095: Ask the American Academy of Pediatrics!

Jen 00:01:37 Hello and welcome to the Your Parenting Mojo podcast. Regular listeners might recall that I launched a new segment of the show a couple months back called Sharing Your Parenting Mojo where I interviewed listeners about what they've learned from the show and what parenting issues they’re still struggling with. My second interview for this segment was with listener Rose Hoberman and at the end of our conversation she just kinda casually threw out, “so, you know, my father in law is actually a past president of the American Academy of Pediatrics. So let me know if you'd like to interview him.” And I was kind of shell shocked for a minute and I just said, yes, if you could set that up for me as soon as you can, I'd really appreciate it. So here with us today is Dr. Benard Dreyer who's Director of the Division of Developmental and Behavioral Pediatrics and also a Professor in the Department of Pediatrics at the Hassenfeld Children's Hospital, which is part of New York University Langone. Jen: 00:02:26 Dr. Dreyer works closely with children who have autism spectrum disorder, ADHD, language delays, genetic problems and behavioral difficulties in school. Dr. Dreyer received his M.D. from New York University and he held a variety of leadership positions within the AAP before serving as its president in 2016 and he continues to serve as its Medical Director for Policies. Dr. Dreyer has also hosted the SiriusXM Satellite Radio Show On Call For Kids, a two-hour show that has run two to three times a month since 2008, which is incredible coming from a podcast perspective. Welcome Dr. Dreyer. Dr. Dreyer: 00:03:02 Pleasure to be here. Jen: 00:03:03 So I solicited most of the questions from this interview from people who are subscribed to the show via my website and who get emails from me and they were able to email me back and send me their questions as well as those who are in the Your Parenting Mojo Facebook group. One thing that really stuck out to me as the questions started rolling in was the extent to which parents, at least in the US to some extent abroad, really like to know what the American Academy of Pediatrics says about a particular topic. And they might not always agree with the AAP’s position and they might even make a decision to ignore the AAP’s advice, but they always like to know what the AAP says before they do that. So the position that AAP takes really does carry a lot of weight. I wonder if you can walk us through what it's like to make one of these recommendations that are probably based on hundreds of studies with conflicting results and boil it down into something like no screen time for children under 18 months and no more than one hour a day for children ages two to five. How does that work? I guess starting at the beginning, how do you decide what studies to include? Dr. Dreyer: 00:04:06 Well, I think even before we decide what studies to include, there is the question of what topics should we have like policies or recommendations on. I think we choose topics based on what we think are the important issues for both pediatricians and practice where they're dealing with issues and so we hear from them and also what factors or issues are very important to parents. Then we look to see if there is enough evidence for us to actually make a recommendation, not every aspect of childcare, etc. is enough evidence for us to feel confident that we are making a recommendation that's based on it. So having said that, for each topic, we do a literature search through the medical and psychological and educational literature and we gather all the studies that exist there, the authors of each policy, review all those studies and throw out some of those studies because they're poorly designed, but include all the studies that are well designed from the research perspective so that we can be sure that their findings are useful. Dr. Dreyer: 00:05:31 As you said, sometimes these studies are conflicting and also sometimes we don't have complete information and we have to use whatever information we have to make a recommendation. I mean we don't choose studies to include, we review all the studies on a topic. So for example, screen time, we reviewed all the studies on screen time for young children and looked at the evidence as to, you know, on the one hand what we know about child development. So there might be studies, for example, that show that children under 18 months of age don't learn from a flat screen. So there are scientists that have studied, for example, language development with adults speaking to children through a flat screen versus speaking the same way to them live so that the child recognizes them as another human being at that young age and showing that they actually don't learn language well from a flat screen experience and certainly in the first year of life, whereas when they're interacting on a live basis with an adult, they actually learn. So that kind of study informs our policies from the point of view of how the child's brain works. We may then have other studies which look at whether children given video games, etc. learn or don't learn from those specific video games or for those specific iPad or other kinds of activities. So that's a different kind of study that's basically testing an intervention to help children learn. So therefore, I mean, we use studies based on physiology or biology or brain function versus studies that actually test an intervention usually in a randomized control way. Jen: 00:07:46 Okay. So I'm curious about whether children's development is the only or the primary concern or is there any weight given to kind of the family structure and parenting relationship? So what I'm thinking through as an example here is okay, we acknowledge the child is possibly not learning very much by looking at a screen for half an hour a day or an hour a day. But if the parent is getting some much needed alone time in that period of time and thus the parenting quality improves for the remainder of time that the pair interacting, is there any weight given to sort of that aspect of the relationship between the parents and the child or is the weight entirely on what is the child developmentally getting out of this particular screen time experience? Dr. Dreyer: 00:08:31 So that's a great question by the way. We do get input from parents on many policies. I can't tell you the exact input we got on the screen time. I was not one of the writers there, but we have a group of families called Family Voices, which often review our policies and give us feedback on them before we put them out to the rest of the world. So, we do get input from families. I can tell you that our recommendations are part of a conversation with families. In other words, this is our recommendation that children don't learn from screen time. That there is no good amount of screen time for them to have. Parents then take that and integrate that into the way they do their lives. I don't think we've ever told a parent that if you put your kid in front of a screen for 20 minutes, their brains will be fried, you know what I mean? Dr. Dreyer: 00:09:32 But we also know that on the average, US children under the age of two have one to two hours of screen a day. So therefore when we come down on our recommendations, our recommendations are also based on what we know many parents in the United States are doing, which is allowing their children to have two hours of screen time. So, therefore we think that's a bad thing for people to be doing because that's bad in two ways. One is children really learn from interactions with their parents or other adult caregivers at younger ages. So we want parents to talk to their kids, to play with them, to read books to them, etc. That's how children learn. And we want to encourage that which we do. We also know that too much screen time is associated with behavior problems in children where they become distracted. Dr. Dreyer: 00:10:35 They developed symptoms like ADHD. I don't mean that it causes ADHD, but they become somewhat scattered. There’s somewhat more aggressive behavior with those kids who have a lot of screen time. So, we want parents to understand that a lot of screen time is not a good thing. I often have parents asked me for example, well what happens if I just want to go into the kitchen and finished cooking something and my kid is watching TV for 20 minutes, is that terrible? The answer of course is no, but that 20 minutes often becomes an hour. So we want parents to really understand that actually under the age of about 18 months, there is nothing your kid is getting out of that and if you want to use it as a babysitter recognize that you’re using it as a babysitter, but alive babysitter would be better. Dr. Dreyer: 00:11:35 Who can talk to the kid. Jen: 00:11:36 For sure. Dr. Dreyer: 00:11:37 Yeah, and also a lot of this image of the parents just putting their kid in front of a TV for 15 minutes while they go into the kitchen or the bathroom or whatever is somewhat of a fantasy. Most of the kids who get put in front of screens are there for quite a while. To be honest, it's not that safe to just stick your kid in another room in front of the screen while you're in another room in the kitchen. That kid should be in the kitchen with you or nearby where you can observe them. Again, we're talking about kids under 18 months of age. We're not talking about two or three year olds or four year olds. We don't want too much screen time. But that's a different question and that's one of the reasons we modified our recommendations is exactly what you're telling me about, which is we felt the original recommendations sounded so rigid that parents felt that either they followed them or they didn't follow them and that was not what our point was. Jen: 00:12:44 Yeah, that was actually another question that I had was around that sort of what is seen from the outside when the revised recommendations came out that that they were being revised because parents were not following them at all because the recommendation was so different from their daily lived experience. So I'm curious, I know the science is changing all the time, but was that changing recommendation primarily changed because of the discrepancy between the recommendation and what parents were doing rather than because the science had changed and suddenly indicated that it was safe for children to be having screen time at younger ages? Dr. Dreyer: 00:13:19 No. So let me put a little wrinkle on that comment. There was more science out there for us to look at. So our policy about our policies is that they should be updated every five years. The reason is there is new information out there. So our recommendations automatically should be changing approximately every five years or at least we should review the information and sometimes we review the information and say there's really nothing new here. We can keep these recommendations for another five years and we will check it five years later. But we do automatically in fact look to change our recommendations approximately every five years because there's new science that informs our decisions and we may have to change our decisions. In the case of, I don't want to focus the entire show on screen time, but in the case of screen time, we kept basically our recommendations for the first 18 months. Dr. Dreyer: 00:14:29 We’ve said there should be no screen time except skyping with your grandparents. We allow skyping with grandparents. We used to get calls like is screen time with grandma in Iowa good? The answer is sure, that's not what we're talking about. First of all, that's interactive. You are going to be with your kid. That's a good thing. So we wanted to sort of explain what we were talking about and we kept basically that we don't recommend, we didn't say we forbid but we don't recommend screen time for the first 18 months. We dropped it from two years because 18 months to two years is a transitional period. There were some kids who can benefit from certain kinds of use of iPads or watching shows on TV that are geared towards children that are entertaining or that they learned something from. Dr. Dreyer: 00:15:27 So we did modify our recommendations based on new information and new studies, which allowed us to be a little more nuanced and graded in our recommendations. Then sometimes we make recommendations which are based on very little evidence. So we had to make a decision like after 18 months or two years, how much screen time should a child be watching? And we don't have hard evidence about exactly what that amount is. That's why we chose like one hour for younger children just to make the point that children should not be in front of the TV or sitting on an iPad or computer for hours a day when they're that young, they still need to be with adults or other children in play. Jen: 00:16:19 Okay. So that was another question that listeners had was it's not that one hour is a magic number, it's more that this is an idea that children benefit more from interacting with parents because parents were wondering, well is the number low because the AAP knows that if they say two hours is okay then parenting can end up doing four hours. Dr. Dreyer: 00:16:40 Yeah. Yeah. But also I think as a parent and a grandparent, I'm going to talk, as well as a pediatrician who takes care of families with children, there isn't really much for children to spend more than an hour a day on an iPad really at the age of three. If they are doing that then they're probably missing out on other activities which would be more beneficial for them. Jen: 00:17:10 Okay. Dr. Dreyer: 00:17:11 But you're right, one hour is not based on some absolute study which showed and I think that's how it's stated in the policy. I decided I was not going to pull the policy stuff in front of me because I want the conversation not about this. I don't think we say one hour is an absolute, but I do think that we picked an hour based on some TV or some computer time or some iPad time or some smartphone time is okay, but not excessively. Jen: 00:17:43 Yeah. Okay, so leaving screen time behind and waiting even deeper into the murky waters, let's go and talk about safe sleep recommendations. So, I know a lot of parents are interested in this topic. So the AAP’s stand on this is pretty clear and that is the safest place for a baby is on a firm flat surface like a crib or a bassinet with no soft bedding in the same room as the parents but not on the same sleeping surface for the first six months. So I have a number of followup questions on this. Firstly, is it true to say that the risk of infant death is always higher when bed sharing than when the child is sleeping on their own sleep surface on their back, in a crib or a bassinet? In other words, is there no way to make bed sharing as safe as the child's sleeping alone on their back in a crib? Dr. Dreyer: 00:18:35 So let me just say in general, I'm all for bed sharing. I mean as a general principle not for the first six months of life. Because we do know that the incidents of sudden infant death syndrome is much higher with bed sharing and also that it's decreased coincident with less bed sharing and less prone sleeping and prone sleeping is probably the biggest issue. But bed sharing can also be an issue. So there are ways of making pseudo bed sharing safe. So there are parents who can buy these extensions to their beds with a flat cribs that kind of attaches to the bed so that the child is there close to them, but on his own flat surface on the back. And what’s good about that is especially for breastfeeding parents, the child is right there. So when they want to breastfeed, they don't have to get out of bed. Dr. Dreyer: 00:19:44 They can just pick up the child, breastfeed, put the child back. That's not bed sharing, but that's why I use the term pseudo bed sharing, and that is in fact what I recommended to the famous Rose Hoberman who was on your show on your podcast, which brought me here and that's the kind of setup that they have. Now regarding sleeping on the back versus the belly, it's really a matter of parent persistence and point of view. Parents who believe that their kid should sleep on their back and encourages the kids sleep is fine. Parents who every time the kids cry feels that they are better off on their belly, once you start putting kids on their belly and then convince yourself that that's the only way they'll sleep, well then that's the only way they’ll asleep. But I can tell you, I have many, many families who are firmly convinced that the baby sleeping on their back is safer and babies sleep on their back fine. Dr. Dreyer: 00:20:58 It doesn't make them cry all night. It doesn't wake up the parents all night. I mean, babies often wake up parents. My usual joke with parents is your baby will sleep through the night sometime before college, because parents sleep, babies sleep is like one of the big issues for most new parents. But that's separate from saying it's related to sleeping on their back. But once parents start moving them to their belly and then want to turn them back to their back then that causes problems. But babies from the get go who are put on their back and sleep there, sleep fine, and there's no evidence that they need to sleep on their belly. Again, remember we're talking about the first six months or so of the baby's life. We're not talking about the first five years of their life. Jen: 00:21:58 Okay. So for that period, after the first six months, is the AAP stands that bed sharing can be done safely? Dr. Dreyer: 00:22:06 I think I'd have to pull up the policy, but I think that we focus on the first year as being of somewhat concerning for bed sharing. Most SIDS cases occur in the first six months, but some do occur later in the first year and so we don't encourage bed sharing for the first year. After that, I don't know if we have a policy that says yes or no for bed sharing. Jen: 00:22:34 Right. Dr. Dreyer: 00:22:35 Remember our safe sleep recommendations are really for the first year, not for the rest of the child's life. We do recognize that many cultures have bed sharing from the get go. That doesn't mean it's safe and many kids do want to be in their parents' beds. It's comforting to them. Though once the risk of SIDS is over, I think that's up to the parents to decide whether they want a kid in their bed or they don't want the kid in their bed. Many parents don't want their kids in their bed because they want to have a good night sleep. Their bed is their bed, but other parents would like their kids in their bed. And I don't know that we're...