May 16, 2016

Screenagers

Nelson Branco, MD FAAP
Tamalpais Pediatrics
Larkspur, California
www.tamalpaispediatrics.com

I recently had the opportunity to watch the documentary Screenagers with some friends, colleagues and two of my children.  This documentary about the pervasive nature of screens in our lives and environment is relevant, informative and well done. The movie centers on a physician parent’s decision to give her middle-school aged daughter a smartphone and explores the ways that screens play a role, both positive and negative, in our lives.

This movie resonated with me as a pediatrician and a parent. I have tried to be thoughtful and balanced about both the rules I set for my family and the anticipatory guidance I give about screen time. Time will tell if my children have learned to manage the different screens in their lives, and whether I have modeled responsible behavior. Nonetheless, there are principles that we can use to guide us when giving advice to families and kids around screen time.

The amount of information at our fingertips and the ability to connect and communicate with virtually anyone in our lives is truly incredible.  It’s not surprising that it is so addictive – these devices are useful, entertaining and engaging. When we deny this we lose credibility with the kids in our lives.

Minecraft is cool.  It really is – spend some time with a Minecraft-savvy tween and you’ll see.  Social media at it’s best is fun and interesting. Texting can be a good way to communicate – more immediate than email but not as intrusive as a phone call. Video games can teach kids to try, fail and try again.  Movies and TV help us relax, share stories and learn.

There are well-documented negatives, of course. Few of us may qualify for the DSM-V diagnosis of Internet addiction, but we all react to the jolt of dopamine that we get from a new email or text.  Minecraft can take over time that could be spent playing outside, reading, doing homework or being creative with another medium besides animated blocks and elements.  Teens can use social media and text messaging to bully, harass or hurt their friends and schoolmates. Violent video games can expose kids to sights and sounds that we would like them to avoid, and can be addictive as well. Movies and TV shows can model unhealthy behavior and unwelcome stereotypes.

 As parents, we work hard to protect our children from harm. In my practice, most families are aware of the need for rules around media and limit their young children’s screen time.  I see it become more difficult in the middle and high school years, once smartphones become ubiquitous. I also see parents who think nothing of pulling out their smartphone while waiting, or while I am talking to or examining their child.


 I’m sure most of us have done the same. We often use the excuse that we are doing “work” when we’re on our screens.  We should remember that teens can use the same excuse.  Their “work” is to connect with their friends and form an identity. Social media, texting, Skype and email are all ways to do that – more efficiently and more pervasively than the phone calls and hanging out that our generation did as teens.

If we are going to teach our kids to use screens and media wisely we need to monitor and track our own use.  Are we reaching for the phone as soon as it dings, even if we’re in the middle of a conversation?  Do we stand around checking email or social media while waiting in line or sitting with our kids in an office? Do we have screen-free times for the whole family?

We can’t expect our kids to learn to eat vegetables if we aren’t serving and eating them ourselves, and we can’t expect kids to use devices and media responsibly if we aren’t doing it as well.

 Screenagers touches on these same points, and uses stories and examples to illustrate these topics. This movie won’t break any new ground for pediatricians – these are topics that we talk and think about every day.

What I liked about this movie is that it gathers interesting information and presents it in a balanced and engaging way. It opens the door for consideration and conversation. I wish more documentaries about parenting, families and kids did this as well.

The movie is being screened in many communities. I highly recommend you see it and engage your colleagues, kids and other parents in the discussion. For information about the movie, visit their website: www.screenagersmovie.com.

April 25, 2016

Young I.V. Parody Rap Videos

Ivy Pointer, MD, MPH
Pediatric Intensivist
WakeMed Health and Hospitals
aka Young I.V.


I have never been afraid to act like a fool for a good laugh and if you’ve seen any of my Young I.V. videos, you will have seen plenty of footage of me acting like a fool (I hope you laughed).  People often ask me “How did you get the idea to start doing this?”

Well, I wish I could say that I planned it out from the beginning but it sort of happened spontaneously.  I had seen many of the Holderness family videos (ed. note - a Raleigh NC family that makes parody videos about various topics) and thought to myself, wow that looks like fun.  So I decided to write a rap about my entire family having gastro for 3 weeks. I shared the lyrics with some colleagues at work who thought they were hysterical.  Since I really will do anything for a good laugh, I turned the rap into a music video and even enlisted the participation of my entire family.

Fast forward about a year, and I have now produced 23 videos on various pediatric topics, with several more raps written and ready to produce. The topics range from helmets, vaccines, and car seats to food allergies, croup, and reflux.
 
At first I joked that the goal of Young I.V. was to rap with Jimmy Fallon. Of course, that is still totally a goal, but as the videos started to gain some popularity outside my inner circle, I realized that these videos could have a broader reach and purpose.

In our social media, digitally-driven, entertainment-addicted world, I am hoping these videos can compete with all the other messages parents are hearing about how to keep their kids healthy and safe.

The goal of Young I.V. is to bring awareness to children’s health issues and educate the public in a nonthreatening and entertaining way.  I hope you’ll enjoy and share them but most of all, I hope you laugh!

Here is my most popular video:
https://youtu.be/48DOigw98TM

And my newest on Back to Sleep:
https://youtu.be/vghgMc84Zek

Find all of the videos at:
www.youngiv.org
https://www.youtube.com/channel/UCFwd3xAmX7x0_pa2D34wbIw

March 29, 2016

Practical Screen Time Advice for Parents




Paul Smolen MD FAAP

Carolinas Medical Center, Charlotte NC
Creator of the blog, Portable Practical Pediatrics

Author of Can Doesn't Mean Should-Essential Knowledge for 21st Century Parents

This COCM post is an adaption of a post from Dr. Smolen’s blog, Portable Practical Pediatrics.
 
You can find some fascinating stuff in a pediatric journal. The other day I was reading my copy of Pediatrics, and I found an article that I thought parents and pediatricians might find interesting and meaningful. The article talks about the activation that occurs in a child's brain when he or she is stimulated by storytelling or being read to. This subject is getting a lot of attention because of its relevance in today's electronic-rich environment where screens have begun to substitute for the storytelling/reading experiences of the past. The article speaks to the core of childhood:  a child’s imagination, language skills, and cognitive development.
   
    I watch the daily struggle that parents have with regard to limiting screen time for their children. As they wait in my office, parents often try to distract and placate their children with a smartphone showing an animated video game or movie.  Cartoons on a little screen seem magically to tame even the most upset, misbehaving, out of control child. Children love these devices, and parents often use them to reward certain childhood behaviors or simply to distract a bored, annoying child.  The peace and quiet is instantaneous!  Everyone appreciates the quiet, but is the method of achieving it—with screen time—good for the children? I'm not so sure.

    Followers of my blog, www.DocSmo.com, will remember the post (1)  about a study (2) showing that an iPad, given to children just prior to surgery is as effective at relieving anxiety as the potent sedative Versed.

    No one would advocate giving Versed to children on a regular basis to relieve anxiety or boredom. This is clearly not in their best interest.  If giving Versed regularly to children to relieve anxiety isn't beneficial, is frequent use of screen time with the same goal any better? Could today’s use of screens be the “Soma,” the negation of negative feelings, that George Orwell warned us about in his novel 1984?

    In the Pediatrics study, researchers used active MRI scans to measure brain cortex activity while young children (three to five years of age) were read to. (3) They found that children with “greater home reading exposure” showed greater cortical brain activity while listening to stories in the lab. They conclude that active imaginary verbal activities such as reading to children, developed the children’s ability to create “mental imagery and narrative comprehension.” Is anybody surprised? I certainly am not.

    We know that reading to children is good for their brains, but the word is still out on screen time. Common sense tells me that children who are not instantly pacified with screens learn more self-control; they learn to be more patient without the screen to fill the void of time. Learning to be patient without demanding to be distracted is actually a skill that children need to learn. Psychologist Dr. John Rosemond believes that children around the world generally stop interrupting their parents’ conversations—a skill that requires patience—by their fourth birthday. (4) Do we observe this tendency in contemporary American children?  No. Perhaps learning to cope without screens while the pediatrician is tending to a sibling is something that children need to master and that we as pediatricians should foster.


    But we live in the times that we live in. Telling parents just to say no to screens is not practical and not likely to happen.  How can we encourage parents to achieve a healthy balance for their children? How can we encourage parents to limit time with virtual, passive devices like screens and, at the same time, help children to develop active imaginations with less need for high stimulus, passive entertainment?

    I think parents should adopt what I call the Zero Sum Solution:  for children over two years of age who are too young to read on their own, parents should read to them for at least as much time as they permit the children to have screen time. Older children who are good readers should earn screen time by reading for an amount of time equal to their screen exposure. It is important to note that the reading/storytelling time should precede their screen time.  No reading, no screens. Using this strategy, children may relax with a screen only after they have spent an equal amount of time stimulating the parts of the brain that use mental imagery and more active verbal engagement. I think the Zero Sum Solution is a practical means of balancing screens with traditional imagination and verbal formation. It also shifts screen time to an activity that is earned, not expected. Oh, and by the way, I do occasionally see children who learn to love reading as much as most children love screens. These book lovers always seem to succeed in school.  Just saying...


References:
(1) See more at: http://www.docsmo.com/electronic-anesthesia-pedcast/#sthash.LxEVOnb4.dpuf

(2) Pediatric Anesthesia Volume 24, Issue 12, pages 1217–1223, December 2014 – http://bit.ly/V1Pcmf

(3) Pediatrics Volume 136 Number 3, October 2015  pp 466-478

(4) Psychologist John Rosemond's developmental milestones for children

February 24, 2016

The Social-Media-Savvy Pediatrician: Do We Physicians Recognize our Own Risks?


Rupal Christine Gupta, MD FAAP
Medical Editor, Nemours Center for Children’s Health Media / KidsHealth
Staff Pediatrician, Nemours Children’s Clinic at Thomas Jefferson University
Twitter: @Doc2Mom

As physicians we frequently talk about how our patients use media for health information. We furrow our brows and ask: Are they thinking critically about what they read, watch, and share?

Well, now that I use social media just as much as the next person, I have come to realize that I need a dose of my own medicine. We doctors need to ask ourselves the same question.

I recently watched a dust-up in one of the physician-mother groups on Facebook that I follow.

A physician posted an online petition involving breastfeeding, formula feeding, and neurological issues - all emotional topics that have profound impacts on children's health.

The post, which promotes a practice not considered standard of care, has gone viral in several circles – and had spread to responses in a variety of blogs and Facebook groups, even spurring a post on the Academy of Breastfeeding Medicine’s blog. Misinformation has spread rampant. Mothers - who feel strongly about their own choices and methods – are standing in opposition to one another. Camps of people are spouting vitriol. Reason is low and emotions are high. The resulting posts? Non-evidence based approaches, anecdotal basis for opinions, name-calling. Who are the culprits but physicians? We should know better.

It's natural for doctors to want to create professional villages through online platforms. We seek one another's help. We also trust one another. We look to the people with whom we graduated from medical school with a mixture of friendship, respect, and awe, and we have chosen to extend this respect to people from other institutions and create social networks around these various allegiances. So our groups are not just professional, they are personal. In these online landscapes, doctors may easily decide to share even more: not only information about our families and personal photographs, but also opinions for which there is scant evidence.

This particular conversation about infant feeding practices reminded me all too well of the professional responsibility we have as physicians. When we post our opinions online, we can't just shoot from the hip. We must pause to consider what we are saying, why we're saying it, and how it might be interpreted by the audience. Who's the audience? Well, it might start out being just our cozy physician group on social media, but it can ultimately include anyone and everyone, including our patients.


Here are some ways to stay above the fray:

  
Join social media groups with attentive moderators:
Active moderators can make or break a Facebook group, and can help prevent healthy  discourse from derailing into unproductive, hurtful conversations. If it looks like things are spinning out of control and you believe you can help, offer the group’s administrators to moderate – your assistance may be welcome. For example, in the past I have voluntarily moderated a small literary-minded group of 20-somethings on a “message board” – social media at the dawn of the Internet. My participation kept us all in check and helped weed out spam. A caveat: the identity of administrators may not always be clear (an obvious red flag). If you have a group and want provide administrator names, pin it to the top of your group’s social media page.  Groups that are not part of a social media service – such as a listserv or a Reddit – should list a contact method prominently.


Look for a group that has a clear mission:
Our Internet village’s value comes from having a clear purpose and acceptable line of messaging for the group. When the expectations are made clear to members of how to source and what types of questions/issues to bring up, the group can function much more healthfully and productively.


Join groups that vet members:
The best Facebook groups will ask members for contact information and will vet their identities before allowing them into the group. The Internet as we know is a Wild West, but if you vet the identities of your own group members you will be doing your participants a great service. You’ll be giving them a healthier environment reliant on mutual trust, responsibility, and higher quality of information shared. Groups in which people share their real names are a plus: Kovic et al. in 2008 noted that medical bloggers who posted under their real name were more likely to link to sources than bloggers who used pseudonyms. Although this may not have been studied yet for social media, personal experience shows me that those who post using real names tend to be more reliable.

For example, Dr. MILK (Physician Mothers Interested in Lactation Knowledge) is a social media group that caters to physicians.  The group invites its participants, their identities and roles are verified through their website, and posts must focus solely on breastfeeding and related questions. There are times that posts here go outside of that realm, and it falls on the moderators to bring the ever-expanding audience back to the core mission.


Represent yourself well:
We all know to think before we post, but it's easy to slip, especially within more personal networks. This litmus test works: Ask, “How would I feel if this post appeared in the newspaper and was read by my grandmother (or my new patient or my department chair).”

We live in a time where people are actively searching and studying posts and tweets released by doctors and analyzing them for their veracity. Let’s make sure we’re sharing what we want to share. If we do this right, we'll be enriched by each others' knowledge and experience while steering those who listen to us toward better health.

December 27, 2015

Podcasts for Kids: Entertainment that Flexes the Imagination Muscle

Kate Vidinsky, M.A.
Communications Director, Tales Untold Media
San Anselmo, California


My first childhood home was a tidy ranch on a flat, tree-lined street in a quiet Northwest Indiana suburb. Beyond that, my memories of the house are murky. And yet, clear as day, I can picture myself crouched in the basement next to my sister, listening intently as stories spun on our record player and my imagination took flight. I feel a shiver move up my spine as I recall the spooky tales we listened to around Halloween each year, and a warmth in my belly thinking about cozy story times with a side of Hanukkah cookies.

I know it’s clichĂ© to say those were simpler times, but my goodness is it ever true. Today, like so many other parents of young children, I’m trying to strike the right balance between modern technology and the “good ole days.” All at once I feel immeasurably grateful for my iPhone, which enables my children to see their long-distance grandparents any time they’d like, and completely frustrated when I see so many eyes focused downward at mobile devices instead of outward at the world’s beauty.

It was this type of parent versus technology tug of war that inspired my husband Nick and me to begin producing podcasts for young children. We feel strongly that kids content doesn’t need to go a hundred miles an hour or shock a child’s senses into submission. It just needs to tell a good story.

During the last few years, podcasting as a medium has surged in popularity. According to a report from the Pew Research Center, the percentage of Americans who have listened to a podcast in the past month has nearly doubled since 2008, and one-third of Americans 12 years of age and older say they’ve listened to at least one podcast before.

Podcasts get straight to the essence of storytelling in an easy-to-use, on-demand format. And with their serial nature, characters can develop, learn and grow along with the audience. For families looking for ways to cut down on screen time while still embracing the power and convenience of today’s technology (and maybe even get some dishes washed or laundry folded in the process), podcasts are somewhat of a home run.

And while it’s not news that listening to stories read aloud aids in language development, recent research has helped pinpoint exactly what’s going on in children’s developing brains when they actively listen during story time. A study published in PEDIATRICS August 2015 used fMRI to observe brain activity in 3-to-5-year-olds as they listened to age-appropriate stories. The researchers found that the children’s brain activity differed according to how much they were read to at home.

Children whose parents reported reading more stories at home showed significantly more activity in the parietal-temporal-occipital association cortex, a hub of sorts in the brain’s left hemisphere that integrates sounds and visual stimulation. In other words, children who regularly practice the art of listening to stories are more adept at visualizing what they hear. Essentially, their brains are in better imaginative shape.

The take home here is we now know for certain that actively listening to stories – as opposed to watching videos or even following along with picture books – increases brain activity, improves the imagination and prepares children for literacy.

Our audio-only podcast app for kids, Tales Untold, is a model for how we can leverage technology to provide children with rich, imaginative experiences, rather than simply plugging them into screens. For when we show children a world, they are outsiders looking in with imaginations gone quiet. But when we encourage them to flex their imaginations while actively listening, they are drawn into their own creation.

Whether it be as an alternative to television in a pediatrician’s waiting room or as a way to cut down on the “are we there yets?” during a family road trip, podcasts are a brain-healthy brand of kid entertainment primed to take off in popularity. I strongly suggest giving them a listen.

November 25, 2015

Mom and Dad: What About Your Screentime?

Hansa Bhargava MD FAAP
Staff Physician, Children's Healthcare of Atlanta
Medical Editor, WebMD
 
I was driving my 9-year-old son home from school the other day, when he said ‘Mom, no texting when you are driving’. It was at a red light, I explained, but he wasn’t buying the excuse.
As researchers focus on how screen time affects kids, I do wonder, should we focus more on how it affects parents, especially how it affects interaction with their kids?
The science is pretty clear that too much of certain types of screen time isn’t good for children. It can take away precious time from academics and exercise. A recent study reported that teens spend about 9 hours a day on media,, mostly on entertainment and tweens about 6 hours. But what’s the impact on a child if she sees her parents always glued to their phones, laptops, or the TV? This is where the science is less than clear.
Parents seem to love screen time almost as much as kids do. A recent Pew Internet Report found that 75% of parents use social media and have a median of 150 friends on Facebook. This is across age, gender, income and education level.  94% post, share, or comment with 70% saying they do it often.
Although there does not seem to be any clear data on parents’ screen time and relationships with their kids, recent research seems to show the links probably aren’t good. A small study at Boston Medical Center found that 40  of 55 adults took out a mobile device almost immediately when eating with their kids at a fast food restaurant
When parents don’t spend time talking to babies and toddlers, it creates a major gap in their language skills, which could put them behind their peers in reading and language by 3rd grade. We know that not engaging with kids at these stages has a colossal impact on their language and academic development, but what does it mean when parents use screens to tune out from older children?
Some schools recognize this issue and are changing their curriculum style to better engage children. The Atlanta Speech School, which teaches children with dyslexia and other language disorders, mentors parents and teachers to be more of a ‘conversational partner’ and to engage their children in discussions.
Screens are not going away and some interactive screen time may even be a good thing. But my kids and I now have some new rules in our home that apply to everyone, kids and grown-ups. No screen time in the car, at the dinner table, or at bedtime. Hopefully these first steps will help us get to what really matters: good relationships and happy children.

In this brave new world, I think that we can still apply that good, old-fashioned rule: Practice what you preach.

.

November 11, 2015

Screens in a Pediatric Office


Paul Smolen MD FAAP
Carolinas Medical Center, Charlotte NC
 Author of Can Doesn't Mean Should-Essential Knowledge for 21st Century Parents

Every practicing pediatrician struggles daily with a growing tension in American medicine. This tension is between the emerging prominence of consumer driven data (such as patient satisfaction surveys, insurance company ratings, and online ratings of patient loyalty) and national expert panel guideline measures of quality and positive health outcomes. Unfortunately, what often makes parents happy with their visit to their pediatrician is not always what makes their children healthier. For example, patient satisfaction begins in the waiting room, and pediatric waiting rooms are usually outfitted with screens, media, and marketing messages.

 In today’s world, scoring well on patient satisfaction surveys and practicing good pediatric medicine are occasionally at odds with one another.  My practice began making patient satisfaction surveys public and searchable to parents in October 2015, presumably to enable prospective patients to compare one pediatrician in my community with another. The assumption is that parents who are happy with their child’s pediatrician have good pediatricians.

The converse assumption is that pediatricians are only good when they make their patients’ families happy.  By this logic, I should prescribe antibiotics for a child who may not need them if her family wishes, or hesitate to describe a child as overweight rather than just a little plump for fear of offending his parent, or provide a flat screen TV with commercial programming in my waiting room if that is what my patients want. In the future, my ability to stay economically viable may be contingent on whether most parents who visit my office have a “pleasant experience” or “get a good vibe” as many parenting magazines suggest is a way of judging an unfamiliar pediatric practice. (1)


Pediatric waiting room screen exposure creates tension between patient satisfaction and expert panel guidelines because time spent in a waiting area is part of the pediatric visit.  Parents have come to expect a media experience that likely makes their child’s pediatric visit easier but is contrary to expert guidelines that direct pediatricians to discourage screen time for children under two years of age (2), to limit entertainment screen time in older children, and to strongly promote reading to children. (3) Many pediatric waiting rooms ignore these guidelines and provide what patients want - screens.  Recently, I surveyed many pediatric practices in my community and found that all but one continuously showed child programming with commercials in their waiting areas, regardless of the ages of the patients or reasons for the visits.

 
    Arguably, television with child-centered programming improves patient satisfaction and may even reduce stress and anxiety for children during a visit.  A recent study demonstrated that an iPad is more effective at reducing anxiety in a child than a dose of Versed! (4). Will the pediatric practices that thrive in the future be the ones with the biggest flat screens showing the most recent Disney blockbuster in their waiting rooms? If the trend toward patient satisfaction is any indicator, the Disney Corporation has nothing to fear.

Maybe in the era of portable screens and streaming of any content, anywhere, anytime, the best solution for waiting room satisfaction is to encourage parents to bring with them whatever will calm and entertain their child - a screen, a toy, a book - and get pediatricians out of the business of entertaining children.  Pediatricians shouldn’t be in the entertainment business anyway.






References:

1. Q: When should I start searching for a pediatrician, and what are the main things I should look for? PARENTS, 2009
http://www.parents.com/advice/pregnancy-birth/my-pregnant-life/what-should-i-look-for-in-a-pediatrician/

2. AAP Policy Statement: Children, Adolescents, and the Media. PEDIATRICS, Volume 132, Number 5, Nov 2013, pp 958-961

http://pediatrics.aappublications.org/content/132/5/958.full

3. AAP Policy Statement: Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. PEDIATRICS, Volume 134, Number 2, August 2014, pp 404-409

http://pediatrics.aappublications.org/content/early/2014/06/19/peds.2014-1384.full.pdf


4. Tablet-based Interactive Distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: a noninferiority randomized trial. PEDIATRIC ANESTHESIA, Volume 24, Issue 12, December 2014, pp 1217-1223

http://onlinelibrary.wiley.com/doi/10.1111/pan.12475/abstract