Vol. 198 September 1, 2018 A RX for Play

September 1, 2018

Hub thumbnail 2015

“Unfortunately both the value and the meaning of play are poorly understood in our hurried society.”
The Hurried Child, 1981

“Play for children buffers toxic stress, builds parental relationships,
and improves executive functioning.”
-The Power of Play,  2018

This month the American Academy of Pediatrics (AAP) recommended that all clinicians write a “prescription for play” for all children at each well child visit. The AAP first touted the benefits of play in 2007.  What’s new about this 2018 report, “The Power of Play”,  is 1) the compilation of 139 scientific studies supporting the benefits of childhood play, 2) the specific recommendation that clinicians give a “prescription to play” to the parents of children at every well child visit in the first two years of life, and 3) the inclusion of a list of specific parental actions and behaviors to help parents actually “fill the prescription”.

What is not new is the knowledge that play is very important for children’s cognitive (academic), social, language, and emotional development. In 1981 (almost 40 years ago!) David Elkind, Ph.D. in The Hurried Child, Growing Up Too Fast Too Soon (1) catalogued how play was one of the antidotes to the toxic stresses on our children at that time. His 1981 list of the sources of that stress on children sound still familiar to us in 2018:

  • early pressure to gain academic skills
  • early intervention to help learning in the early years (concept of “readiness” was disputed)
  •  media presentations of adult clothing and behavior as models for children
  •  changes in the traditional family model (dual-career couples, increased single parent families, single parent dating, increased divorce rate )
  • summer camps (and after school programs) becoming competitive training sites for specific skills
  • Cutting of recess, physical education (“gym period”), art, music and drama from school curriculum
  • increasing modes of passive play (no real-time human interaction; media play is passive).

“Play has been transformed into work. Perhaps the best evidence of the extent to which our children are hurried is the lack of opportunities for genuine unstructured play available to them. Genuine play involves human interaction, mostly child to child but also child to adult. Play is nature’s way of dealing with stress for children as well as adults.” – All written in 1981 by Dr. Elkind.

What are some of the specific ingredients listed by the AAP to fill the 2018 “prescription for play”? (2)

Newborn- 6 months

  • talk to your infant, mimic his or her sounds
  • make various faces at the infant so he or she can mimic you
  • let him or her put safe objects in their mouth

7-12 months

  • put infant in different positions so that he or she can view the world from different angles (“tummy time”)
  • use a mirror to show different faces to your infant
  • Peek a boo is a BIGGIE !
  • give him or her more toys to drop (teaches that actions have effects)
  • let infant safely crawl and explore freely

1-3 years

  • give paper, crayons, etc. to encourage scribbling
  • play make-believe with the child
  • read regularly to the child
  • sing and play rhythms to the child

4-6 years

  • allow child to move between make-believe and reality (pretend making biscuits and then tolerate the “spreading of flour all over the kitchen table”; if you can’t tolerate the mess, maybe change this play into ‘actions have effects’?)
  • tell stories and ask your child what she or he remembers about it
  • encourage a variety of safe physical movements (climbing, somersaults, etc.)

“Play with parents and peers is fundamentally important for developing a suite of 21st century skills in a competitive world that requires collaboration and innovation.”(3)

Dr. Elkind won me over completely when he explained why young children are entranced by dinosaurs; something that has perplexed me for years.
“Dinosaurs provide children with a symbolic and safe way of dealing with the giants in their world, namely adults.” (pg. 196)

1. Also “The Power of Play, Learning What Comes Naturally”, 2007, David Elkind, Ph.D
2. from www.pathways.org
3. Michael Yogman, MD, lead author of The Power of Play, AAP, 2018

Vol. 114 June 1, 2014 Much Ado About Nothing

June 1, 2014


“[In response to] an announcement from another U.S. infant formula manufacturer
about its plans to decrease the caloric density of some of its formula to 19 kcal/fl. oz,
Mead Johnson Nutrition (MUN) would like to assure youthat we have
NO plans to modify the density of our formulas from 20kcal/fl oz to 19 kcal/fl oz.”
-Mead Johnson news bulletin to pediatricians, April 1, 2014


My last two blogs discussed the evils of added sugar documented by the movie “Fed Up” and the possibility of an FDA ban of added trans fats in manufactured foods.  Both describe politically correct responses to the growing awareness of U.S. and global obesity rates and prevalence. We are urged to become ingredient list readers and to “buy healthier” as a defense against food corporations’ slick advertising and successful lobbying against transparent ingredient lists.

Abbott is the latest food corporation to claim to save us all from the scourge of infant obesity, all by reducing its Similac calories by  1 kcal/fl. oz.   Mead Johnson’s (Enfamil) rebuttal warns that reducing the formula calories means that infants would need to consume 1.5 more ounces per day to “meet their daily energy requirements during the first six months.”  All my kids have left more than that on their bibs  and chins every day, or as Stephen Colbert might say,  “Give me a f&*king break!”

Abbott’s stated reason for the formula change, already labeled by Abbott as “Innovative”, is to help decrease excessive infant weight gain by matching its formula content more closely to breast milk. In my increasingly skeptical (cynical) view Similac is merely adding new marketing buzz words to the current debate about what makes obese infants and do they become obese adults?

It is hard for me to get too excited about minimal formula calorie changes when I remember that one can of Coke, Pepsi, or Sprite contains more sugar than  100% of the total daily requirement of sugar as defined by the American Heart Association (36 g).  Mayor Bloomberg’s campaign against the super-size soda which contains 128g of sugar and the efforts to remove soda vending machines from schools even make some sense. One kcal/fl oz. or 1.5 more ounces of formula a day certainly pales by comparison on the spectrum of “sublime to ridiculous”.

One of the perks of being a pediatrician is being reminded daily about the flexibility, innate wisdom, and versatility of infants and toddlers. In a two-page  news announcement peppered with scientific journal citations the American Academy of Pediatrics Committee on Nutrition notes that ” the number of formulas choices have increased and the selection process is more complicated”.  It concludes in one of its more common-sense statements that “infants appear to eat to satisfy energy needs and will compensate for low food energy density … by increasing food intake.” Duh? More importantly,  “Neither parents nor pediatricians should assume that newer and more expensive products have health benefits for infants.”

Vol. 54 November 1, 2011 Violence in the Media DOES Matter

November 1, 2011

“A thousand studies over the past 40 years have shown that viewing violence in the media changes children’s behavior.”
-Michael Rich, MD
Associate Professor of Pediatrics, Harvard Medical School
aka the Mediatrician

Dr. Rich who founded and serves as the Director of the Center on Media and Child Health  at Children’s Hospital, Boston reports that viewing violence in the media causes:
1) increased feelings of fear and anxiety in the viewer,
2) desensitizes the viewer, particularly to conflict resolution methods other than violence, and
3) increases the aggressive behavior of the viewer.

A compelling demonstration of the latter was a video taken by hidden camera of toddlers dancing, singing, and shaking maracas after watching a Barney cartoon, and the same toddlers doing karate kicks and tackles on each other after watching a Power Rangers cartoon. (Yes, the girls too.)

Other tidbits that may comfort, or not, us parents and grandparents who wonder about the opportunities and pitfalls of current electronic media include:

1)    NO significant learning occurs from viewing a screen until the child is 30 months old. Baby Einstein videos are entertaining, amusing, and hold the child’s attention, but the child under 2 ½ is NOT getting an academic head start on KG. The American Academy of Pediatrics recommends no TV viewing under the age of 2 years., primarily because it substitutes for “more interactive activities that promote brain development”; ie. free play and social interactions.

2)    53% of 2-4 year olds use computers. 39% of 2-4 year olds have Apps and know how to use them on smartphones and iPads.

3)    The reason that the kids are so much better at operating the iPads, iPhones, and other smartphones is that these devices are designed to be intuitive. Our adult knowledge retards our intuition. The kids, not burdened with pre-conceived frameworks, enjoy a much faster learning curve. On the downside, the fact that my grandchildren can learn to use these devices so quickly is because the software is designed to be very intuitive and NOT because my offspring are “above average.”  Dr. Rich calls kids “Digital Natives” while we adults are “Digital Immigrants.”

4)    After 3 years of age ALL media is educational. Studies show that toddlers learn commercial logos, retain the image, and are able to identify them in another context; ie. the grocery store or restaurant.

5)    Sesame Street viewing between the ages of 3 and 5 is associated with better school performance and social skills compared to children who did not watch Sesame Street. The differences persist to the age of 17. One of the problems now is that the current demographic of Sesame Street viewers is from 18 months to 3 years of age.

6)    47% of 5-8 year olds have a TV in their bedroom. Studies show that the TV reduces the quantity and quality (flashing lights and changing sounds puts the sleeper “on alert”) of sleep and apparently doubles the risk of developing obesity.

What happens as the kids get older?

1)    The average use of electronic media by children ages 8-18 yrs is 7 ½ hours per day, and that study was done before the cell phone “explosion”.

2)    The average number of text messages for high school kids is 300-500 per DAY. Those messages have got to be short like “LOL”, “DIY”, or “PRW” , but they count as messages.

3)    Vewing sexual content in the media advances the first sexual experience by about 2 years.

4)    58% of high school kids who have experienced electronic cyberbullying have NOT revealed it to their parents because “they wouldn’t understand how it all works.”

5)    85% of teenagers take their cell phone to bed at night. They are never “not connected”. “You never know what people might be texting about you.”

What can you do? 

Dr. Rich has some very “simple” and practical recommendations:

1)    Remove your child’s computer from his/her room and put it on the dining room table because it is now in a “public place” and the child will self-monitor his/her own use.

2)    Move the computers from the dining room table once each day and have a family meal, the single most important influence on children for learning good role models and avoidance of high-risk behavior.

3)    If you don’t want your child to use his/her device during meals or family gatherings PUT YOURS DOWN. “Kids hear about 1% of what we say, but see 100% of what we do.”

4)    Take the TV out of his/her bedroom, and set the rule that all cell phones rest (recharge) in the kitchen overnight.

5)    Increase free play outdoors. Being “Huck Finn with mud between his toes” may better prepare your child for successful problem solving in the modern world than time at video games. (Unless your child aspires to be an Israeli tank driver or a U.S. drone controller.)

1) PriMed Continuing Medical Education Conference, Boston, October 29, 2011

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