t a cause-and-effect, the association certainly is worrisome. There may actually be a physiological base to this, as research shows that inadequate sleep causes changes in the hormones which control appetite. Less sleep leads to less leptin and more grehlin, which increases our instinctive hunger reflex. Since the obesity rate in Chinese children is rising alarmingly, I think all parents at least should consider proper sleep in this context.

I can’t control the noisy kids upstairs, but in my own home I’m happy that we’ve taught Alex good sleep patterns, and we have plenty of leeway for 8:30 or 9 pm times if needed, all the way until his teen years. And when we choose schools we would definitely consider later start times as a positive factor.