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 against bed sharing forever. It’s just during the period when kids gonna have SIDS. Because we do know that bed sharing or soft blankets, bumpers even all of that increases the risk of a Sudden Infant Death Syndrome in early infancy.

Jen: 00:23:38

Right. I think that that sort of gets to the heart of it, doesn’t it? I mean it’s not necessarily that sharing a bed is unsafe. It’s sharing a bed with western style sleeping practices on a nice soft plush mattress like I have with nice down comforters and puffy pillows and then lots of places to fall off.

Dr. Dreyer: 00:23:55

Also parents, I mean most parents don’t oversleep on their kids, but kids can theoretically or possibly, you know, we think the way SIDS works is that it has to do with the child retaining CO2 (carbon dioxide). So if their nose gets pushed into a soft bed or to a parents or to a parent’s body, even without soft bedding then there is an increased risk of SIDS. So that’s why even if you strip your bed, I’ve said, I’m not going to sleep with a blanket. I’m not going to sleep with a pillow. Of course, most parents don’t want to do that. We don’t want most parents to have to do that, but there’s still the risk of the child snuggling up to the parent and having some increased CO2 and you know, dying of SIDS. We also know that we have a lot of work to do still with SIDS and that there are many parents who don’t follow these recommendations for a variety of reasons. One reason may be, and this probably impacts poor people, poor families more than wealthy parents or middle class parents where they have one room where all the kids and all the parents are sleeping together. There’s always another option. But the options are much more difficult for those. We also know that the incidents of SIDS is higher in those family.

Jen: 00:25:30

Although I am not sure what all of the risk factors for SIDS are but I wonder if there are other sort of co-occurring risk factors that come with poverty?

Dr. Dreyer: 00:25:37

There are some and mostly smoking is another risk factor, but poverty per se other than crowding and perhaps increased smoking, etc. But it’s not poverty per se that causes it.

Jen: 00:25:54

Yeah. So I’m curious about what you make of guidelines, I’m not sure if you’ve seen guidelines from other countries. I just wanted to see what are organizations like the AAP in other countries recommending to parents? Both organizations in England and Australia, it seemed to promote a risk reduction approach to children’s sleep. They’re essentially saying there are some benefits associated with bed sharing and if you choose to do it, then here’s how to do it more safely. So I’m sort of thinking, okay, are these ahead of the curve and that they’re sort of taking parenting practice into account or are they behind the curve because they aren’t looking at all the data in promoting this kind of save lives at all costs approach that we take here.

Dr. Dreyer: 00:26:33

Yeah. So as I think I mentioned to you, I don’t like the term save lives at all costs because I’m not sure what those costs are. All costs implies some terrible thing that we’re accepting or some really bad outcome that we’re accepting just to save the child’s life. The child is scarred for life but is alive. I don’t like the term saving lives at all costs. I do think that there are differences of opinion about a lot of things and I personally have humility that we don’t know everything in the United States. I think our interpretation of the evidence is that at least at this time, we think that the risk of SIDS is great enough to recommend pathway we have given. I haven’t personally reviewed (maybe I will after this call) the recommendations and what evidence Australia or Great Britain have used to modify their recommendations or whether their recommendations are simply reality based.

Dr. Dreyer: 00:27:44

We know certain parents are going to bed share and therefore we don’t recommend it. But if you’re doing it, this is the best way of doing. So, I’d have to review those. I think that there are good, well-meaning pediatricians and public health physicians and other public health people often have somewhat different points of view and that’s because our evidence is never perfect and therefore one can come down slightly differently on a lot of issues. I mean, I’m surprised when my son and daughter-in-law moved to Germany, which is where they live now, that their immunization practices are somewhat different than the United States. It is a pretty much the same science. People in Germany get certain vaccines before we give them in the United States and other vaccines that we give before they give the ones they give in Germany. So I always find when speaking particularly to knowledgeable parents who searched the internet and want to know everything, that it’s hard for them to understand how science is not perfect.

Jen: 00:29:04

My listeners will understand this point by now, I think 90 episodes in.

Dr. Dreyer: 00:29:08

But I mean we want it to be perfect.

Jen: 00:29:10

Yes we do. Yes, we want the answer.

Dr. Dreyer: 00:29:13

They want the answer. And sometimes we have to give, well, you know, this is what we know and this is how we’ve decided the best pathways forward. But how do you explain somewhat different immunization practices that are not based on differences in diseases but choices that public health people made in different countries. There are some differences. They are not huge, but there are some differences.

Jen: 00:29:43

Yeah. Yeah, that’s fascinating. So as we sort of leave sleep behind here, I just wanted to briefly mention the rock in place as we are speaking. The AAP has somewhat recently within the last month or so I think rescinded or issued guidance on the rock and play sleepers. They have been linked to over 30 infant deaths in the US and for years the consumer product safety commission just kind of issued these weak worded statements about making sure to use the restraints within them. And so I’m wondering what happened here? Did the AAP have to wait for the consumer product safety commission to issue a recall before the AAP could act or were there other factors at play? And do you have any concerns about baby swings that aren’t technically rock and plays but they have kind of the essentials design components the same as the rock and play?

Dr. Dreyer: 00:30:30

Yeah, so that’s another really good question. So there are a couple of answers to that. The first answer is that the, AAP does not do its own studies. So we don’t fund people to do studies. We have to review whatever is out there and for most safety, we do depend upon other people to collect the data. And then at some point we say, okay, the data is strong enough for us to, in addition to what anybody else is saying to come out. And most of our statements on recalls of products are based on recalls of products. They’re not based on us studying the literature. So in that way we’re behind the eight ball and we’re behind the curve I should say regarding product safety recalls. Rarely do we on our own discovery because we don’t do that kind of research. We depend upon consumers safety people to do the research. We occasionally come out, I shouldn’t say against them, but against government agencies because we feel they’re not being strong enough.

Jen: 00:31:47

Is there an example of that you can think of?

Dr. Dreyer: 00:31:49

Yes. So recently, this is often true regarding environmental issues. So we recently came out with a food additives statement policy. We are very concerned about a lot of food additives and their impact on children’s brain development, etc. We came out with a policy that was certainly ahead of the curve of the FDA and we actually asked the FDA to make some stronger recommendations about how to study this. And our major goal is not to criticize the FDA, but we were definitely ahead of the curve of the FDA because we felt that the way they decided that things were safe was not protective enough for children. So for example, I think this is another question that you may have as I recall, but basically if there’s any possible evidence that things can be harmful, we would want to protect children from them rather than wait until 20 years from now and we decide.

Dr. Dreyer: 00:33:02

Now we have enough evidence that they’re really very harmful. Regarding environmental issues or I think that’s the best example where there is a lot of science, where we do have environmental experts that are part of our policy making apparatus that we do often come and that’s true for safety as well regarding sports where we sometimes are ahead of the curve regarding a safe sports or equipment for sports, auto safety, etc. When it comes to recalls, I think we’re generally not ahead of the curve where whenever there’s enough evidence usually coming from people who study the safety issues. Our role there is really to make people aware. We’re a magnifier, a megaphone so that every pediatrician knows and every parent who might go on our website knows that these are unsafe. We’re not the originator there, we are the magnifier or megaphone.

Jen: 00:34:15

Okay. That’s a helpful distinction. Just going back to what you said about food additives, I know that there’s a lot of kind of uncertainty on that. There are some food additives that are banned in the EU because their belief is that they are not safe for children or people to ingest that are considered safe here.

Dr. Dreyer: 00:34:37

So that was exactly our point actually. Not exactly our point, but I mean our point was that we are more a cavalier in this country about the safety of lots of chemicals in our environment including food additives. On the other hand we reviewed the literature. So, we couldn’t find evidence for example, that certain food additives cause ADHD and we didn’t say that that was the case. Whereas many parents believe deeply that when their kids eat certain food additives say, become wild. Well there isn’t any good scientific evidence that that’s the case. And we didn’t come out to say that in that policy. But we do feel there is a lot of evidence that things that we allow in the United States to get into both the environment and into food may not be safe and we should be more careful. I think we in general, to some degree would lean towards what the EU is doing rather than what the United States.

Jen: 00:35:42

Okay. It seems as though your stance is going to be potentially more in opposition to the government’s stance as the government weakens recommendations on these kinds of things.

Dr. Dreyer: 00:35:51

Yeah. Well, now of course we are very concerned about the EPA especially because we actually have policies on climate change, which we feel is extremely harmful especially to children. But of course to all of us and the earth itself. We do have a policy on that because we strongly believe that that’s the case and we are very concerned now about changes that are being made by our government regarding that.

Jen: 00:36:21

Yeah. I think I read in the news just yesterday that the EPA is changing the way it calculates, deaths are accounted so that far fewer children are now dying of inhaling particulate matter that is really bad for them. So that’s interesting that you sort of tease out for us that you are following the precautionary principle in many ways closer to the way the EU thinks about these kinds of issues. And that does bring me to a question that I had for you on organic foods and your recommendation on that. Some parents in a very academic group that I’m in on Facebook, we’re surprised by this because there is, as far as I’m aware, and as far as this commenter was aware, no evidence that chemicals and pesticides cause harm to the child who is ingesting the fruit or vegetable. Of course I would argue that the reason I eat mostly organic foods is that it’s not just my child that I’m worried about. It’s the parent who’s standing there in the field with the sprayer. So are you thinking about that child as well and that parents donning the field with the sprayer when you’re making this recommendation or is it around the residues on the fruits and vegetables?

Dr. Dreyer: 00:37:23

So most of our recommendations are related to good things or bad things for children. Children includes adolescents, young adults, and to some degree includes their parents when their parents are caregivers, but primarily our bailiwick so to speak, our strong point is our knowledge about what is good or bad for children, adolescents and young adults. So we try to stick to where we are the experts. Sometimes we feel the family is threatened, but mostly we focus on the threat to children and so the answer to your question is if we were recommending organic foods, it would be because there are pesticides on those foods or that there are general environmental issues that affect the environment, which secondarily can affect children. So runoff of chemicals into the water system or other ways that the child can be harmed. It’s not that we don’t worry about the poor person who’s picking the vegetables in the field, but really that’s not who we are.

Dr. Dreyer: 00:38:38

We are people who know a lot about children and we feel our expertise is in what harms children. There is some evidence, there is not a lot of evidence, there is some evidence that we do know that a number of organophosphate insecticides are associated with impact on brain development. We don’t know. There isn’t a controlled study that shows that children who eat organic food have better brains than children who do not eat organic food. But again, sometimes we look, as I said earlier, at the physiological evidence. So in this case, we know that there are good experiments that shows that organophosphate poisons and other insecticides do impact brain develop. So on the basis of that, we think that children should be protected from ingesting those chemicals. There’s no reason they need to ingest it and therefore we would recommend that they don’t ingest those on foods. Recognizing that organic foods are more expensive and for some families who are poor that may be a real issue.

Jen: 00:39:54

All right, so you’ve mentioned humility. The need for humility, and I’m thinking about, it’s not entirely unheard of for the AAP to reverse its stance on recommendations and of course it’s too soon for us to say what’s going to happen regarding organic. And maybe 10 years down the line, some evidence will come up, that means that we can sort of think about this differently. But for right now I’m thinking about specifically the recommendation from 2000 that said that high risk infants and high risk means those with severe eczema and egg allergies should avoid peanuts until age three and then that guidance was rescinded in 2008 and the new guidelines said there is no current convincing evidence that delaying the introduction of peanuts beyond the introduction of other solid foods has a significant protective effect. Then there’s some new 2017 guidelines that actually promote early ingestion for the highest risk infants. So what’s happening behind the scenes here? Was the original research the best quality available or were you sort of going out on a limb and had to step back a bit?

Dr. Dreyer: 00:40:53

No, I think this is actually another great question. This is a perfect example of sort of how science marches on, but if parents understand science, we live in a world where there are decisions made based on the best evidence at that time. People were afraid of peanut allergy and therefore since there was no evidence that giving peanut early to children was good, we recommended what pretty much everybody recommended by the way. It wasn’t actually just the AAP. It was every scientist recommended to withhold certain things early in life because it was felt physiologically that their immune systems were not able to handle certain allergens and that you should delay giving those allergens until later. There was some evidence from studies with eczema that children who had, not necessarily peanuts, but a number of allergens earlier were more likely to have eczema or asthma and the evidence we dealt with then.

Dr. Dreyer: 00:42:07

It became clear over the last, I guess 10 or more years, that there was no evidence. So what do you do when there’s no evidence? You change your mind about it. That’s what people do all the time in science. Science is never complete. We learned because certain societies including Israelis, gave all their kids peanuts early in life and not only did they not have more peanut allergy, but they seem to be protected. So then people started to study that and so we moved based on the science, which is what we should be doing, right? I mean we shouldn’t be sticking with our 2000 or 1995 policy when we suddenly have new evidence that, whoops, actually there’s no evidence that this is not a good thing to do. And whoops there’s no evidence now that this is exactly the opposite thing is a good thing to do.

Dr. Dreyer: 00:43:08

These are new studies by the way. As I said, we have built into our policies to review every five years exactly for this reason. I did not write these policies, but I was very much involved in these changes over the last 15 years as somebody who’s at a university and who teaches residents and medical students. That’s another part of this paper. It’s not only the AAP policy, but it’s also what do we teach new doctors about what they should be doing. I changed my mind completely over the same way, just like the AAP did as new evidence came out that in fact number one, there was no evidence that it was harmful; but number two, there was some now some really good studies which are quite recent that show that in fact it’s not only not harmful but it’s extremely helpful. And it gives us a safe way of doing it because there’s still some kids who may react badly to it and the new evidence tells us exactly how to do this.

Jen: 00:44:17

Okay. So as we start to wrap up here, I want to talk a little bit about pediatricians and it just kind of when we go to our well child visits, which happens with increasing gaps between them in the US, I think it’s three months, six months, a year, and then every annual birthday after that, there seems to be this heavy focus on meeting these developmental milestones like sitting and walking and also on getting parents to do kind of the least bad thing. So we got to hand out the recommends using timeouts. I can only assume because timeouts are better than spanking as a disciplinary method. So I have heard, although I don’t have any evidence to back this up, that pediatricians don’t get a lot of training on children’s development. I’m curious as to your perspective on that and whether you see pediatricians moving towards getting more training on these issues and so sort of focusing less on these achievement of milestones in the well-baby visits.

Dr. Dreyer: 00:45:14

Yeah, so another good question. A really good question. So pediatricians do get some significant training in child development and behavior, really behavior is as important as development. Of course they don’t get enough, but there is a mandatory one month rotation in developmental behavioral pediatrics for all pediatric residents, which didn’t exist, I don’t know exactly how long it’s been here, but let’s say 20 years ago it didn’t exist. It does exist now. There’s an organization called the ACGME, which sort of mandates how every subspecialty gets trained, including pediatrics and they decide what kinds of experiences are best to train them. So number one, pediatricians don’t get trained well enough in anything, but in three years they do at least get a number of areas in child development that they get training in. One is this whole month of just specific training in developmental behavior pediatrics. Another is they have something called a continuity clinic where each week they follow patients it’s either for well child care or chronic diseases and as part of that they do get hands on experience in doing developmental screening, in giving advice about development, etc. Now I don’t give parents a handout on timeout unless I have a parent who tells me that they have a problem, which I feel the timeout will help. So I can’t comment on why you got handouts.

Jen: 00:47:12

It was a generic one that had a paragraph in it on timeout. I wasn’t singled out for it.
Dr. Dreyer: 00:47:19 You’re focusing on probably a handout that had a lot of different kinds of advice and that’s a small part of that. So there you go. I mean I think the answer is it would be artificial to give somebody a handout when they’re not having behavior problems with their kids that would benefit from timeout and I don’t know what your handouts said, but our recommendation in our policies on discipline is that timeout is useful but should not be overused. You can’t use timeout for everything. It should be used very sparingly, but in certain situations it’s effective. So that’s an example of one piece of advice. We’ve also moved to some degree in our latest discipline policy, said no spanking under any circumstances.

Jen: 00:48:12

And parents I know said yay and what took so long?

Dr. Dreyer: 00:48:17

Well, it didn’t take so long. Our last policy, which is I think from 1998 said we don’t recommend spanking and there are alternatives to it.

Dr. Dreyer: 00:48:28

What we didn’t say, and that is no spanking under any circumstances. So there’s a subtle difference by the way. We never recommended spanking.

Jen: 00:48:39

Yes. To be fair.

Dr. Dreyer: 00:48:41

We actually didn’t ever recommend spanking and the last previous policy we said we don’t recommend spanking and other things should be done instead, but didn’t say never spank your kid. There were two reasons for that ‘cause I remember that decision, although I wasn’t in charge of anything at that point. What is that like screen time, we were reacting to the fact that 50% of parents said they still spank their kids. I’m making that number up. But yeah, it’s reasonably high. And we felt just saying to everybody without some evidence that it’s harmful to spank your kid. Just like you said to me, you gave me a story like putting your kid in front of a TV for half an hour is not gonna destroy their brain, etc.

Dr. Dreyer: 00:49:32

Likewise, we felt a little uncomfortable to say never spank your kid because we didn’t have evidence to say that if you spank your kid once every month or once, whatever, and it’s not really violent that it’s actually harmful. We also didn’t have good evidence at that point in 1998 or I think it was not 1998, but whenever that previous policy was written that it never made a difference, a positive difference in the child’s behavior. Now we are in a much better position because there’s more evidence. I shouldn’t say new more. There’s a lot more evidence that number one, spanking is bad, meaning kid do get spanked enough are more aggressive, they have more behavior problems in the long run. So we now are in a better position to say, you know what, spanking should not be done because it causes bad things.

Dr. Dreyer: 00:50:32

We also have some better evidence now if you’re looking at the policy that says that actually it doesn’t really help change the kids’ behavior. It’s not actually, you may feel better because you’ve gotten your anger out, but it’s really not going to make your kid behave better. So it doesn’t work and it potentially has long-term harm to the kid. So now we slightly moved from saying we don’t recommend spanking, you should do other things too, spanking is bad. But we feel comfortable saying that because we now have really good evidence that spanking is bad and it’s not helpful because there are still a lot of parents who think it is really helpful, but we’re not going to report somebody for spanking their kid in the usual manner to child protective services. But we want parents to know that it’s not a good way of handling.

Jen: 00:51:34

Yeah.

Dr. Dreyer: 00:51:35

And actually, you know, if you speak to most parents as I do, as you do too, I think on your podcast that they will admit to you that the reason they spank their kid is that they were angry or had lost it rather than they had this grand plan to improve their child’s behavior.

Jen: 00:51:57

Yeah.

Dr. Dreyer: 00:51:58

It is more blowing off steam because of frustrations, some perhaps related to their child’s, some perhaps related to lots of other things going on, rather than saying this is a good. Also I heard this all the time, well, I was spanked as a child.

Jen: 00:52:15

And I turned out fine.

Dr. Dreyer: 00:52:17

And I turned out fine. Well, let me, can I admit to you on this podcast, I was spanked as a child and I don’t know if I turned out fine. I’m not willing to commit to that. But I do remember being spanked as a child. And I’m not liking it.

Jen: 00:52:35

Yeah. I was occasionally spanked as well.

Dr. Dreyer: 00:52:38

Yeah, I wasn’t spanked every day. But I was a pretty willful child. So, when I was spanked, I just sat there and said, you’re not hurting me. This is not going to do anything. You can spank me all you want and guess what, after a while my mother stopped spanking me because she was like who’s gonna want to spank a child who is sitting there and talking back to you while you are doing that.

Jen: 00:53:05

Clearly it’s not working. So I know we’re running out of time here and my listeners had so many other questions about adverse childhood experiences and the measles outbreak we’re in right now and when they should go to the dentist and I’m sorry that we can’t get to all these things.

Dr. Dreyer: 00:53:20

You can ask me a little about any other questions about pediatricians I can spend a couple more minutes.

Jen: 00:53:26

Okay. Yeah, I mean there were a couple though. The first one was around parenting based on respect, which is an approach that I use and so I sort of see my daughter as a person who is worthy of respect and has deserved that since she was an infant. So the way that that comes out is I talk with her rather than about her when she’s in the space. I don’t tickle her without her consent. I don’t even pick her up without her consent actually. But when we go to the pediatrician, all that kind of goes out the window and the doctor ignores her and just talks to me and the nurse just comes in with the needle and sticks it right in without even a word. So I’ve kind of managed this by asking our pediatrician to put a note in my daughter’s file to ask the doctors to talk with her rather than with me. So now every doctor that we see does that.

Dr. Dreyer: 00:54:13

How old is your daughter?

Jen: 00:54:14

She’s almost five now. But I had to do this really early on because the doctors were just ignoring her except when they needed to look at something or touch something on her. I’m just wondering why the standard of care doesn’t promote more respect and also agency when pediatricians are working with children. So the child feels, you know, this is my body and I’m allowing you to touch it. And I’m also responsible for my own care and healing to some extent.

Dr. Dreyer: 00:54:42

So again, another good question. So my answer is pretty simple. Number one, the way doctors treat patients has greatly changed in pediatrics, but also in all of medical care over the last 30 years. So what I mean by that is the things you’re describing are not things I would recommend to anybody I was training as a resident to be doing and when we now train residents to be pediatricians, we model much better behavior than you’re describing to me you’re receiving from your pediatrician. So that if I saw a resident doing that now I wouldn’t call them out in front of the patient, but I would try to model better behavior in front of the patient. We always encourage pediatricians to engage the child even in infancy, although obviously the way you engage your child, as you know, changes over time as the child is more verbal, is more involved. And I would never approve of a pediatrician not talking to a child and only talking to her parents. So I’m in complete agreement with your concerns. But my response to you would be change your pediatrician or you’ve to do something else, you’ve to try to modify what goes on there.

Jen: 00:56:11

Yeah. And it’s worked. And I wonder if other patients have benefited as well.

Dr. Dreyer: 00:56:15

I think they have. But it is all disturbing because I know, and I work with a lot of pediatricians here and they wouldn’t treat their patients that way. And actually they would probably get grief from the parents of their patients if they did so. But there are pediatricians who still do things like that as they usually say pediatricians aren’t perfect, especially people who’ve been doing things for a long time, get in often. This is not just pediatricians, this is any doctor and into a lot of things that seem to work for them. But I completely agree children should be treated like human beings from the moment that they’re in your office. You treat them differently as they get older. Of course as they get, we have something called ascent now, you know, that school aged kids, for example, should actually give actual verbal agreement before anything is done to them. Even though legally we don’t need that consent. We want them to be part of the decision process and we take it seriously if the kid doesn’t want something done and I think it’s barbaric if the nurse just comes in and gives the kid the shot without any preparation or understanding or involvement of the parent. So again, my usual advice is, well if your pediatrician is doing that get another pediatrician, there are a lot of pediatricians who are not doing that. I think, I forget where you’re living now.

Jen: 00:57:51

Yeah. I’m in California. This question actually came from somebody who lived in Ohio and didn’t have so much of a problem with it there, but is now in the southeast and says that it’s a regular occurrence there.

Dr. Dreyer: 00:58:01

Yeah. So, you know, I can’t take responsibility for whatever it is, but actually the AAP would never support not involving children and many of our policies focus on that. In fact, if you look at Bright Futures, which is our magnum opus on what to do at every well child visit and how to speak to parents and how to speak to children and what to do, there’s very specific language in that about how to involve children, how to respect children, how to respect parent’s point of view. We do view ourselves as partners with parents. So again, I’ll repeat if you have a pediatrician who doesn’t want to be your partner, you need to find a different pediatrician. Because there are a lot of pediatricians. I don’t know what’s going on where this poor woman who moved to Ohio to the southeast is going on, but actually I know pediatricians in the deep south who are really caring and very much involved with working with families too. So it’s not a universal southern thing. Much as we still view the south as you know, a separate country in many ways.

Jen: 00:59:17

Okay. So as we wrap up here, I understand this is probably going to be a difficult question asking the medical director of policies to pick a favorite child, but is there a piece of AAP sort of policy or recommendation that you think is going to have the biggest impact on the generation of children being born today?

Dr. Dreyer: 00:59:37

Well, it’s not a difficult as much as a complex question. So I think there are a couple of things. I think I could answer in several different ways and so I will. I mean the short answer is no, there isn’t one policy that we’re going to recommend or come out with that’s going to make all the difference for kids in the future. I do think worrying about climate change and the environment clearly has really important long-term issues for children and their children. So I would say perhaps our next version of our climate change policy and all of those things is important. I would say our policy on poverty and its impact on children is probably another policy that we came out in 2016 and I was very much involved in making that happen. So I do think that incoming inequality and poverty in this country have major, major impacts on the future of so many of our children and those policies and the advocacy that the AAP does in Washington to try to make things better for poor families are probably extremely impactful. As you probably have heard this before, but we know that the social determinants of health probably account for more than 50% of outcomes and what we do in our office probably accounts for 20% or 30% of that. So that’s where my humility comes from is that if I want to help children and families, I need to go out there into the social stratosphere and try to change things for them in that environment if I’m really gonna make a difference.

Jen: 01:01:33

Yeah, and I know that’s a big research focus of yours, isn’t it? And you’ve done a lot of work in that area.

Dr. Dreyer: 01:01:38

I think the other thing that’s happening now, of course, I don’t know if this is the long term issue is our policies on immigration and helping immigrant families and children of which we have several and we’re modifying them and we have huge amount of advocacy. One of the things we didn’t talk about is one of the things we do with some of our policies is advocate at the federal and state level to support programs that support families with children and come out against bad things that are happening to children, like what’s happening to immigrant children on the southern border or wherever they are in the United States.

Jen: 01:02:20

Yeah. And being separated from their parents.

Dr. Dreyer: 01:02:23

Yeah.

Jen: 01:02:24

Well thank you for doing that work and for advocating for all of our children and for taking the time to talk with us today and just kind of pull the curtain back a little bit on sort of what sometimes seems in parents to be sort of this black box and we don’t really understand all the machinations of what’s happening inside. It’s very helpful to us to understand that a bit more and I’m grateful for you spending the time doing that with us today.

Dr. Dreyer: 01:02:45

Not at all. Actually, the AAP wants to be transparent to families. One way they do that is through HealthyChildren.org. Not a perfect piece, but we try to put information for families on HealthyChildren.org that reflect what is in our policies and whatever we know about various problems in somewhat understandable language. Not always as understandable as I think it probably should be, but it’s pretty, you know, the effort is there to make it as understandable.

Jen: 01:03:19

Yeah, so I’ll definitely put a link to that in the references as well as to all the policies that we’ve discussed today and studies that I looked in preparing for this conversation and listeners can find all of that at YourParentingMojo.com/AAP. Thanks so much for your time, Dr. Dreyer.

Dr. Dreyer: 01:03:34

Oh, my pleasure.

 

References

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