Tag: The Checkup

The Merits of Reading Real Books to Your Children


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A new Harry Potter book and a new round of stories about midnight book release parties reminded me of the persistent power of words printed on a page to shape children’s lives.

How do we think about a distinct role for paper, for “book-books” in children’s lives? My own pediatric cause is literacy promotion for young children. I am the national medical director of the program Reach Out and Read, which follows a model of talking with the parents of babies, toddlers and preschoolers about the importance of reading aloud, and giving away a developmentally appropriate children’s book at every checkup.

We are talking about very young children here, and we begin by giving out board books which are designed to be chewed and drooled on by babies who are still exploring the world orally, or thrown down (repeatedly) off the high chair by young children who are just figuring out object permanence and experimenting with ways to train their parents to fetch and retrieve. But the most essential attribute of those board books, beyond their durability, is that they pull in the parent, not only to pick them up, but to ask and answer questions, name the pictures, make the animal noises.

I love book-books. I cannot imagine living in a house without them, or putting a child to bed in a room that doesn’t have shelves of books, some tattered and beloved, some new and waiting for their moment. It’s what I wanted for my own children, and what I want for my patients; I think it is part of what every child needs. There’s plenty that I read on the screen, from journal articles to breaking news, but I don’t want books to go away.

I would never argue that the child who loves to read is worse off because those “Harry Potter” chapters turn up on the screen of an ebook reader rather than in those matched sets of thick volumes that occupy my own children’s shelves. (Although I think there’s something wonderful about looking at the seven books of the series and remembering a midnight party in a bookstore or two, and sometimes coming home from high school or college and taking one — or all seven — to bed with you.)

But what about the younger children, the ones who are working to master spoken language while taking the early steps in their relationships with books and stories? There’s a lot of interest right now in pediatrics in figuring out how electronic media affect children’s brains and children’s learning styles and children’s habits.

In a 2014 review of studies on electronic storybooks, researchers outlined some of the ways that such stories could help young children learn, and some of the ways that they could hurt. They pointed out that especially for children with language delays, certain features of electronic books that reinforce the connection between image and word (for example, animated pictures) may help children integrate information, but that distracting features and games may cause “cognitive overload,” which gets in the way of learning. And they worried, of course, that screen time might displace parent-child time.

Dr. Jenny Radesky, a developmental behavioral pediatrician and assistant professor of pediatrics at the University of Michigan at Ann Arbor, is one of the authors of the coming American Academy of Pediatrics policy statement on media use for children from birth to age 5. “Preschool children learn better when there’s an adult involved,” she said. “They learn better when there are not distracting digital elements, especially when those elements are not relevant to the story line or the learning purpose.”

In a small study published in February in JAMA Pediatrics, researchers looked at the interactions between parents and their children, ages 10 to 16 months, and found that when they were playing with electronic toys, both parents and children used fewer words or vocalizations than they did with traditional toys. And picture books evoked even more language than traditional toys.

Words and pictures can do many things for the reader’s brain, as we know from the long and glorious and even occasionally inglorious history of the printed word. They can take you into someone else’s life and someone else’s adventure, stir your blood in any number of ways, arouse your outrage, your empathy, your sense of humor, your sense of suspense. But your brain has to take those words and run with them, in all those different directions. Brain imaging has suggested that hearing stories evokes visual images in children’s brains, and more strongly if those children are accustomed to being read to.

And a parent can offer questions and interpretations that take the experience beyond bells and whistles. “A parent can ask, ‘Oh, remember that duck we saw at the pond?’,” Dr. Radesky said. “When a parent relates what’s on the page to the child’s experience, the child will have a richer understanding.”

Story time can also be good for the grown-ups. “Parents have said to me, ‘I need that 30 minutes of reading, it’s the only time my child snuggles with me,’ ” Dr. Radesky said. “We shouldn’t only think about what the child is getting from it.”

Part of what makes paper a brilliant technology may be, in fact, that it offers us so much and no more. A small child cannot tap the duck and elicit a quack; for that, the child needs to turn to a parent. And when you cannot tap the picture of the horse and watch it gallop across the page, you learn that your brain can make the horse move as fast as you want it to, just as later on it will show you the young wizards on their broomsticks, and perhaps even sneak you in among them.

Reading and being read to open unlimited stories; worlds can be described and created for you, right there on the page, or yes, on the screen, if that is where you do your later reading. But as those early paper books offer you those unlimited stories, the pictures will move if you imagine the movement; the duck will quack if you know how to work your parent. It’s all about pushing the right buttons.


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Attention, Teenagers: Nobody Really Looks Like That


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The universal truth of puberty and adolescence is body change, and relatively rapid body change. Teenagers have to cope with all kinds of comparisons, with their peers, with the childhood bodies they leave behind, and with the altered images used in advertising and in the self-advertising on social media.

It may be that the rapid way the body changes during these years can help adolescents believe in other kinds of change, including the false promises that various products can significantly modify their size and shape. A study published last month in the journal Pediatrics looked at two kinds of risky behavior that are increasingly common over adolescence: the use of laxatives for weight loss and the use of muscle-building products.

It used data from an ongoing study of more than 13,000 American children, the Growing Up Today Study (GUTS). The participants’ mothers took part in the Nurses’ Health Study II, and the children were recruited in 1996, when they were 9 to 14 years old, and surveyed about a variety of topics as they grew up.

By age 23 to 25, 10.5 percent of the women in this large sample reported using laxatives in the past year to lose weight; the practice increased over adolescence in the girls, but was virtually absent among the boys. Conversely, by young adulthood, about 12 percent of the men reported use of a muscle-building product in the past year, and again, this increased during adolescence.

So a lot of young women are taking laxatives to try to become very thin, and a lot of young men are using products to help them bulk up and become more muscular. The researchers were interested in how these practices were associated with traditional ideas of masculinity and femininity. They found that, regardless of sexual orientation, kids who described themselves as more gender conforming were more likely to use laxatives (the girls) or muscle-building products (the boys).

“The link is the perception that they are going to alter your weight, shape, appearance,” said Rachel Rodgers, a counseling psychology researcher who studies body image and eating concerns and is an associate professor of applied psychology at Northeastern University.

“The representations of ideal appearance in society are very restrictive and very unrealistic both for men and for women,” she said. “They portray bodies that are unattainable by healthy means.”

Jerel Calzo, a developmental psychologist who is an assistant professor at Harvard Medical School, and the lead author on the study, said that one important aspect of this research was the way it highlighted the vulnerability of those who identify with traditional gender ideals.

“Usually in research we tend to focus on youth who are nonconforming, who we might focus on as more at risk for negative health outcomes, depression, who might be ostracized or victimized,” he said. But there are risks as well for those who are trying to measure up to what they see as the conventional standard.

The GUTS participants were asked to describe themselves as children in terms of the games they liked and the movie and TV characters they imitated, and this was used to score them as more or less “gender conforming.”

The early patterns of gender conformity were significant, Dr. Calzo said, because they were linked to behaviors that lasted through adolescence and into young adulthood. “Laxative use increases with age, muscle-building product use increases with age,” he said. “There is a need for early intervention.”

Chronic use of laxatives can affect the motility of the bowel so that it can be hard to do without them, and overdoses can alter the body’s balance of electrolytes, to a really dangerous extent.

“There’s a lot of shame and guilt for laxative abuse,” said Sara Forman, an adolescent medicine specialist who is the director of the outpatient eating disorders program at Boston Children’s Hospital. And many products marketed as cleanses or herbal teas are not labeled as laxatives, though they contain strong laxative ingredients.

The muscle-building products in the study included steroids, creatine and several others. The risks of steroids are well known, from hormonal imbalances and shrinking testicles to acne and aggression. With other commercial muscle-building products, the risks may have more to do with the lack of regulation, Dr. Calzo said. The products can contain banned substances or analogues of banned substances, like the amphetamine analogue found in popular diet and workout supplements last year.

And of course, the muscle-building products won’t reshape you into the photoshopped model any more than the laxatives will.

As Dr. Calzo says, we need to worry about the vulnerabilities of children who are growing up with issues of gender identity and sexuality. But don’t assume that more “mainstream” or “conforming” kids have it easy when it comes to body image. Parents can help by keeping the lines of communication open and starting these conversations when children are young. We should be talking about the images that our children see, about how real people look and how images are altered.

And that conversation should extend to social media as well; in a review by Dr. Rodgers, increased social media use was correlated with body image worries. “Teenagers are looking at their friends on social media and seeing photos that have been modified and viewing them as something real.”

The other message for parents is about helping to model healthy eating, family meals, realistic moderation around eating and exercising, and to refrain from any kind of negative comments or teasing about a child’s body. “Research has shown people who have more body satisfaction actually take care of themselves better, which suggests that the approach of making them feel bad is actually not helpful,” Dr. Rodgers said.

Every adolescent, across gender, gender identity, gender conformity, and sexuality, lives with a changing body and the need to navigate body image and identity. There are a lot of unrealistic images out there to measure yourself against, and a lot of false promises about how you might get there.


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Helping Our School-Age Children Sleep Better


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Everyone knows that getting a baby to sleep through the night can be a big challenge for parents. But sleep problems are common among preschool and school-age children, too. As we ask children to function in school, academically and socially, fatigue can affect their achievement and behavior.

Australian research on sleep problems in children has included work aimed at the “school transition” year in which children adjust to a school schedule. In a study of 4,460 children, 22.6 percent had sleep problems, according to their parents, at that transition age of 6 to 7 years. “We were surprised, we thought it was all baby sleep” that was the problem, said Dr. Harriet Hiscock, a pediatrician who is a senior research fellow at the Murdoch Childrens Research Institute at the Royal Children’s Hospital in Melbourne who was one of the authors of the study.

Those results led to a randomized controlled trial of a brief intervention for children in their first year of school. A group of 108 parents who felt their children had sleep problems was divided into two groups. One group got a consultation at school, with a program of strategies tailored to the child’s sleep issues, and a follow-up phone consultation; the other group got no special intervention and served as controls. Parents in the intervention group were counseled about a range of possible measures to improve sleep, from consistent bedtimes and bedtime routines to relaxation strategies for anxiety that might be contributing to insomnia. The children in the intervention group resolved their varying sleep problems more quickly, though sleep problems got better over time in both groups. The interventions also produced positive effects on the child’s psychosocial function and parents’ mental health.

The most common sleep issues for children around the age of school entry, Dr. Hiscock said, definitely include limit-setting issues — that is, some of them need their parents to make the rules and routines clear. But there are also children with what sleep specialists call “sleep onset association disorder,” in which a child has become habituated to falling asleep only in a certain context, requiring the presence of a parent, or needing to have the TV on, to cite two common examples. Very anxious children are also often problem sleepers. And then there are children beset by nightmares, night terrors and early morning waking.

Screen use is a major issue in childhood sleep, and more generally in childhood these days. The first recommendation is always to get the screens out of the bedroom, the same recommendation made for improving adolescent sleep, and for adults in the current best-selling book by Ariana Huffington. All of us, old and young, are vulnerable here, but it’s a good place for parents to draw the line for their children, even when they can’t quite manage it for themselves.

Reut Gruber, a psychologist who is an associate professor in the department of psychiatry at McGill University, where she is director of the Attention Behavior and Sleep Lab, said that there is a close association between sleep and a wide range of cognitive functions, including attention, executive function and memory. When children go to school, “they need to pay attention and plan and follow instructions, all of which fall under executive function, which is very much affected by sleep,” she said.

Many parts of the brain work less well when children are tired. “The prefrontal cortex is very sensitive to sleep deprivation, and it is key to the brain mechanisms which underlie executive function and some of the attentional processes,” she said. “The amygdala is affected by sleep deprivation and is essential for emotional processes.”

These different but connected brain pathways led her to be interested in the way that sleep affects many different aspects of academic performance. In an experimental study of a small group of 7- to 11-year-olds who did not have sleep, behavior or academic problems, the children were asked to change their sleep patterns, so that they were sleeping an hour less per night, or an hour more. After five days with less sleep, she said, there was measurable deterioration in alertness and emotional regulation, and after five days with more sleep, there were gains in these areas.

For the past several years, Dr. Gruber and her colleagues have worked with a school board in Montreal to develop a school-based sleep promotion program that was piloted in three elementary schools; results were published in May in the journal Sleep Medicine. The intervention involved a six-week sleep curriculum for the children, to teach them about healthy sleep habits, and materials designed to involve parents, teachers, and school principals, who were asked to consider the sleep ramifications of school schedules, extracurricular activities and homework demands.

The children in the intervention group extended their sleep by an average of 18.2 minutes a night, and also reduced the length of time it took them to fall asleep by 2.3 minutes. These relatively modest changes correlated with improved report card grades in English and math; the control group children’s sleep duration did not change, and their grades did not improve.

The goal of the intervention was to help families make sleep a priority.

“How do you make changes in your priorities, find the way as a family, as a school, as an individual, to reshuffle things, no matter how much homework, no matter how many aunts and uncles coming for a visit, that bedtime will still be respected?” Dr. Gruber asked. “We all agree in principle, but how do we actually incorporate it into daily life?”

The American Academy of Pediatrics recently endorsed the 2016 guidelines issued by the American Academy of Sleep Medicine, that 3- to 5-year-olds need 10 to 13 hours of sleep per day (including naps), while 6- to 12-year-olds need nine to 12 hours for optimal health and well-being.

Dr. Gruber advised that a child should wake up naturally, without requiring energetic parental encouragement. If after nine or 10 hours of sleep, a child still seems very tired, parents might wonder about whether a sleep disorder is affecting the quality of the child’s sleep, she said.

But for most school-age children, it’s an issue of habits and routines, screen time and setting limits. Many of us know, as adults, that we don’t get as much sleep as we should, or that we don’t practice very good “sleep hygiene,” as the experts would say when they advise us to get the screens out of our bedrooms, create regular routines and avoid caffeine too close to bedtime. Making school-age sleep a family priority is a good way to get everyone focused on what really matters: waking up rested and ready to function well, in body and mind.


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A Pediatrician’s View on Gun Violence and Children


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What does it mean to consider gun violence a public health problem, especially when it comes to children?

The American Academy of Pediatrics announced the development of a new initiative last week reacting to the violence in St. Paul, Baton Rouge and Dallas, an attempt as pediatricians to find ways to protect children, adolescents and young adults.

This isn’t a new issue for the academy; the existing policy on firearm injuries in children emphasizes the importance of sensible gun control, along with the importance of counseling parents about how to reduce risks. Pediatricians as a group have long been concerned about the psychological effects of exposure to violence and the culture of gun violence.

But how can pediatricians make a difference? “I would like us to think deeply about this being trauma for kids,” said Dr. Benard Dreyer, the president of the academy. He emphasized that the discussion must include the overlapping issues of race and the impact of racism on children and adolescents.

This past week, children, along with the rest of us, have seen a truck used as an assault weapon in Nice, France, reminding us that violence takes many forms. Many families worry about how to discuss with our children the disturbing images and stories that play out in the news media. There is an overarching sadness to this discussion. We would like to tell our children that they live in a better, safer country, that the world is getting safer, and that we are making some progress on racism and racial disparities.

Parents need to protect young children from repeated exposures to graphic images, and to be mindful with all children about just how much they’re seeing and hearing. Be there to watch with an older child, both so that you can monitor the exposure, and so that you can talk about disturbing stories and convey the message that it’s O.K. to have these conversations, even when there are no easy answers. The A.A.P. offers age-related guidelines for talking to children about tragedies and other news events on the Heathy Children website.

When children are very upset or worried, they may have nightmares or other sleep disturbances, or complain of physical problems which perhaps will keep their parents nearer, or otherwise, according to their ages, may signal depression or anxiety. Again, it can help to make it clear that you’re willing to talk about these events and the emotions they engender, and willing to get pediatric or mental health help for a child who is particularly distressed.

Beyond what we say in difficult conversations with our frightened or troubled children, adults face the challenge of really making the world safer.

Dr. William Begg, the emergency medical services medical director for the area of Connecticut that includes Newtown, was in the emergency room when the shooting happened at Sandy Hook Elementary School in 2012. He co-founded United Physicians of Newtown, a medical group working to keep children safe from guns.

“I’ve said at every opportunity we have to look at gun violence as a public health issue,” he said. “I think we have to do more as physicians.”

Parents who choose to own guns need to understand how dangerous an accessible gun can be, especially a gun kept in the home, often loaded and unlocked.

“Those are the guns that get used in suicides and unintentional killings and some of the intentional killings,” said Eric Fleegler, a pediatric emergency physician and health services researcher at Boston Children’s Hospital.

As sample safety measures, Dr. Fleegler brought up good safety locks, or even biometric safes, which can be opened only by the right person’s fingerprints, as well as the possibility of safe repositories where people could store guns outside their homes, either temporarily or permanently.

Dr. Begg said it’s important that pediatricians have the opportunity to talk to parents who are gun owners.

“I would never tell a parent, you can’t own a gun; what I would tell a parent is, you should make an informed choice knowing the facts, knowing your family situation,” he said. “I think if people understood the data, many people would make a different choice.”

But these conversations can be controversial; Florida, Montana and Missouri have laws that restrict doctors’ discussion of guns; eight other states have considered such legislation.

When you consider guns as a public health issue, the first thing you look for is data and research, but under pressure from the gun lobby, Congress has restricted the Centers for Disease Control and Prevention and the National Institutes of Health from doing or funding research on gun violence and how to prevent it.

Researchers look for associations between injury rates and possible interventions, safety measures and regulations. A study published in 2013 in the Journal of the American Medical Association by Dr. Fleegler and his colleagues showed that states with more firearm laws had fewer firearm-related fatalities; the association was true for both homicides and suicides.

As with so many public health issues, risks are greater for children in poverty and greater for minority children. “The numbers are staggering no matter who you are, but worse the poorer you are, the darker your skin, especially for violence and homicide,” Dr. Fleegler said.

According to the C.D.C., in 2014, homicide by firearm was the second leading cause of death among 15- to  24-year-olds in the United States, with suicide by firearm in fourth place. For those 10 to 14, where the numbers are much lower, the order was reversed, with suicide by firearm the third leading cause of death, and homicide by firearm fourth.

We lost more than 10,300 males from age 10 to age 19 to violence-related firearm deaths from 2010 to 2014; 63 percent of them by homicide, 36 percent by suicide, and 1 percent by legal intervention. The death rate for the black males was 26.3 per 100,000, compared with 6.6 per 100,000 for the white males.

The public health approach means talking to parents about how to keep their children safe, and looking for strategies—technological, behavioral, and legal—to make everyone safer.

Think about what it has meant to bring down the numbers of children dying in car crashes. We don’t look at collisions as unavoidable twists of fate. We look for strategies — technological, behavioral, and legal — to reduce the incidence of collisions and minimize the damage that they do to small bodies.

“We need to take away the notion that we shouldn’t regulate the safety of firearms,” Dr. Fleegler said. “We take pride in our cars, but the idea of removing safety regulations makes no sense.”

Dr. Begg said that for the first 25 years of his career, while practicing in different emergency rooms around the country, he saw patients harmed by gun violence and took care of them, but did nothing to address the larger problem.

“After the Sandy Hook tragedy where I saw the children of my friends and the children of my community, I didn’t know if my children were going to be affected — they were in lockdown also in school,” he said. “I decided I was going to devote the next 25 years of my career to promoting gun violence safety. There’s a lot more change to come.”

Thumb Suckers and Nail Biters May Develop Fewer Allergies


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Babies have been seen sucking on their fingers in utero weeks before birth. But the sight of an older child with his fingers constantly in his mouth, sucking her thumb, biting his nails, can drive parents crazy, bringing up fears about everything from social stigma to germs.

A new study suggests that those habits in children ages 5 to 11 may indeed increase exposure to microbes, but that that may not be all bad.

When a pediatrician discusses thumb-sucking, it’s usually because a parent is worried. The thumb is in the mouth so constantly that there’s a worry about speech or about whether the teeth may be affected. It’s gone on too long, and an older child is being teased about it. And in those situations, especially when a child is over 4, we work with parents and children on how to break the habit.

Nail biting worries parents for similar reasons, and we often end up giving similar advice: Don’t make negative comments; look for the situations that bring on the behavior and find alternate strategies; praise and reward the child for not doing it; put a glove or a bandage on the hand to remind the child.

In a study published Monday in the journal Pediatrics, researchers drew evidence from an ongoing study of New Zealand children to show those whose parents described them as thumb-suckers and nail-biters were less likely to have positive allergic skin tests later in life.

The children were in the Dunedin Multidisciplinary Health and Development Study, in which 1,037 children born in 1972-73 in Dunedin, a coastal city in New Zealand, were assessed and tested as they grew up, with the most recent assessment done at age 38. Stephanie Lynch, a student at Dunedin School of Medicine and the first author of the paper, had the idea of using the data to look at a possible relationship between children who tend to have their fingers in their mouths and allergic sensitization.

The question of such a connection arose because of the so-called hygiene hypothesis, an idea originally formulated in 1989, that there may be a link between atopic disease — the revved-up action of the immune system responsible for eczema, asthma and allergy — and a lack of exposure to various microbes early in life. Some exposure to germs, the argument goes, may help program a child’s immune system to fight disease, rather than develop allergies.

In the study, parents were asked about their children’s nail-biting and thumb-sucking habits when the children were 5, 7, 9 and 11 years old. Skin testing for allergic sensitization to a range of common allergens including dust mites, grass, cats, dogs, horses and common molds was done when the children were 13 years old, and then later when they were 32. Thirty-one percent of the children were described as “frequent” nail biters or thumb suckers (or both) at one or more of those ages.

The study found that children who frequently sucked a thumb or bit their nails were significantly less likely to have positive allergic skin tests both at 13 and again at 32. Children with both habits were even less likely to have a positive skin test than those with only one of the habits.

These differences could not be explained by other factors that are associated with allergic risk. The researchers controlled for pets, parents with allergies, breast-feeding, socioeconomic status and more. But though the former thumb-suckers and nail-biters were less likely to show allergic sensitization, there was no significant difference in their likelihood of having asthma or hay fever.

Robert J. Hancox, one of the authors of the study, is an associate professor in the Department of Preventive and Social Medicine at Dunedin School of Medicine, a department that is particularly oriented toward the study of diseases’ causes and risk factors. He said in an email, “The hygiene hypothesis is interesting because it suggests that lifestyle factors may be responsible for the rise in allergic diseases in recent decades. Obviously hygiene has very many benefits, but perhaps this is a downside. The hygiene hypothesis is still unproven and controversial, but this is another piece of evidence that it could be true.”

Malcolm Sears, one of the authors of the paper, a professor of medicine at McMaster University in Hamilton, Ontario, who was the original leader for the asthma allergy component of the New Zealand study, said, “Early exposure in many areas is looking as if it’s more protective than hazardous, and I think we’ve just added one more interesting piece to that information.”

Dr. Hancox pointed out that the study does not show any mechanism to account for the association. “Even if we assume that the protective effect is due to exposure to microbial organisms, we don’t know which organisms are beneficial or how they actually influence immune function in this way.”

Thumb sucking, especially in an older child, can still be a problem if it interferes with the teeth, or causes infections on the fingers, or gets a child teased. Lynn Davidson, a developmental pediatrician who is an attending physician at the Children’s Hospital at Montefiore in the Bronx, and the author of a review article on thumb sucking, said she tends to be “very low-key” about thumb sucking, since children often stop on their own as they grow.

With older children, Dr. Davidson suggests that parents, if they are worried, should try to analyze when and why the child resorts to thumb sucking or nail biting, and then try behavioral techniques, like offering a child a foam ball to hold and squeeze at those moments. “In an older child you can use their input, ask, what would you do with your hands instead of putting them in your mouth,” she said.

Dr. Sears said, “My excitement is not so much that sucking your thumb is good as that it shows the power of a longitudinal study.” (A longitudinal study is one that gathers data from the same subjects repeatedly over a period of time.) And in fact, as researchers tease out the complex ramifications of childhood exposures, it’s intriguing to look at long-term associations between childhood behavior and adult immune function, by watching what happens over decades.

So perhaps the results of this study help us look at these habits with slightly different eyes, as pieces of a complicated lifelong relationship between children and the environments they sample as they grow, which shape their health and their physiology in lasting ways.

Sunscreen and Bug Spray: Children’s Summer Skin Care


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Summer is here, and we know we’re supposed to shield children from the sun. There’s strong evidence that early sun exposure can increase children’s risk of later skin cancer, and that’s true also for darker-skinned children who are less likely to burn. Boston and Miami Beach are providing free sunscreen in public places, and now New York is talking about it, too.

Parents have certainly gotten much more aware about sun protection, though they sometimes feel a little overwhelmed by the variety of products and by the job of keeping up with the imperatives for proper use.

And with old worries about ticks and new worries about mosquito-borne viruses, parents wonder if they should also be coating a child’s exposed skin with bug repellent.

But babies’ delicate skin is more permeable than adults’, so any chemicals we apply may be more likely to be absorbed, and their immature organs may be less able to handle those chemicals. What stays on the skin may be absorbed; but what doesn’t stay on the skin doesn’t shield. Dermatological toxicology involves considering the balance between “wash in,” the risk of absorbing potentially toxic substances through the skin, and “wash out,” the loss of protection as substances are lost by sweating or water exposure or rubbing. Both are highly complex processes, with many variables, and not necessarily well studied in young children.

With little babies, the advice is always to rely on reducing exposure, on shade and clothing for sun, and on adding screens and netting to keep the bugs off. Both the Food and Drug Administration and the American Academy of Pediatrics emphasize that babies under 6 months should be kept out of direct sunlight, protected with shade, shielded with sunhats and protective clothing when they do have to be out, rather than relying on sunscreen.

Babies’ skin surface is large in proportion to their body volume and their internal fluids, putting them at high risk for heat and dehydration. So make sure they are drinking and wetting their diapers regularly.

Adults and children alike are advised to avoid the hours of maximum exposure — to stay out of the sun between 10 and 2, and to avoid going outside at dusk in areas with lots of mosquitoes. But of course, that isn’t necessarily easy.

Sun hats and protective clothing are important for older babies and toddlers, and so is avoiding those peak hours. For children under 2, “the rule of thumb in this age group is clothing first,” said Jacqueline Thomas, an assistant professor of dermatology and surgery at Nova Southeastern University in Fort Lauderdale, who is the senior author on a commentary reviewing pediatric sunscreen and sun safety guidelines published last year in the journal Clinical Pediatrics. Dark colors and more tightly woven fabrics are more effective.

As to sunscreen, experts say not to choose by what is marketed for children or babies, and to read the label carefully. In 2011, the F.D.A. required much more information to be standardized on sunscreen labels; parents should look for products with an SPF of 30 or higher, advises the American Academy of Dermatology, and make sure they are labeled as “water resistant” (lasts 40 minutes in the water) or “very water resistant” (80 minutes), and as “broad spectrum,” meaning that they block both UVA and UVB rays, both of which do damage. There is no such thing as waterproof sunscreen.

The active agents in sunscreen can be either chemical blockers or physical blockers, and the physical blockers are safer for children because they are much less likely to be absorbed. For children ages 2 to 12, look for products with titanium or zinc as their active ingredients, rather than chemical agents, which really haven’t been studied in children.

The recommended amount for an adult-size body is variously described as a shot glass and a golf ball for the trunk and extremities; for under 12, some authorities suggest using the amount that would fill a child’s cupped hand as a rough guide. It needs to be reapplied after two hours, because the efficacy is gone, even if you can still feel the lotion on your skin, and sunscreens with higher SPFs don’t last any longer than those with lower SPFs (in fact, there is no evidence that SPFs over 50 are more protective).

Although spray-on sunscreens are popular, their efficacy has not been studied,, and there’s concern about children inhaling them. The F.D.A. has asked for more data.

What about insects? Mosquito repellents generally contain either DEET, picaridin or one of several essential plant oils, most commonly oil of lemon eucalyptus, as an active ingredient; permethrin, which is meant to be applied to clothing (or sometimes already applied by manufacturers) works to repel ticks.

There has been concern in the past about DEET toxicity, and the recommendation is to avoid DEET and picaridin for babies younger than 2 months, and to avoid oil of lemon eucalyptus for children under 3. But most pediatricians would recommend being very sparing with all of these substances on babies and young children, applying them only to exposed skin, right before going outside, and washing them off when you come back in. Don’t let young children apply the stuff themselves, and keep it away from their eyes and their mouths, and their hands if they tend to put those in their mouths. If possible, put the repellent on the clothing, or on the tent; there are also clip-on devices that can be attached to strollers.

Dr. Adelaide A. Hebert, a professor of dermatology and pediatrics at McGovern Medical School at the University of Texas Health Science Center at Houston, said she tends to recommend picaridin-based insect repellents such as Cutter Advanced and Off Clean Feel for children over those that contain DEET. “I like picaridin. I feel there’s less concern for parents using it with regard to toxicity,” she said. The strength of these insect repellents can vary as well, so again, it’s important to read the label. “We don’t recommend DEET strength above 20 percent because of concern about toxicity,” Dr. Hebert said.

Combination products are another problem, though the idea of a single lotion that protects against both sun and insects is very appealing. “I never recommend combination products,” said Dr. Hebert. “We don’t want to reapply the insect repellent as often as we may need to reapply the sunscreen.” Further, there’s evidence that the mixture may make the sunscreen less effective, and the chemicals more likely to be absorbed.

So keep babies out of the sun, be scrupulous about sun hats and protective clothing, about screens and mosquito netting. As children grow, don’t forget about protecting the eyes; think about broad-brimmed hats and sunglasses. If you need protection against insects, apply insect repellent over sunscreen, and reapply the sunscreen after two hours, on top of the insect repellent, which does not have to be reapplied so frequently.

The skin is the largest organ of the body, proportionally larger in the smallest children, and protecting it properly needs our care and attention.


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The Connections Between Spanking and Aggression


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In the 1990s, in my first month in practice as a pediatrician, I asked the mother of a 4-year-old about discipline and she told me that her son was often out of line and wild, and spanking was the only thing that worked, though she was sure I was going to tell her not to, just as her previous pediatrician had done. Around the same time, my colleague in the same clinic walked into an exam room to find a cranky toddler who was acting out, and a frustrated father who was taking off his belt and threatening punishment. In each case, and in many others, we had to decide how to talk to the parents, and whether to bring up the issue of child abuse — which is definitely an issue when a child is being struck, or threatened, with a belt.

Corporal punishment, also known as “physical discipline,” has become illegal in recent decades in many countries, starting with Sweden in 1979. The United States is not one of those countries, and pediatricians regularly find ourselves talking with parents about why hitting children is a bad idea. The American Academy of Pediatrics officially recommends against physical discipline, saying that evidence shows it is ineffective and puts children at risk for abuse; pediatricians are mandated reporters, responsible for notifying the authorities if we think there is a possibility of abuse, though the boundaries are not clearly defined by law.

But many parents continue to spank, even when they don’t think it does much good. In a recent report by the nonprofit organization Zero to Three of a national sample of 2,200 parents of children birth to age 5, parents were asked which discipline strategies they used a few times a week or more. Twenty-six percent said they “pop or swat” their child, 21 percent spank, and 17 percent reported hitting with an object like a belt or a wooden spoon. (Parents could respond that they used more than one strategy.) Zero to Three reported that even those who used these strategies frequently did not rate them as effective, and 30 percent agreed with the statement, “I spank even though I don’t feel O.K. about it.”

One reason the A.A.P. opposes spanking is because of evidence that it is associated with aggressive behavior in children. But does that mean that hitting children produces aggressive behavior, or that aggressive behavior in children elicits more and sterner parental measures?

Michael MacKenzie, an associate professor of social work and pediatrics at Rutgers, called the association “bidirectional and transactional.” How you discipline your child shapes your child, but also shapes you as a parent. But if you control for the child’s behavior, comparing more aggressive young children with other children who behave in the same ways, those who are frequently hit or spanked are more likely to show aggressive behavior and rule-breaking later on.

In a study published last year, he and his colleagues looked at these bidirectional effects. Children who were spanked were more likely to show disruptive, aggressive behaviors later on. Those behaviors, in turn, made it more likely that those children would be spanked more in the future.

“It mattered for everybody, but it mattered more for these kids in riskier contexts, the families facing more stress,” Dr. MacKenzie said. Other research showed that spanking was associated with poorer cognitive outcomes for children, even when the researchers controlled for factors such as maternal intelligence, maternal depression and cognitive stimulation in the home.

Dr. MacKenzie suggested that some families get caught in a “feedback loop,” in which children who are spanked respond more aggressively, and become even more challenging, reinforcing parents’ sense that only harsh discipline will work, so parents find themselves escalating the discipline, which in turn evokes more intense behavior.

“We want to think about these cycles and how they amplify,” he said, and to think as well about how to support families early on so that they set up different patterns. “We’ve sort of suggested the removal of a tool that many parents use, most parents use, without discussion of what the alternatives might be.”

Michael Lorber, a research scientist in the Family Translational Research Group at New York University, has found that parents who interpret their children’s behavior more negatively than an objective observer tend to use more harsh discipline. These patterns begin younger than we think, he told me, with parents in their studies clearly identifying children as young as 8 months old as difficult and aggressive.

“We think the infancy period is probably the time when parents begin to develop their disciplinary practices,” Dr. Lorber said. “Call it difficult temperament or incipient externalizing behaviors or contentiousness, it’s definitely the case that infants’ behaviors influence their parents, including physical discipline.”

One complicated question that researchers raise about physically aggressive children and their physically aggressive parents is whether there may be a genetic component to this behavior, which would be shared across the generations.

Leslie Leve, a professor of counseling psychology and human services at the University of Oregon College of Education, said that it was possible there were genetic predispositions toward aggressive behavior, which might affect both parents and children. “There is a common misperception that when people think of a behavior as ‘genetic’ that it’s not changeable, and that is not true,” Dr. Leve said. “With A.D.H.D. or aggression we know there is a genetic component, but there is a lot we can do in a family or educational environment. Genetics does not mean immutable.”

Dr. Leve has participated in studies of adopted infants, which can help tease out these effects, but which also show how complex the interactions are, with harsh parental responses affected by the child’s characteristics but also by factors in their own temperaments and their marriage.

Zero to Three reported that 69 percent of the parents said that “if they knew more positive parenting strategies they would use them.” Pediatricians try to help parents develop such strategies, discussing what behavior is developmentally realistic for young children; helping them interpret behavior without regarding it as defiant; counseling them about setting limits; and helping them find positive behaviors to praise and enjoy.

Disciplinary choices reflect parental stress, family circumstances and the whole complex cocktail of emotion and personal history and daily life at home. What parents do affects their children — their brains and their behavior — and the ways that children behave affects their parents. And the cycle of spanking and aggressive behavior seems to leave everyone worse off.


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Why Handwriting Is Still Essential in the Keyboard Age


Credit Anna Parini

Do children in a keyboard world need to learn old-fashioned handwriting?

There is a tendency to dismiss handwriting as a nonessential skill, even though researchers have warned that learning to write may be the key to, well, learning to write.

And beyond the emotional connection adults may feel to the way we learned to write, there is a growing body of research on what the normally developing brain learns by forming letters on the page, in printed or manuscript format as well as in cursive. In an article this year in The Journal of Learning Disabilities, researchers looked at how oral and written language related to attention and what are called “executive function” skills (like planning) in children in grades four through nine, both with and without learning disabilities. Virginia Berninger, a professor of educational psychology at the University of Washington and the lead author on the study, told me that evidence from this and other studies suggests that “handwriting — forming letters — engages the mind, and that can help children pay attention to written language.”

Last year in an article in The Journal of Early Childhood Literacy, Laura Dinehart, an associate professor of early childhood education at Florida International University, discussed several possible associations between good handwriting and academic achievement: Children with good handwriting may get better grades because their work is more pleasant for teachers to read; children who struggle with writing may find that too much of their attention is consumed by producing the letters, and the content suffers.

But can we actually stimulate children’s brains by helping them form letters with their hands? In a population of low-income children, Dr. Dinehart said, the ones who had good early fine-motor writing skills in prekindergarten did better later on in school. She called for more research on handwriting in the preschool years, and on ways to help young children develop the skills they need for “a complex task” that requires the coordination of cognitive, motor and neuromuscular processes.

“This myth that handwriting is just a motor skill is just plain wrong,” Dr. Berninger said. “We use motor parts of our brain, motor planning, motor control, but what’s very critical is a region of our brain where the visual and language come together, the fusiform gyrus, where visual stimuli actually become letters and written words.” You have to see letters in “the mind’s eye” in order to produce them on the page, she said. Brain imaging shows that the activation of this region is different in children who are having trouble with handwriting.

Functional brain scans of adults show a characteristic brain network that is activated when they read, and it includes areas that relate to motor processes. This suggested to scientists that the cognitive process of reading may be connected to the motor process of forming letters.

Karin James, a professor of psychological and brain sciences at Indiana University, did brain scans on children who did not yet know how to print. “Their brains don’t distinguish letters; they respond to letters the same as to a triangle,” she said.

After the children were taught to print, patterns of brain activation in response to letters showed increased activation of that reading network, including the fusiform gyrus, along with the inferior frontal gyrus and posterior parietal regions of the brain, which adults use for processing written language — even though the children were still at a very early level as writers.

“The letters they produce themselves are very messy and variable, and that’s actually good for how children learn things,” Dr. James said. “That seems to be one big benefit of handwriting.”

Handwriting experts have struggled with the question of whether cursive writing confers special skills and benefits, beyond the benefits that print writing might provide. Dr. Berninger cited a 2015 study that suggested that starting around fourth grade, cursive skills conferred advantages in both spelling and composing, perhaps because the connecting strokes helped children connect letters into words.

For typically developing young children, typing the letters doesn’t seem to generate the same brain activation. As we grow up, of course, most of us transition to keyboard writing, though like many who teach college students, I have struggled with the question of laptops in class, more because I worry about students’ attention wandering than to promote handwriting. Still, studies on note taking have suggested that “college students who are writing on a keyboard are less likely to remember and do well on the content than if writing it by hand,” Dr. Dinehart said.

Dr. Berninger said the research suggests that children need introductory training in printing, then two years of learning and practicing cursive, starting in grade three, and then some systematic attention to touch-typing.

Using a keyboard, and especially learning the positions of the letters without looking at the keys, she said, might well take advantage of the fibers that cross-communicate in the brain, since unlike with handwriting, children will use both hands to type. “What we’re advocating is teaching children to be hybrid writers,” said Dr. Berninger, “manuscript first for reading — it transfers to better word recognition — then cursive for spelling and for composing. Then, starting in late elementary school, touch-typing.”

As a pediatrician, I think this may be another case where we should be careful that the lure of the digital world doesn’t take away significant experiences that can have real impacts on children’s rapidly developing brains. Mastering handwriting, messy letters and all, is a way of making written language your own, in some profound ways.

“My overarching research focuses on how learning and interacting with the world with our hands has a really significant effect on our cognition,” Dr. James said, “on how writing by hand changes brain function and can change brain development.”


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Should Pediatricians Refuse to Treat Patients Who Don’t Vaccinate?


Alice Hansen, 2, receives a pertussis vaccine while her mother, Alishia Hansen, holds her.

Alice Hansen, 2, receives a pertussis vaccine while her mother, Alishia Hansen, holds her.Credit Matthew Ryan Williams for The New York Times

Parents who don’t want to vaccinate their children are a perennial sore subject in my profession. The question bubbled up again this spring at the American Academy of Pediatrics’ Annual Leadership Forum, where academy leaders vote on issues of concern to pediatricians across the country.

Two of the top three resolutions this year were about vaccine refusal. One requested a policy statement calling for the elimination of nonmedical exemptions to the requirement that children be immunized to attend school and day care. The other asked the academy to support “pediatricians who decide to discharge patients after a reasonable, finite amount of time working with parents who refuse to immunize their children according to the recommended schedule, or who fail to abide by an agreed-upon, recommended catch-up schedule.”

Let me tell you about two cases of pertussis — whooping cough — from about 15 years ago. The first one is my own, probably caught from a sick kid, back before the development of the adult booster shot; thanks to an astute colleague, I got the diagnosis, and we began the wearisome task of contacting the families of every child I had seen in the clinic or the newborn nursery during my infectious days to inform them of the possible exposure.

I didn’t give it to him, but the second case was a preschool-age patient of mine whose mother had refused vaccination, insisting that she wanted to wait on the vaccine that protects against pertussis. It wasn’t a terribly dangerous case of whooping cough; the patient’s airway wasn’t compromised, the way infants’ airways often are, but he was pretty sick and pretty miserable for a good long time. As was I; we treat pertussis with antibiotics, which make the sick person noninfectious, but the cough, which is severe enough to cause rib fractures in some unfortunate patients, can persist for six weeks or more.

I felt guilty that I had failed to diagnose the illness in myself promptly enough. I felt a different guilt about my patient, wretchedly certain that if I had only been more eloquent and more persuasive, his mother would have come around to the idea of vaccination and he would have been spared the coughing paroxysms that convulsed his little body, often followed by vomiting.

I tell you this to help explain the way that pediatricians feel about immunizations.

The resolution about “discharging” nonvaccinating families was introduced by Dr. Kimberly Avila Edwards, a pediatrician in general practice in Kyle, Tex., with a large multispecialty group that serves the Austin area. Some of their offices were seeing increasing numbers of parents who refused vaccination, and the physicians were struggling with how to care for those families. And she said parents who do vaccinate and were worried about possible exposures to diseases in the waiting room “were asking, ‘Do you accept nonvaccinators, because if so, we don’t want to come here.’” The biggest waiting room fear is that babies too young to be fully immunized might be exposed to preventable illnesses like whooping cough, measles, and influenza.

The doctors discussed the question, she said, reading the current A.A.P. policy, which seemed to them to discourage doctors from discharging these patients, and then decided to make a new practice rule. “We are going to give families a finite amount of time for a parent to say, O.K., I am going to start vaccinating my child and adhere to the catch-up schedule,” she said. “If parents still choose not to vaccinate, we are unfortunately not going to be able to continue to see you.”

This is a strategy for private practices, where families have some choice about which doctors to patronize; “safety net” clinics, like the one where I practice, which serve poor children, cannot “exclude” families in this way. And studies have shown that in this country, those who don’t vaccinate tend to be affluent, white and suburban.

Even if they have the choice, should we be steering nonvaccinating families toward health care settings that may not push as hard to change their minds? Dr. Carol Baker, an expert in pediatric infectious diseases and a professor of pediatrics at Baylor College of Medicine, thinks the academy should not change its existing position. Doctors are reacting negatively to the time and effort that these families consume, she told me, and the fear of being sued if a dangerous disease is passed along in their waiting room.

Even so, she said, doctors have to keep talking to the parents, and trying to get the children vaccinated. “For the academy to give permission that you don’t have to try is an ethically poor position,” she said.

Although the resolution met with general approval at the meeting, there was opposition from some bioethicists present. Dr. John Lantos, a pediatrician who is the director of the Children’s Mercy Bioethics Center in Kansas City, argued that the current A.A.P. statement strikes the correct balance in encouraging pediatricians to keep talking to “vaccine hesitant” parents: “Try hard to work with people.”

Dr. Avila Edwards said that the new rule at her practice that gives families a finite time period to consider vaccination led to “respectful one-on-one discussions,” which often ended up with families making the decision to vaccinate and stay.

Dr. Lantos argued that doctors are saying that this is a question of beliefs so fundamentally divergent that it’s impossible to work together, as if “vaccines are an order of magnitude higher than anything else.” Parents may choose to disregard other pediatric guidelines — smoking in the home, not applying sufficient sunblock — without being asked to leave a practice. The medical obligation is to educate parents, to try to get them to do the right thing for their children, not to give up on them.

If the worry is other children’s being exposed in the waiting room, he said, doctors could focus on measures to keep sick kids separate, or out of the waiting room until a doctor is available. “And if your concern is that these infected kids are going to go out and infect other kids — if you fire them from your practice, there would be more unimmunized kids in the world,” he said, since the hope is that if the families stay in the practice, eventually they may be persuaded. “Most people don’t say, nobody should see these kids; they just say, my practice shouldn’t see these kids. But if everybody said it, the world would be a much worse place.”

Most pediatricians have seen at least some of the diseases that vaccines protect against, from whooping cough to meningitis to the really bad cases of influenza and rotavirus. The children who aren’t protected worry us, because they make us feel we aren’t doing our job of keeping them safe in a world that is a much better and safer place to grow up — because of vaccines.


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Early Puberty in Girls Raises the Risk of Depression


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When girls come in for their physical exams, one of the questions I routinely ask is “Do you get your period?” I try to ask before I expect the answer to be yes, so that if a girl doesn’t seem to know about the changes of puberty that lie ahead, I can encourage her to talk about them with her mother, and offer to help answer questions. And I often point out that even those who have not yet embarked on puberty themselves are likely to have classmates who are going through these changes, so, again, it’s important to let kids know that their questions are welcome, and will be answered accurately.

But like everybody else who deals with girls, I’m aware that this means bringing up the topic when girls are pretty young. Puberty is now coming earlier for many girls, with bodies changing in the third and fourth grade, and there is a complicated discussion about the reasons, from obesity and family stress to chemicals in the environment that may disrupt the normal effects of hormones. I’m not going to try to delineate that discussion here — though it’s an important one — because I want to concentrate on the effect, rather than the cause, of reaching puberty early.

A large study published in May in the journal Pediatrics looked at a group of 8,327 children born in Hong Kong in April and May of 1997, for whom a great deal of health data has been collected. The researchers had access to the children’s health records, showing how their doctors had documented their physical maturity, according to what are known as the Tanner stages, for the standardized pediatric index of sexual maturation.

Before children enter puberty, we call it Tanner I; for girls, Tanner II is the beginning of breast development, while for boys, it’s the enlargement of the scrotum and testes and the reddening and changing of the scrotum skin. Boys and girls then progress through the intermediate changes to stage V, full physical maturity.

In this study, the researchers looked at the relationship between the age at which children moved from Tanner I to Tanner II — that is, the age at which the physical beginnings of puberty were noticed — and the likelihood of depression in those children when they were 12 to 15 years old, as detected on a screening questionnaire.

“What we found was the girls who had earlier breast development had a higher risk of depressive symptoms, or more depressive symptoms,” said Dr. C. Mary Schooling, an epidemiologist who is a professor at the City University of New York School of Public Health, and was the senior author on the study. “We didn’t see the same thing for boys.” Earlier onset of breast development in girls was associated with a higher risk of depression in early adolescence even after controlling for many other factors, including socioeconomic status, weight or parents’ marital status.

Other studies, including in the United States, have shown this same pattern, with girls who begin developing earlier than their peers vulnerable to depression in adolescence. Some studies have found this in boys, though it’s not as clear. But there is concern that girls whose development starts earlier than their peers are at risk in a number of ways, and across different cultural backgrounds.

“Early puberty is a challenge and a stress, and it’s associated with more than depression,” said Dr. Jane Mendle, a clinical psychologist in the department of human development at Cornell University. She named anxiety, disordered eating and self-injury as some of the risks for girls. In her studies of puberty, she has found associations between early development and depression in both genders in New York children. In boys, the tempo of puberty was significant, as well as the timing; boys who moved more rapidly from one Tanner stage to the next were at higher risk and the increased depression risk seemed to be related to changes in their peer relationships.

Before puberty, Dr. Mendle said, depression occurs at roughly the same rate in both sexes, but by the midpoint of puberty, girls are two and a half times more likely to be depressed than boys.

Some of these children may already be at risk; Dr. Mendle said that early puberty is more common in children who have grown up in circumstances of adversity, in poverty, in the foster care system. But some of it is heredity and some of it is body type and some of it, probably, is chance.

Researchers have wondered about hormonal associations with depression; Dr. Schooling pointed out that their study found that depression was associated with early breast development, controlled by estrogens, but not with early pubic hair development, controlled by androgens. “There is no physical factor that we know about that would explain this; estrogen has been eliminated as a driver of depression in earlier research,” she said in an email. “We probably need to explore social factors to seek an explanation.” They also plan to follow up with their study population at age 17.

The biological transition of puberty, of course, occurs in a social and cultural context. One very important effect of developing early, Dr. Mendle said, is that it changes the way that people treat you, from your peers to the adults in your life to strangers. “When kids navigate puberty they start to look different,” she said. “It can be hard for them to maintain friendships with kids who haven’t developed, and we also know that early maturing girls are more likely to be harassed and victimized by other kids in their grade.”

Parents should be aware of the difficulties that children may experience if they start puberty earlier than their peers, but lots of children handle early development with resiliency, and even pride.

Children who start puberty early – say, 8 instead of 12 — are faced with handling those physical changes while they are more childlike in their knowledge and their cognitive development, and in their emotional understanding of what goes on around them.

Parents should keep in mind that the same protective factors that help children navigate other challenges of growing up are helpful here: All children do better when they have good relationships with their parents, and when they feel connected at school. And we should be talking about the changes to their bodies before they happen, and make it clear that all of these topics are open for discussion.


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Day Care Infections May Mean Fewer Sick Days Later


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All three of my children started out in day care as infants, and the day care center was, in so many ways, at the center of our lives for years. The teachers taught us most of what we knew about young children (including, I am sorry to say, the difference between well-meaning parents and truly talented professionals). The day care cohort provided my children with their close friends (who keep turning up in their high school and college classes). We even bought our house so we could live near the day care center.

But yes, there were the infections. The worst battles my husband and I had were fought when a small child had to stay home with fever or diarrhea, and we had the eternally nasty whose-work-day-is-more-important-mine-or-yours-and-just-what-makes-you-think-so discussion. On the other hand, as our children got a little bigger, the infections essentially vanished — they had nearly perfect attendance records by the time they got to kindergarten and beyond.

In a study published last month in the journal Pediatrics, researchers in the Netherlands followed a large group of children over the first six years of their lives, looking at how often doctors diagnosed acute gastroenteritis, the stomach bugs so familiar to parents; 1,344 out of the total 2,220 children studied attended day care during the first year of life. Being in day care as an infant increased a child’s risk of having acute gastroenteritis in the first year of life, but it also had a protective effect after that.

Interestingly, the protective effect lasted at least till age 6, which is as far as the study went; the children who were in day care by the age of 1 had more gastroenteritis earlier, but the non-day care children got sick more often as they got older. By age 6, children in the two groups averaged similar numbers of total episodes.

“We think if you are infected at an early age you build up immunity against these viruses or bacteria,” said Marieke de Hoog, an epidemiologist at University Medical Center Utrecht and the senior author on the study. “There is even a possibility that the protective effect we have seen will continue when children grow up — we need more research.”

Day care attendance is known to be a risk factor for upper respiratory infections, which are much more frequent than gastroenteritis — the average child may have as many as eight upper respiratory infections a year, to maybe one bout of gastroenteritis, said Dr. Timothy Shope, an associate professor of pediatrics at Children’s Hospital of Pittsburgh, who is the co-editor of the American Academy of Pediatrics book Managing Infectious Diseases in Childcare and Schools: A Quick Reference Guide,” the fourth edition of which is due out next month. And going to day care also puts a child at higher risk for the ear infections that can follow those upper respiratory infections.

In fact, the gastroenteritis study from the Netherlands was an offshoot of a larger study focused on respiratory infections in children, and Dr. de Hoog and her colleagues published an article in 2014 in which they demonstrated a similar pattern in upper respiratory infections and ear infections: Children who attended day care in the first year of life had more infections earlier and fewer later. For the early day care group, this led to more doctor visits overall, and more antibiotics.

Some infections can be more severe or more dangerous in babies, which is probably one reason children who get sick younger get more medical attention. And there can certainly be moments in those early years of day care when, even though children are not dangerously ill, parents can feel overwhelmed by the parade of runny noses and runny bowel movements.

There is a more complex relationship between day care attendance and the risk of developing asthma and eczema, where there are several other important factors, like family history, antibiotic exposure, and the risk of infection with one particular virus called respiratory syncytial virus, or R.S.V., which has been linked to developing asthma. Still, Dr. Shope said, day care attendance may protect against these so-called “atopic” diseases, which are related to hypersensitivity reactions in which the body’s immune system is overreactive, and it has been suggested that this connects to the “hygiene hypothesis,” that early exposures may be beneficial for the immune system.

There are three basic lines of prevention for bringing down the frequency of infections in day care children, and the most effective is immunization. We immunize against several of the most common organisms that cause gastroenteritis (oh, how I wish there had been a vaccine against rotavirus when my children were born — that diarrhea lasted for weeks) and also against some of the organisms that can complicate respiratory infections. But we have to get better at making sure all young children get the influenza vaccine, which unfortunately has to be given every year, since the virus is particularly dangerous to children.

Infection control is also important in day care, especially around diaper changing and hand-washing. However, there are limits to how much young children can cooperate regarding what they put in their mouths, or whether they cover their coughs. Studies show some benefit of infection control measures, but “not as much as we would like,” Dr. Shope said.

Then there is the always complex pediatric decision about who needs to stay home. Although there are very specific recommendations around diarrhea and diaper changing, for example, it’s also true that with many viral illnesses, children are infectious before symptoms develop and after they cease, while other children are infected and infectious but never develop symptoms, so the protective value of excluding the symptomatic children is limited.

I often see parents who are told their children have to stay home from day care, and I still identify with them. So does Dr. Shope. “When I’m seeing a typical parent with a child under a year who’s in child care, and they’re missing work, they’re wondering if something is wrong with the child,” he told me. “I tell them this is normal, they’re making an investment for the future, their child is less likely to be ill going into kindergarten when other children raised with less contact are more likely to be ill.”


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Parents Shouldn’t Feel Guilty About Training Babies to Sleep



When my first child did not dependably sleep through the night, my parents were puzzled. My mother told me that to the best of her recollection, neither I nor my siblings had ever been troubled by night waking. I suspected that, back in the 1950s and ‘60s, they might have let us cry it out, but they didn’t recall. There might have been some difficult nights, but what was the big deal?

In our era of more anxious parenting, there’s a lot of debate about what has come to be called sleep training, that is, behavioral techniques for getting a baby who is 6 months old or older to fall asleep alone and sleep through the night. The debate comes when these techniques involve some periods of crying and protest on the baby’s part. Parents (and experts) who believe in sleep training feel that babies can develop “self-soothing” skills: learning sleep cues that help them comfort themselves and fall back asleep when they wake at night — as we all tend to do. Opponents of sleep training, many of whom are more generally committed to “attachment parenting,” say that in fact sleep training results in “learned helplessness,” with infants making the agonizing discovery that no matter how hard they cry, no one will come.

In a study published this week in the journal Pediatrics, 43 infants in Australia, 6 to 16 months old, all healthy, but identified by their parents as having sleep problems, were randomized to three different groups. In one group, the parents tried graduated extinction, the technique in which babies are allowed to cry for short, prescribed intervals over the course of several nights. The second group tried a technique called bedtime fading, in which parents delay bedtime in 15-minute increments so the child becomes more and more tired. And the third group, as a control, was just given sleep information.

The researchers measured the babies’ stress by sampling their levels of cortisol, a hormone indicating stress, and also looked at the mothers’ stress; 12 months after the intervention, they evaluated parent-child attachment and looked at whether the children had emotional and behavioral problems.

“What we were interested in is this hypothesis that there are these long-term consequences from doing something like graduated extinction,” said Michael Gradisar, an associate professor of psychology at Flinders University in Adelaide who was the first author on the new study.

Both sleep techniques – graduated extinction and bedtime fading — decreased the time it took children to fall asleep and graduated extinction reduced night wakings, compared to the control group. All the salivary cortisol levels were within the normal range in all three groups, but the afternoon levels in the two sleep training groups declined over time more than the controls. And there was no difference among the groups, 12 months later, in the measures of the children’s emotional and behavioral well-being.

Although critics of graduated extinction believe that strategy disrupts parent-child attachment, Dr. Gradisar said: “We couldn’t find any differences. The more studies we get, the more confident we can feel that this is actually safe to perform.”

This research builds on a follow-up study that appeared in Pediatrics in 2012, which looked at a large group of Australian children who, as babies, had participated in a controlled study of the effectiveness of behavioral sleep techniques. The original study, from 2006, had found that these techniques were effective both in reducing parents’ report of sleep problems in their 10-month-olds and also in reducing maternal depression, which has been linked to children’s sleep issues.

The 2012 research looked at those children at age 6, and checked out their mental health, stress regulation, sleep and a variety of measures of the parent-child relationship.

“We measured cortisol in saliva,” said Dr. Anna Price, a postdoctoral researcher in pediatric psychology at Murdoch Childrens Research Institute in Melbourne, who was the first author. “We also looked at parents’ mental health as well, all the effects the early program might have had on their later development and behavior, and the two groups looked very similar on all the measures.” The researchers found no differences between the children whose parents had been advised about the behavioral sleep techniques and the controls.

Another study of infant cortisol levels, published in 2012 in the journal Early Human Development, has been cited as showing that these behavioral techniques can be highly stressful for infants; it suggested that babies might be in distress even though they were not crying. Wendy Middlemiss, an associate professor of educational psychology at the University of North Texas, who was the first author on that study, said: “You have to be responsive. You can’t let them cry for long periods of time.”

But how cortisol is measured and interpreted is thus at the very center of this debate. Dr. Price and Dr. Gradisar were both among the authors of a letter responding to the Middlemiss article and challenging the cortisol methodology.

All these researchers agree that parents shouldn’t do anything that makes them uncomfortable; parents know best what their children need. But not-so-subtly, there’s a sense on one side that parents feel pressured and guilted into leaving their tiny babies to cry and cry at night, and on the other, that parents feel pressured and guilted into not letting their children cry for even a moment. And both may be true.

If what we really mean is, parents should do what they’re comfortable doing, and our job as pediatricians and pundits is to help them feel confident in their parenting, we have to accept that different families will make different reasonable choices.

There’s some good evidence that the various methods of “sleep training,” none of which should involve letting a small infant cry for hours in a dark room, work for many children and many families. There’s no evidence that they do lasting damage to the child or the parent-child bond and, in fact, some reassuring evidence that they don’t.

There also doesn’t seem to be evidence that you do harm by deciding to forgo “sleep training” and waiting for the child to outgrow the night waking — as long as that doesn’t damage your marriage or your mental health.

As a pediatrician, I think about the baby, but I also try to take into account how the parents are doing. I sometimes wonder how the people who are most strongly opposed to any form of sleep training would feel about having their children’s teachers, or doctors or bus drivers, coming to work sleep deprived after really disrupted nights. Sleep matters, as we have learned to acknowledge in medical training. Babies matter, and so do parents.

What your baby needs most is a loving family, which ideally includes parents who are enjoying the adventure. And no expert can tell whether you are enjoying the adventure better than you yourself.

See you in the morning.


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Clumsiness as a Diagnosis


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Years ago, I took care of a little girl whose mother worried tremendously about her clumsiness. When she was 4 or 5, my patient was still tripping and falling more than other children her age, her mother thought. She had trouble with the clapping games in her preschool. The mother was visibly distressed when she talked about this. She told me that she herself had been “that kid,” the clumsy one, the last one chosen for every team.

For a long time, a variety of terms were used in medicine and education to describe children who struggled with coordination but had no underlying condition, terms like the ominous-sounding minimal brain dysfunction, the milder movement-skill problems, and yes, clumsy child syndrome. In 1994, these were consolidated under a single diagnosis, developmental coordination disorder, though this covers a wide range of children who may struggle with anything from handwriting to riding a bicycle.

There is always a risk when you apply a diagnosis, always a chance that it will be seen as “pathologizing” or stigmatizing children. Are kids better off thinking of themselves as just kind of awkward? Should parents shrug and say, “no one in our family is a good dancer”?

“I think there is a perception out there that children who are clumsy are just children who aren’t good at sports,” said Dr. John Cairney, a professor of family medicine at McMaster University in Hamilton, Ontario, which maintains a website about the disorder with useful advice for parents. It’s more important, he said, to think about “how it affects children and adults in everyday activities — tying shoelaces, using knives and forks.”

The need for a diagnosis depends on whether the child is actually struggling. Pediatricians and pediatric neurologists do sometimes encounter parents who worry because a child isn’t gifted at sports, or at a particular sport. Not being gifted, or even good, at sports is not a diagnosis, and it’s probably more important for that child’s well-being to help parents take a new look and find the child’s real strengths and inclinations.

“Some of these kids come in referred to me, and they really look pretty normal; a lot is parental anxiety,” said Dr. Stephen Nelson, a pediatric neurologist and an associate professor of pediatrics at Tulane University, who wrote the Medscape article on developmental coordination disorder. “It’s O.K. if he doesn’t throw the ball well; he can have other skills,” Dr. Nelson said. “We don’t all have to excel at everything.”

On the other hand, a child whose fine-motor skills are far behind what is age appropriate may struggle to put on clothing, or feel bad about activities that children do for fun, like playing with Legos. And there are children whose problems go beyond just being average (or a little worse) at basic athletic skills, and those children can find themselves dreading gym class, and in some cases even being bullied.

“You have parents and teachers attempting to push them into activities, believing the problem is motivational, not neurologic or motoric,” Dr. Cairney told me. “They get bullied, called stupid or klutzy.” With a diagnosis, he said, the children’s quality of life might improve, especially if they are given good advice about how to manage the problem.

Taking the clumsy child for evaluation is all about whether the child could use some help. That may involve modifying the child’s environment: Lots of children are referred for evaluation because of dysgraphia, or terrible handwriting. Learning how to use a keyboard can make a huge difference for their school functioning.

Occupational therapy is a mainstay for these children. They have to practice the specific skills they want to improve, whether that means handwriting, tying shoelaces or using a knife and fork.

An evaluation may help tease out problems that aren’t actually coordination issues. Some children look clumsy because they’re distracted, not paying attention to the motor — or athletic — task at hand. Others may have visual impairments. Doctors worry more if a child is delayed in several realms at once; if speech, fine-motor and gross-motor are all lagging. Most concerning of all is when a child who wasn’t originally clumsy starts to lose coordination skills, or begins to walk differently. Such a child should definitely be evaluated, because something new and medically serious could be going on.

So what about my patient? Well, she illustrates another point: Developmental coordination disorder is found more often among children with other issues, like attention problems, learning issues and autism. Parents with a child who is not doing well in school and also seems uncoordinated should take the lack of coordination as a reinforcing reason to have developmental and academic testing done.

That was true with my patient; her mother was very focused on her daughter’s clumsiness, but her preschool teachers were worried that something was getting in her way in the classroom. She ended up needing some special help with reading and schoolwork as she entered school. I would probably take her mother’s concern about clumsiness more seriously sooner these days, looking at it as a clue to that larger issue.

Clumsier children may become more self-conscious about displaying their motor skills and less likely to participate in games and activities, and this may mean they get less practice. And practice does help everyone, from the naturally gifted to the rest of us.

“In general, most of this gets better with time,” Dr. Nelson said. However, he added, it’s not something that children completely outgrow; clumsy children, on the whole, tend to become clumsy adults.

With more screen time and less freedom to play outside unsupervised, there’s also a concern that many children may have a lower chance of developing and practicing many motor skills (other than swiping and clicking). “We need to do more to support children’s global motor development,” Dr. Cairney said, “not to ensure they become athletes, but to ensure they can participate in a range of activities.”


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Parents, Stop Feeling That Everything You Do Is Wrong


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When was the last time you heard a curmudgeonly adult complain that kids today have it easy?

Results from this year’s National Poll on Children’s Health were released in April, suggesting that many adults — both parents and nonparents — think that children today are experiencing more stress, and worse mental health, than when they themselves were young.

This is a striking reversal of the traditional dynamic, in which adults recall the hardships and dangers of the old days, and conclude that kids today have it easy, said Dr. Matthew M. Davis, a pediatrician who is director of the poll at C.S. Mott Children’s Hospital at the University of Michigan.

Not that the curmudgeons have shut up. Everyone knows that first world, privileged kids today are cushioned, shielded, protected from the literal and figurative bumps and bruises of the real-world playground. Everyone gets a trophy. We monitor children’s social interactions and if someone says something harsh, we call it bullying and we intervene. Parents are helicopter parents (hover hover), or worse, snowplow parents (pushing all the obstacles out of their children’s way). Kids are overprotected, spoiled, entitled and lazy.

And everyone knows, of course, that kids today are overscheduled, highly stressed, burdened by completely unrealistic and hypercompetitive parental expectations of all-around achievement and success at a prestigious college. Few get that all-important trophy because the odds are so incredibly poor. Parents are would-be tigers, entitled demanding perfectionists, kids are stressed, pushed past what they can do, and miserably aware that they aren’t measuring up.

So our children aren’t turning out right because we are dangerously overprotective in our parenting or too strict and demanding. To sum up, everything you do is wrong.

Can we really be getting it so wrong at both ends? Can we be this bad at it?

It’s time to put an end to the everything-you-do-is-wrong school of parent criticism, which puts us all in an impossible bind. You helped your kid with a difficult school assignment? You helicopter, you! You referred to the importance of your child’s high school G.P.A.? You hyper-critical, prestige-minded stress machine! (Even back in the 1970s, my parents were known to do both things.)

Parents also feel stressed by this perception that children are so stressed. “There are some real challenges for parents today in terms of encouraging them to be protective while at the same time not be overprotective,” Dr. Davis said. “That can be a very hard balance for parents to strike and it’s also a hard balance for communities to find.”

Dr. Kenneth Ginsburg, a pediatrician specializing in adolescent medicine at the Children’s Hospital of Philadelphia drew a specific connection between the apparent extremes of what he called “self-esteem parenting” and the high stress and anxiety of children who feel the weight of parental expectations. The problem, he said, is that if we praise children for being smart, they may become anxious about losing that label, and therefore less likely to take on hard tasks.

But parents can help children become more willing to work hard, more perseverant, even more creative, he said. “We have this enormous amount of research on what kind of parenting produces the best effect.”

The model that Dr. Ginsburg has put forward in his book, “Raising Kids to Thrive: Balancing Love With Expectations and Protection With Trust,” published through the American Academy of Pediatrics, is what he calls lighthouse parenting.

“You should look down at the rocks and make sure they never crash against them, and prepare them to ride the waves.”

This is the style of parenting described as authoritative, often contrasted with the extremes of permissive parenting and authoritarian parenting, and there is a lot of research to back it up. “The authoritative or balanced parent essentially says, I love you so much but I’m your daddy, I’m not your friend,” Dr. Ginsburg said, “I’m going to give you lots of opportunity to grow, a deep sense of connection so that you’re going to be firmly rooted. I’m going to give you lots of opportunity to make mistakes. But when something comes down to safety or morality, you’re going to do what I say because I know best.”

I hope I have my lighthouse days, when I get the balance right. I know I also have my tiger days and my helicopter days, and for all I know, my free-range moments and my snowplow episodes, maybe in rapid succession. Everything I did when my kids were growing up was probably wrong, except when it was right.

As parents, we all make decision after decision after decision — stand back and let a kid take a chance or interfere. Watch a kid struggle or offer help; encourage perseverance or say it’s O.K. to quit sometimes. Sympathize and reprove, console or tell them to suck it up. And the balance changes with the particular kid involved, but also with the day of the week and the month of the year.

Except for the crazy people (and yes, there have to be some crazy people, or what would be the dirty fun of P.T.A. meetings and open school nights), most parents are somewhere in the middle, trying our best, getting it right sometimes, getting it wrong sometimes, and often unsure, especially as our children get older, whether today is a right day or a wrong day.

When my oldest child was born and my husband was feeling swamped by the (predictable and appropriate) terror of this new responsibility and all the decisions to be made, my own father very kindly told him to stop worrying. There was no one thing that we would do or not do that would matter all that much, no individual decision or speech or act, he said.

Our child would understand who we were by everything we did and how we lived, our tones, our values, our random eccentricities, not just by what we said parent-to-child, but by how we lived in the world. Eventually, our son would know us better than we knew ourselves.

And somehow, that was a comforting thought, that parenting was not something we could purposefully decide, that it was who we were and how we lived that would inevitably constitute the family environment that would shape our child.


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When Parents Blame Themselves for That ‘Difficult’ Baby


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In March, I wrote in this column about how different babies are different assignments, some much more challenging than others. Does a difficult baby mean parents are doing something wrong? How do you know when a baby — or small child’s — behavior signals problems more serious than a challenging temperament? And when nothing major is actually “wrong,” do parents have any real reason to complain?

Many parents commented, here or by email, about the contrasts between their own children — the easy baby and the hard one; the happy, satisfied and satisfying child (“After my husband and I had our first child, we realized quickly that we were the world’s best parents,” wrote “Olderandlesswise” in the comments here) followed by the demanding impossible child. (“Turns out we totally suck as parents. Who knew?”)

A number of people described having a very difficult first child who was therefore also a last child — or having a difficult second child and thinking, if this one had come first, there would never have been a second one.

Everybody telling these stories had experienced that sense of direct parental responsibility — the bad sleeper must be a bad sleeper because of something the parents did or didn’t do. The screamer wouldn’t be a screamer, if only you had done something differently. You get credit for the happy affectionate child, you get blamed for the one who isn’t. You blame yourself, and other people blame you.

And sometimes the pediatrician says the right thing, but there are also parents who come away from the doctor’s office just feeling more shamed, more unable to meet the standards.

As a pediatrician, I need to acknowledge that your job as a parent is to love and cherish and civilize the particular child you were given — not the child you had planned on, not the child your own parents were sure you would get, not the child in any particular parenting book.

My own first child did not like to be put down, ever, under any circumstances. We bought one of those soft baby carriers and one of us wore him pretty much all the time — washing dishes, standing up and typing with the typewriter on top of a dresser — and that made him happy, and when he was happy, he was delightful.

We had a book that showed photos of someone else’s baby lying on his back and smiling. I assumed that the baby in the photos had probably been drugged. A decade later, when I had one who enjoyed being put down, I apologized mentally to the author and the photographer.

There is no one-to-one correlation between what you do and and how your baby behaves. You work it out together, you and the baby. Sometimes you can successfully intervene, and part of the pediatrician’s job is to help you find guidelines that sometimes work — sleep training, breaking bad habits and reinforcing good ones, helping a baby learn to self-soothe, dialing down tantrums. But you can only do what you can do, and there are children who specialize in chewing up the guidelines — what a pediatrician friend of mine calls, “what to not expect.”

There is always the worry that something else is wrong with a child who seems to be distressed a great deal of the time, or with a toddler whose behavior continues to be extreme. In cases of excess crying, people wrote in to blame everything from the trauma of circumcision to food allergies, from gastroesophageal reflux to autism. I want to be very clear that good pediatric practice involves searching out the source of distress when you can — and that every pediatrician worries about classifying crying as “colic” when it’s really something else. On the other hand, there are a lot of true colicky babies out there.

And sometimes, especially as a baby grows, parents find that problems go beyond temperament. My colleague Dr. Karen Hopkins, a developmental behavioral pediatrician at New York University Langone Medical Center, told me, “a typical complaint is, I can’t find anyone that who will agree to babysit for him because he’s too difficult, or he’s had to change day care centers or babysitters three times because they can’t manage him.” Those children may need to be evaluated for early evidence of hyperactivity or oppositional behavior that goes even beyond the toddler norm, or for autism.

“Where the parents feel out of control, where they’re very unhappy, where they observe significant differences in a playground setting or a playroom between their child’s play and others,” Dr. Hopkins said, families may need extra help.

Every pediatrician I know is in awe of the parents who cope with medical and developmental problems, who “go to medical school the hard way” and find themselves mixing expert nursing and constant advocacy with the love and care of parenting. They are, as a group, pediatric heroes.

But acknowledging and celebrating that kind of parental heroism shouldn’t stop us from discussing and celebrating the more everyday parental dedication of coping with a challenging though healthy baby. It’s really important not to take for granted the daily toil — however joyful — of caring for young children; that would be in the long tradition of ignoring and undervaluing the work done primarily by women in this world, too easily dismissed by those who haven’t put in the effort.

Some wrote to say, well, as long as you have a healthy child, you have nothing to complain about. That’s true, in a certain sense. But you need to pay attention to your own trials, even if they aren’t mortal, and acknowledge the energy and dedication and love and good humor that get you through the difficult days of parenthood, which can be truly difficult, even when you have a lot to be thankful for.

So here’s to the everyday dedication of parenthood — that truly for-better-or-for-worse commitment. Let’s enjoy them when they’re easy — without taking undue credit, and without necessarily predicting what they will become from their infant temperaments — and let’s acknowledge that sometimes they’re really hard. Especially some of them.


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Offering Kids a Taste of Alcohol


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I discovered a new category for myself as a parent when I read a study published in March in the journal Pediatrics called “Parents Who Supply Sips of Alcohol in Early Adolescence: A Prospective Study of Risk Factors.” I confess I bridled a bit at the idea that the investigators might mean me: A ceremonial drop of Champagne on New Year’s Eve? A token “sip” of wine at Passover? Doesn’t this sound a little, well, puritanical?

It turns out that there is a growing body of research, much of it in specialized journals on alcohol use, on parents’ providing small tastes of alcohol to relatively young children in the context of family events, and trying to tease out what it does or doesn’t mean in terms of children’s later relationship with alcohol. Mind you, the sipping children aren’t high school students; we’re reaching back earlier than that. And the research came about because it is so common for parents to offer those sips at home, before children have had other tastes of alcohol.

“The whole issue of sipping came as a surprise,” said Dr. Monika Wadolowski, an epidemiologist who is a postdoctoral research fellow at the University of New South Wales Australia and the lead author on the study, which looked at 1,729 Australian seventh graders. She was drawn to the topic, she said, because some statistics were identifying high rates of early alcohol use in adolescents, but they weren’t distinguishing between the kids who had “sipped” and the kids who had had whole drinks.

Some researchers are trying to get at a child’s very first experience with drinking, “the earliest transition in the youngest population, specifically, from abstention into sipping or tasting alcohol among children,” according to a study published in 2014 in the journal Alcoholism: Clinical and Experimental Research. And that can mean going back pretty early. Researchers looked at 452 children in Pennsylvania to see what factors might predict which ones would start tasting alcohol from ages 10 to 12. Sipping wasn’t associated with the kinds of behavior problems that have predicted problem drinking in other studies. Instead, it was connected to whether parents approved of the sipping and to children’s perceptions of those attitudes.

The lead author, John E. Donovan, a professor of psychiatry at the University of Pittsburgh, recently wrote to me in an email that based on the cumulative research: “Child sipping is related to earlier initiation of drinking, which is a risk factor for a lot of other problem behaviors,” and related to binge drinking and drug use. His conclusion: “Parents should not be providing alcohol to their kids.”

That connection between early sipping and more serious drinking was explored in 2015 study, again published in a specialized journal, the Journal of Studies on Alcohol and Drugs, which followed a group of children from the beginning of sixth grade to the beginning of ninth grade to look at whether early sipping behavior was associated with patterns of early alcohol use. They excluded alcohol in the context of religious services. The children who had tried alcohol before sixth grade — mostly at home, mostly beer and wine, mostly given by a parent — were more likely to have had full drinks or gotten drunk by the beginning of ninth grade.

The researchers controlled for a variety of risk factors, including child behavior problems, parents with a history of alcoholism, and parental drinking. Even so, they found that early sipping was strongly associated with more serious alcohol use by ninth grade.

What does that early sipping do, the researchers wondered. Does it change a child’s sense of what is normal behavior? Of how available alcohol is or should be? Is it possible that the taste — or the effects — of even small sips of alcohol may reinforce drinking behavior in young children?

Parents may think that by providing sips of alcohol to children, we are actually protecting them against problem drinking. We may think that we are modeling — at family occasions or on religious holidays — a healthy, festive attitude toward alcohol, consumed in moderation and in celebration. As a mother who supplied occasional sips, I want to ask about parental motivation, cultural patterns, community context, and about conversations between parents and children.

In Dr. Wadolowski’s study, the most powerful association was that parents who perceived that their child’s peers were using drugs or alcohol were more likely to be providing those sips at home; there were also associations with increased home access to alcohol and lenient rules about alcohol.

“What was really interesting,” she said, “was to find the parents who were supplying alcohol to their children, they had good parenting practices, they had strict rules, they monitored their children’s relationships.” What correlated with their decision to offer those sips? “The biggest predictors were whether they thought their children’s friends were drinking,” she said. So perhaps they were deliberately trying to offer an alternative model.

Dr. Wadolowski is concluding another study that looked at how the seventh graders who had had sips of alcohol behaved over the next year. It found that those who progressed to drinking whole drinks were more likely to have problem behaviors, friends who drank, and less parental monitoring; these factors were more important than the history of sipping. And the risk factors are interrelated.

Because it is so widespread, “we really do need to understand what the long-term effects are and whether it really does relate to binge drinking,” Dr. Wadolowski told me. “The research is so young.”

And so, of course, are the children.



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Where Have All the Ear Infections Gone?


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Dr. Perri Klass

Dr. Perri KlassCredit Vivienne Flesher

One way I knew my pediatrician was a good doctor was that he resolutely refused to diagnose an ear infection in my youngest child.

My older son had had quite a few ear infections, and we’d gone through any number of bottles of amoxicillin, which, fortunately, he rather liked. My daughter had one or two ear infections; she hated all liquid medicine, and resisted it so successfully, with the spitting fountain approach, that the doctor once found dried amoxicillin in her ears, prompting some concerns about me as both a mother and a pediatrician (“Um, you do know she needs to take the medication by mouth?”).  But not the youngest. Fever, cough, runny nose, cranky, it was always just a viral upper respiratory infection, with no evidence of infected fluid collecting behind the eardrum, no reason to treat with antibiotics.

When I started practicing pediatrics in the 1990s, it seemed we diagnosed a case of otitis media — middle ear infection — every few minutes. I knew the antibiotic dosages by heart for children of every weight. I knew the risk factors for ear infections: day care, exposure to parental smoking, not being breast-fed. But risk factors or no, it seemed like most small children had ear infections, every now and then.

Now in clinic, ear infections are much less common. When one of the residents gets ready to make this diagnosis, the supervising doctors sometimes get called in to verify: is the eardrum really red, bulging, not moving? (If there’s a buildup of infected fluid behind the drum it bulges out; you blow a little air into the ear, and the eardrum doesn’t move.)

In a study published in March in the journal Pediatrics, researchers tracked 367 babies during the first year of life, regularly swabbing their noses to see what viruses and bacteria had colonized them, and watching to see when — or if — they would get their first ear infections. Six percent had a first ear infection by 3 months of age; 23 percent by 6 months, and 46 percent by a year; the babies who got ear infections had twice as many colds as the babies who didn’t, reinforcing the relationship between viruses and the ear infections that can follow. They were also more likely to be colonized by bacteria that can cause infections. As in many past studies, breast-feeding lowered the risk, for both colds and ear infections.

These rates are lower than the rates found in the older studies, done in the 1980s and 1990s, in which 18 percent of babies had an episode by 3 months, 30 to 39 percent by 6 months, and 60 to 62 percent by a year. Dr. Tasnee Chonmaitree, an infectious diseases specialist and professor of pediatrics at the University of Texas Medical Branch at Galveston, and the lead author of the study, told me, “we all know we don’t see as many otitis media cases as we used to.” 

What they were trying to do in this study, she said, was look carefully at the actual incidence of ear infections now, in this new environment, in which children are routinely vaccinated against Streptococcus pneumoniae, or pneumococcus, one of the types of bacteria that can cause ear infections (it can also cause more serious infections, including pneumonia and meningitis), and also against influenza, since viral infections like flu may precede bacterial ear infections. Neither vaccine is directed specifically at ear infections, but both have probably affected the incidence since my children were young.

study published in 2014 in JAMA Pediatrics looked at the number of medical visits for otitis media made by children up to the age of 6 and found a downward trend from 2004 to 2011, with a significant drop in 2010-11. The first routine childhood pneumococcal vaccine was introduced in 2000; we changed to a vaccine effective against a wider set of bacterial serotypes in 2010.

There’s another factor that is probably contributing to the decline in ear infections, and it has to do with tightening the definition of what we call a true otitis media, and even beyond that, what we treat. There’s been a push in pediatrics to prescribe antibiotics only when really necessary. The reason my pediatrician’s behavior 20 years ago made me trust him was that I was clearly shopping for a bottle of pink medicine. It would have made me feel better to be treating something. When our doctor resisted that pressure, and instead looked carefully at the ear, I knew my child was in good hands.

It’s not always absolutely clear whether an ear infection is present. Crying can make a small child’s eardrum appear red — or at least pinkish — and having a doctor look in an ear can make a young child cry.  But we’re trying hard these days not to overprescribe antibiotics, both because we worry that we’re breeding resistant bacteria, and also because of concerns about the effects that antibiotic treatment can have on the microbiome, the bacteria living on and in a healthy child.

So in clinical practice guidelines that were revised in 2004 and then again most recently in 2013, the American Academy of Pediatrics has pushed hard to tighten the diagnostic criteria for otitis media to cases where the eardrum is clearly bulging, and to suggest that older children without bad ear pain or high fevers do not have to be treated immediately with antibiotics.

“Protecting people from unnecessary antibiotics exposure helps people have a healthier microbiome, which is important for a healthy immune system,” said Dr. Carrie Byington, a professor of pediatrics at the University of Utah and chairwoman of the A.A.P. committee on infectious diseases.

So ear infections, once the very definition of “bread and butter pediatrics,” have become rarer, as a result of a combination of vaccines, breast-feeding, decreased parental smoking and increased medical vigilance about making the diagnosis and treating young children with antibiotics. It’s a happy pediatric story of the convergence of improved preventive measures, healthier environments for young babies and the medical profession’s trying to be scrupulous about limiting interventions.

“The reason goes back to the parents and the good decisions they’re making, to immunize their children, to breast-feed their children, to not smoke around their children,” Dr. Byington said. “It’s parents making these good decisions for their kids, and it’s paying off.”


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Fear of Crying: The Problem of Babies and Airplanes


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Dr. Perri Klass

Dr. Perri KlassCredit Vivienne Flesher

First of all, nobody takes a small child on an airplane for the fun of it. I have been there and I know. Don’t get me wrong, I’m no airplane saint; you won’t generally catch me offering to hold someone else’s kid, or making friends around the seatback. I don’t usually admit to being a pediatrician, for fear of hearing a medical saga. But I have put in my time on airplanes with my own infants and toddlers and small children, and I certainly know how it feels.

Probably the best thing that can be said for traveling with young children is that it teaches you to appreciate traveling without them, however puzzling the inflight announcements, however long the delays, however tightly spaced the seats. I did enough economy-class traveling with children while my own were young that my reflexive reaction to all flight cancellations, turbulence or the moment when the person in front of me reclines the seat very suddenly, knocking my laptop closed, is now: At least I don’t have a small child with me – thank heavens.

Babies do not cry on airplanes for the fun of it either. Nor do they cry, by and large, to let you know that their parents are neglectful or callous. They cry for infant versions of the same reasons that adults snap at one another about reclining seats, or elbow each other with quiet savagery over the armrest. They cry because their ears hurt and they’re being made to stay in a certain position when they don’t want to or the air smells strange and the noises are loud, or their stomachs feel upset or the day has been too long and they still aren’t there yet or they’re just plain cranky. As are we all.

Crying is an evolutionary strategy to summon adult aid; over millennia, crying has probably evolved to be hard to ignore. I don’t know if it’s any comfort, but when you’re the parent with the crying baby, it doesn’t particularly help to be an expert.

“I remember one flight where my daughter screamed the whole way and kept trying to get out of her seatbelt,” said my old friend, Dr. Elizabeth Barnett, a professor of pediatrics at Boston University and a travel medicine specialist. “As a parent, you feel two things — you’re in distress because you’re trying to comfort your child and not succeeding, so you feel bad for your child, and you also feel guilty because you know your child is disturbing everybody else.”

Many children behave remarkably well — even delightfully — on airplanes. Many more manage pretty well, but occasionally give way to despair. Many parents are full of interventions and distractions. All of this deserves at least a smile or a word of praise.

Those of you who are still in the traveling-with-small-children years probably know the basic advice — nursing or sucking on something during takeoff and landing may help with painful pressure changes in the ears. But it’s also important not to overfeed babies on airplanes, pointed out Dr. Karl Neumann, a pediatric travel specialist and author of the site Kids Travel Doc, where he recently posted a comprehensive update on air travel. “At 30,000 feet, the air in your intestine is increased by 20 percent because of atmospheric pressure, so you shouldn’t give the kid more than you would at home,” he told me, or the child may end up crying (or worse) because of abdominal discomfort.

So do your best, and let people see that you’re doing your best. “If your child is crying, start talking to the people around you, explain to them how bad you feel, ask the flight attendant if there’s a seat somewhere else,” Dr. Neumann suggested. “Before they get angry around you, tell them you’re sorry, you’re doing the best you can and likely they’ll be on your side.”

Parents sometimes wonder about sedating babies, usually with antihistamines, and pediatricians advise against that. In general, it’s not good to give extra medications to the young. The effects can be unpredictable, and in some cases paradoxical; there are children who get more active with the medications that are supposed to make them sleepy. And a groggy child may actually be crankier and harder to console.

Somewhat self-servingly, I always believed that one important tip was: Whenever possible, give the kid to his father. People smile at men holding babies — even crying babies — on airplanes. Flight attendants offer them assistance. I wondered about this, till I read in my favorite parenting manual, “Miss Manners’ Guide to Rearing Perfect Children”: “A father traveling with a screaming baby is presumed to be a widower who is devoting himself to the welfare of his poor babes… A mother traveling with a screaming baby is presumed to be a slovenly person whose husband was driven away by her neglect of discipline and the resulting bad behavior of the children.”

Airplanes, like it or not, are common spaces, at least for those of us who fly commercial. We need to go easy on one another. We do not know the stories of the people jammed up against us. That played out parent who doesn’t seem up to coping with that energetic toddler may be on leg three out of five of a tragic transcontinental journey to attend a family member’s death bed. That parent who dared to sneak a quick nap may have been up three nights straight with a bout of teething, stomach flu or diaper rash. By and large, people do their best, and no, everything was not much more orderly and children were not much better behaved 20 years ago, or 50 years ago. I have been that baby, and I have been the parent of that baby, and I know.

“Just try flying the Eastern shuttle with a baby,” wrote Nora Ephron in “Heartburn” in 1983. “Try flying any plane with a baby if you want a sense of what it must have been like to be a leper in the 14th century, but try the shuttle for the ultimate in shunning.” The Eastern shuttle is no more. But babies on airplanes we will have with us always, along for the ride, all of us doing our best.


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When Parents Have a Favorite Child


Dr. Perri Klass

Dr. Perri KlassCredit Vivienne Flesher

To my own mother, it was an article of faith to show no favoritism. If two of us asked her whose drawing she liked best, the answer was predetermined: I like them just the same. When I tried to trick my mother by saying I had done both drawings myself, she saw right through me; she understood that children are constantly trying to elicit evidence of who is ahead and who is behind. And to the end of her life, if someone tried to draw my mother out in public praise, by saying, with reference to some particular milestone or achievement, oh, you must be so proud of your child, she would respond, firmly, yes, I’m proud of all my children.

Her parents, back in the 1930s, had no concerns about treating children equally; the boy was the boy was the boy; the girls were the smart one and the pretty one.

Dr. Barbara Howard, a developmental behavioral pediatrician who is the president of Total Child Health and an assistant professor of pediatrics at Johns Hopkins University School of Medicine, often sees behavioral problems that stem from a child’s sense of not being the preferred one. “It’s impossible not to have favorites, and we do know that the perception of favoritism is one of the biggest factors in sibling rivalry,” she said.

“Often the child is trying to get the attention of the parent who is rejecting them — the more you push a kid away, the more he will come at you,” she said. “So if you see a kid coming at a parent, being aggressive or being clingy or needy or overly attention-seeking, often the parent doesn’t like the kid that much, or the kid perceives it.” She may ask the parent what that child’s behavior evokes; which other family member does it make you think of; what possible future does it make you imagine? Often, she says, the parent is aware of feeling strained toward that child, and feels terribly guilty about it; finding ways to enjoy spending time together can help them both.

Years ago I read a novel — someone please tell me what it was — in which a mother secretly and privately assured each of her children, don’t tell the others, but you have always been my favorite. I liked that system, and, as a mother, I think I could do it with perfect sincerity — one on one with each of my three children, I think I could say it and it would be true.

Ellen Weber Libby, a clinical psychologist and author of “The Favorite Child,” said some families have a shifting favoritism, where different children hold the advantage from day to day or week to week. That kind of rotation, she said, yields a healthy, normal competitiveness. Ask the children, she says, and they will tell you. “The people who don’t know are usually the parents, who live in denial because there’s a myth that to have a favorite child is bad.”

The danger comes when the favoritism is steady and persistent and becomes a lasting part of the family dynamic.

Evolutionary psychologists think of parental investment in their offspring as the division of a finite pool of resources, rather than, perhaps, an infinity of love. “I would argue that parents do sometimes have favorites and do invest unequally,” said Catherine Salmon, an associate professor of psychology at the University of Redlands in California, who studies relationships and is a co-author of “The Secret Power of Middle Children.” Birth order can matter here, she said, with middle children perhaps less likely to be favorites, compared with first children, who monopolize their parents, for that first period, and last children, who represent a final chance to invest.

Dr. Salmon pointed out that the effects of parental favoritism may be much sharper in families where there isn’t enough to go around in the first place, so the inequities may be particularly harsh. On the other hand, Dr. Libby said, in a prosperous family, the favorite child may grow up entitled, immune from the rules that apply to the other children.

“I think you can let people off the hook from feeling guilty about having a favorite — put it right out there and say of course you have a favorite, people have favorites, it’s what you do with it that matters,” said Dr. Howard. “You’ve got to find something you appreciate about each kid and build on that.” With children whose behavior is problematic, she may suggest developing new rituals, like an early-morning cuddle before the day gets going.

“Parents don’t appreciate the difference between love and favoritism,” said Dr. Libby. “I think it’s hard for parents to say, I love my children the same and from time to time there is a child I do favor. I favor a child because at that moment that child makes me feel more successful as a parent.”

So yes, there may be real inequities — but what may matter more is the perception of favoritism, and what everyone involved does with it, both in terms of behavior, and in terms of memory and emotion. We all carry with us into adulthood a sense of where we stood, how we were perceived and how we were treated.

On a good day, the idea of the favorite child can be a bit of a running joke, which serves as a reminder to parents to play fair, and as a reminder to children that while love is infinite, parental approval and esteem need to be earned, and are worth competing for, within reason.

When Dr. Libby had to put together her first PowerPoint presentation, she said, she found herself feeling overwhelmed. She texted her children: “Whoever gets back to me first is my favorite child for today.”

“Within a nanosecond my daughter, who never has time to call me, was on the phone, and my son said, damn, when your phone was busy I knew my sister was on it!”


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The Benefits of Spicing Up a Breast-Feeding Mother’s Diet


Credit Anna Parini

When I had my children I felt that there was a tendency by experts, including those in my own pediatric profession, to push certain principles that took all the fun out of life. This played out for me, in particular, after I gave birth to my first child, and was told as part of my breast-feeding “support” that I should avoid all spicy foods, because they would upset the baby. Like any good Cambridge, Mass., mother, I turned this into an argument about multiculturalism (“What about the mothers in Sichuan?”), but what I really thought was that it harked back to some old ideas about spices heating up the blood, and generally making life too interesting for the nursing mother.

Why are women told to avoid strong flavors when breast-feeding?

Twenty-five years ago, researchers asked a group of nursing mothers to load up on garlic. In the study, “Maternal Diet Alters the Sensory Qualities of Human Milk and the Nursling’s Behavior,” which ran in 1991 in the journal Pediatrics, nursing mothers who ate garlic produced breast milk with a stronger smell, as evaluated by researchers who didn’t know which sample was which. What was most interesting was how the milk tasted to the babies, those poetically named “nurslings.” When the garlic effect was there, the babies stayed longer on the breast, and nursed more vigorously.

Julie Mennella, a biopsychologist at the Monell Chemical Senses Center in Philadelphia, was the lead author on the 1991 study; she has continued to study the effect of early exposures on the development of taste. “Amniotic fluid and mother’s milk have a lot of sensory information,” she told me. “The baby gets the information when they feed on the milk.”

Another study, published in 2001, showed that babies who had been exposed to a flavor in utero or while nursing were more likely to like that flavor when they were weaned.

What goes into your stomach goes into your bloodstream, broken down into molecules of protein, carbohydrate, fat. The flavors cross as well, including potent molecules called volatiles, which carry scent, which in turn heavily influences taste, as you know if you have ever tried to eat something delicious when you have a bad head cold.

The variety of flavors that you eat during pregnancy go into your blood and then into the amniotic fluid, which the baby is constantly drinking, in utero, and the flavors that you eat while nursing cross from the blood vessels that supply the mammary glands into the breast milk. So instead of restricting the maternal diet, there’s now good evidence that by eating a wide variety of healthy and tasty foods during these periods, we are actually doing our babies a major favor.

“Breast-fed babies are generally easier to feed later because they’ve had this kind of variety experience of different flavors from their very first stages of life, whereas a formula-fed baby has a uniform experience,” said Lucy Cooke, a psychologist specializing in children’s nutrition, who is a senior research associate at University College London. “The absolute key thing is repeated exposure to a variety of different flavors as soon as you can possibly manage; that is a great thing for food acceptance.”

Her own research has included working with children at the age of weaning to increase the acceptance of vegetables by offering repeated exposures to them.

“Babies are tremendously adaptable and very accepting of all sorts of strange flavors,” Dr. Cooke told me.

What about the idea that some foods in the mother’s diet can make a baby fussy or gassy or colicky? By definition, the foods that cause gas in the mother do so because they are not absorbed, and sit in her intestine, making trouble. On the other hand, a number of studies suggest that some colicky babies do better if their mothers stay away from cow’s milk, so doctors may advise nursing mothers to cut that out for a 10- to 14-day trial, while making sure they still get plenty of calcium.

Caffeine is sometimes also a culprit, pointed out Dr. Pamela High, a professor of pediatrics at Brown University and medical director of the Infant Behavior, Cry and Sleep Clinic at Women & Infants Hospital of Rhode Island. But mothers of colicky babies often restrict their diets further and further, and many ultimately give up nursing, Dr. High told me in an email, even though this usually doesn’t help.

So yes, the flavors we eat when we’re pregnant, or when we’re nursing, go to the baby, aromatics and all. But this should be a positive message rather than a list of thou-shalt-nots, since it means that we are providing something beyond protein and calories; we’re actually letting our babies, unborn and born, into some of the joys of our human omnivory.

“A diet of the healthy foods she enjoys is modeling at its best,” Dr. Mennella said. “The baby only learns if the mother eats the foods.”

When, as a nursing mother, I ate the spicy foods that I love so well, I’ll have you know that I was actually modeling. My children, after all, were going to grow up in a family in which spicy food was part of every possible family occasion.

And if the flavors of the foods you love can make the experience of childbearing and child rearing a little tastier, or spicier, for mothers, that’s all to the good as well, and very much in line with what we hope our children are drinking in mother’s milk.

“Food gives pleasure,” Dr. Mennella said. “There’s a lot of biology underlying the pleasure of eating.

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A Reconsideration of Children and Screen Time


Derek and Isabella Galustians play on their tablets. The siblings each have their own tablet and each have one of their parents' old phones, without a phone plan, to use apps and play games.

Derek and Isabella Galustians play on their tablets. The siblings each have their own tablet and each have one of their parents’ old phones, without a phone plan, to use apps and play games.Credit Emily Berl for The New York Times

The digital world is changing around us at a dizzying pace; parents want guidance, and pediatricians want to answer their questions with helpful and scientifically valid advice. The American Academy of Pediatrics’ policy on children and media is probably best known for two recommendations: to discourage any screen time for children under 2, and to limit screen time to two hours a day for older children.

As new technologies have transformed many aspects of daily life, new questions have arisen. Did discouraging screen time for children under 2 mean no Skyping with Grandma? Did a limit of two hours for older children mean that if a sixth-grader did her homework on her computer, as assigned, she had used up her allotment? When those guidelines were originally composed in the 1990s, screen time was essentially taken to mean time in front of the television, or time spent playing old-style computer games; by 2013, the policy had changed to limiting “total entertainment screen time” for older children, while still “discouraging” all screens for those under 2.

The children and media policy and guidelines are undergoing review and revision, but in the interim, the academy convened Growing Up Digital, a symposium of experts and researchers last May, and came up with a list of tips — “Beyond ‘turn it off’: How to advise families on media use” — published in September in AAP News, which goes to pediatricians. These suggestions were meant to expand and enhance the existing guidelines by taking notice of new technology and new science.

“We have a variety of policy statements, but technology is always faster than how we can deal with it,” said Dr. Ari Brown, an Austin, Tex.-based pediatrician who was the chairwoman of the American Academy of Pediatrics’ Children, Adolescents and Media Leadership Work Group, and the lead author of the article. “We need to be able to provide practical guidance for parents that they can use now based on science.”

Although these tips on children and media were not meant to replace the existing guidelines, they attracted a good deal of media attention themselves, some of which suggested that a major change had taken place: The collective pediatric wisdom, which had been essentially anti-screen, was now opening the door and letting in the LED light.

”When you look at the press response, this was a foreseeable response but an unfortunate response: The AAP says media is great for kids!” said Dr. David Hill, the chairman of the A.A.P. Council on Communications and Media’s executive committee, and one of the authors of the article. In fact, he continued, the message was much more nuanced: “The A.A.P. says media are diversifying, that quality of the media is critical, that there is much we still have to learn.”

The pediatric wisdom has always been that you should err on the side of protection and prevention; we advise no screens for children under 2 because there’s no evidence of benefit, and a lot of concern about harm; because we worry about what screen time may be replacing in the lives of young children, who need direct human interaction to learn and develop.

Take that Skyping-with-Grandma question (or Skyping with a deployed military parent), which keeps being raised as an example of good screen time for children under 2. Every single pediatrician I spoke with brought that up — not, I suspect, because it’s such a burning question for parents, but because it’s pretty much the best reason anyone has come up with for encouraging a very young child to look at a screen.

“There are some preliminary studies — and I emphasize preliminary — that babies as young as six months can learn from prosocial media,” said Dr. Victor Strasburger, a distinguished professor emeritus of pediatrics at the University of New Mexico School of Medicine and a co-author of the original policy statement, “but they learn 20 times better from parents. I think very judicious use of technology for under-2s may be okay, but personally I don’t see the hurry.”

I hope very much that the go-ahead-and-Skype-with-Grandma message doesn’t somehow blur into a more general sense that screens are a good idea for the very young. Grandma is a good idea for the very young, and the technology here is supporting the interacting, not displacing it.

Whatever we may learn about what young children can or cannot learn from the screens in their lives, what we know is that they need human contact and interaction — and there’s a real worry that screens may take up time and space in babies’ and toddlers’ lives and replace some of what they most need.

But Dr. Dimitri Christakis, a pediatrician who directs the Center for Child Health, Behavior and Development at Seattle Children’s Research Institute, who was one of the authors of the existing guidelines, argued in a 2014 editorial in JAMA Pediatrics for the value of high-quality electronic experiences even for very young children, and for up to an hour a day of what might be considered playing with educational digital toys.

What we should be emphasizing for older children, he said, is that parents need to make sure that they get true nonscreen time built into their days. That means, in part, no screens in the bedroom, and cellphones left for the night in a different room. Families need to create a couple of hours of high-quality offline time each day.

Dr. Strasburger noted that the content of what children watch is very significant. “Media violence will never be good for kids; sexual content at a young age will never be good for kids; first-person shooter games will never be good for kids,” he said. “The research is very clear, and it will never change.”

Even high-quality educational electronic content shouldn’t crowd out the other parts of childhood. “Unstructured, unplugged playtime is very important for all children and especially very young children,” said Dr. Benard Dreyer, the president of the American Academy of Pediatrics and a professor of pediatrics at N.Y.U. “This does not negate the previous recommendations,” he told me. “We still don’t think kids under 2 should be watching TV; we still don’t think older kids should be spending more than two hours a day watching TV.”

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Some Babies Are Just Easier Than Others


Credit Getty Images

I got my good sleeper second. My oldest child, my first darling baby, did not reliably sleep through the night till he was well past 2. Since he is now an adult, I can skip right over all the questions of whether we could have trained him to self-soothe and stop calling for us in the night — we tried; we failed; we eventually gave up.

The good sleeper was a good sleeper right from the beginning. She followed the timeline in the books, slept longer and longer between feedings, till she was reliably giving us a real night while she was still an infant and she never looked back. Had we matured as parents, become less anxious, more willing to let her learn how to soothe herself? Were our lives calmer? Well, no. In fact, kind of the opposite. We just got dealt two very different babies.

I supervise pediatric residents as they learn to provide primary care, to offer guidance to parents as they struggle with all the complexities of baby and toddler sleep, eating, potty training, discipline and tantrums. All of the stuff that shapes your daily life with a small child, and I’m talking about an essentially healthy, normally developing small child. And the hardest thing to teach, especially to people who haven’t yet done any child-rearing, is how different those healthy, normal babies can be, right from the beginning.

So we review our sensible pediatric rubrics that deal with these questions, from establishing good sleep patterns to setting limits to encouraging a healthy varied diet. But sometimes it seems that these rubrics work best with the children and families who need them least.

Every child is a different assignment — and we can all pay lip service to that cheerfully enough. But the hard thing to believe is how different the assignments can be. Within the range of developmentally normal children, some parents have a much, much harder job than others: more drudge work, less gratification, more public shaming. It sometimes feels like the great undiscussed secret of pediatrics — and of parenting. Babies and children are different, assignments are different, and we spend a lot of time patting ourselves on the back — as parents and as pediatricians — when the easy babies and toddlers behave like themselves, and a lot of time agonizing and assigning blame when the more difficult kids run true to form.

We talk a lot about temperament in my line of work. We look at where a child — or an adult — falls along a set of axes. High activity to low activity. Adapts easily to adapts with difficulty. Intensity, mood, attention span. And while no one would argue that these are fixed and immutable traits, it’s also true that — again, as every parent and teacher knows all too well — you can’t possibly make child A into child B. You work with the temperament you’re given — it’s the assignment. And some assignments are harder than others.

We talk about “goodness of fit,” and certainly, it can be helpful to think about how one child’s temperament might be less problematic in another family — the high-energy child who is driving two somewhat sedentary, somewhat older parents crazy might be an easier assignment for two younger, more active parents.

I have had a mother explain to me why one twin was the angel child and the other the devil child. And then she started to cry. I have had a father ask me if I ever knew a couple to get divorced because their baby didn’t sleep through the night. And sure, some of those struggles reflect parental practices and habits and the way those children have been reared and how their parents reacted to earlier iterations of the behavior. But ask any parent who has brought up two children of wildly different temperaments — some of it is just the kid you get dealt.

As a pediatrician, I feel this in the exam room all the time — respect for parents who are coping good-naturedly with the cranky and the colicky. Sympathy for parents who break down when they describe public tantrums and the judgments passed by onlookers who assume that a crying baby must automatically reflect either a too-indulgent or a too-neglectful parent — or both at once.

There are children whose level of activity, or rigidity, or shyness, crosses over into the pathological, and will actually complicate their lives far beyond the variations of normal temperament. As a pediatrician, I want to start by making sure that nothing is really wrong — but when nothing is really wrong, I want to acknowledge that the job of rearing one healthy, normal child can be much more challenging than the job of rearing the one who came before — or who will come after.

My good sleeper was actually my challenging child. I’m telling you this with her full consent — like her brother, the bad sleeper, she’s now grown up. She was what we like to call a “spirited” child: unbelievably stubborn, ready to battle to the death over any small choice, and subject to periodic, and generally very public, melt-downs which I sometimes thought would get me arrested. And yes, now that she’s an adult, I can see that many of these same traits translate into determination, and strength of character. But looking back, I’m not sure any of us would have made it through, if we hadn’t been, at the very least, well rested.

Well, of course we would have made it through. As a pediatrician, you try to help and encourage; even the crankiest can be soothed; even the children most averse to new experiences can start to sample the world. Sooner or later, almost everyone accepts potty training, gives up the pacifier, sleeps through the night. And given a longer distance — years stretching into decades — most of us, parents and children, do find it possible to look back and smile.

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The Always Hungry Teenage Boy


Credit Anna Parini

Ah, the adolescent male appetite. Those always hungry growing boys who eat standing up, drain the quart containers of milk or juice, and are fully capable of finishing off as an after-school snack the whole lasagna or pot of stew or cold roast beef that was supposed to serve as dinner for the family. I have come home to this myself: the teenager who greets his parents in the evening with an empty refrigerator, a sink full of dirty dishes, and the hopeful question, “What’s for dinner?”

In January, when the recently revised Dietary Guidelines for Americans came out, adolescent boys were specifically mentioned in a slightly unexpected context: “Some individuals, especially teen boys and adult men, also need to reduce overall intake of protein foods by decreasing intakes of meats, poultry and eggs, and increasing amounts of vegetables or other underconsumed food groups.”

Are teenage boys eating too much protein? What do we actually know about the dietary habits of adolescent males, beyond the sitcom jokes?

Dr. Elsie Taveras, the chief of general pediatrics at Massachusetts General Hospital for Children, is an expert on childhood obesity. “The forces that are working against good diet quality in adolescent boys,” she told me, begin with that famous appetite. “They’re always hungry, and that hunger, and a lack of satiety with small portions, leads to impulsive eating and eating large portions. And the foods they are choosing aren’t really keeping them full, since foods with high fiber levels are the kinds of foods which do keep people full.”

The dietary guidelines include graphs of what people in different age groups eat, drawing on data from the large National Health and Nutrition Examination Survey and showing, for each food group and at each age, how those amounts compare with the recommended daily intake. No one will be surprised to hear that when it comes to vegetables, both males and females of all ages eat significantly less than what is recommended.

For protein, the graphs look very different. For males, intake rises steadily from the 9- to 13-year-old category up through 31- to 50-year-olds, so that by the time they reach late adolescence and young adulthood, males report eating significantly more protein than recommended. Females, on the other hand, report eating quantities at the bottom of the daily standards, and 14- to 18-year-old girls say they’re eating less protein than recommended.

“There’s so little research focused just on boys,” said Alison Field, an obesity and eating disorders expert who is the chairwoman of epidemiology at the Brown University School of Public Health. “We know that at puberty, boys will acquire more muscle mass, and females will end up with more fat mass,” she said. “When males go through their growth spurt, which is longer than females’, their appetite is tremendous.”

These hungry fellows have big appetites, and as a group, they don’t tend to fill up on salad. So the primary dietary advice for them is probably “eat more vegetables,” and the hope is that would mean less meat. “What this recommendation really says is that teen boys should be eating more of their calories from vegetables but less from meat to better balance their nutrient intake,” Marion Nestle, a professor of nutrition, food studies and public health at New York University wrote in an email.

We know as much as we do about the dietary habits of teenage girls because there has been so much concern about obesity and also eating disorders. Many, if not most, adolescent girls are trying to lose weight whether they need to or not. Eating disorders are less common in males, but adolescent boys, on the other hand, are often preoccupied with building muscle, particularly if they are athletes in a sport like football, where size matters. “Males may want to bulk up, may want to be big,” Dr. Field said.

“We really underestimate how important weight and shape are to males,” she told me, suggesting that airbrushed images of models and sports figures in the media promise quick results. “Young men are just as influenced as young women by these images.”

The extra protein in the supplements that many boys buy in hope of bulking up may be useless. “The body can only absorb so much protein,” said Jerel Calzo, a developmental psychologist who studies eating disorders in adolescent males and is an assistant professor of pediatrics at Harvard Medical School. Boys who are eager to build muscle may exceed the recommended amounts, he said. “If you’re doubling up, you’re only getting the extra calories — sugars and fats.” Further, he said, the supplements are under-regulated, and the marketing is often deceptive.

In the worst-case scenario, these protein supplements can damage your kidneys, especially if you get dehydrated, so boys who dabble in protein supplements have even more reason to keep drinking fluids. But again, that can lead to problems, since sports drinks, also heavily marketed to young men with athletic ambitions, include additional refined sugars and empty calories. “We do a lot to push the fact that children don’t need sports drinks,” Dr. Taveras said. “Water is just fine.”

Although some teenage boys are clearly preoccupied with their bodies, others manage to eat their way right through adolescence without ever making very clear connections between any aspects of diet and health.

The unbounded adolescent male appetite, the athletic ambitions and the concomitant desire to add muscle, taken together with the very deliberate drumbeat of marketing, can add up to a poor diet. “To me, protein is a nonissue,” Professor Nestle said. “You can’t talk about protein in isolation from everything else people eat.”

The most essential message for adolescent boys and young men is a variant of the basic unsurprising message in the overall report: Eat more vegetables, and substitute healthier, less processed foods for the junk. Oh, and while you’re at it, guys, be careful of the protein powders. By and large, extra protein is not what you need.

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