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

Anna Parini

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

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. 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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