Infants need human interaction for healthy development

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Both the American Academy of Pediatrics and the World Health Organization recommend that infants avoid screen-media exposure. Yet many babies up to 18 months old are regularly exposed.

A team of physical therapists and nurses looked into this issue in a paper that was published in the Journal of Pediatric Nursing. And here to talk with me about it is Dr. Danielle Hoose. She's a doctor of physical therapy and a pediatric clinical specialist and part of the voluntary clinical faculty in Upstate's department of physical therapy education.

Welcome to "The Informed Patient," Dr. Hoose.

Danielle Hoose, DPT: Thank you for having me.

Host Amber Smith: Let's start with a definition of screen-media exposure. Are we talking about TV screens, mobile phones, computers? What is it?

Danielle Hoose, DPT: Yeah, that's exactly what we're talking about. So screen media includes anything that has a screen that's showing audiovisual things on them. So, televisions, computer screens, tablets, cellphones, all of those include screen media.

Host Amber Smith: So how early are babies handling or looking at these devices?

Danielle Hoose, DPT: From our literature review, we found that most infants are pretty regularly exposed from right out the get-go, so we're seeing that they are exposed to as little as one hour, up to five hours, per day.

And we find that this is because many parents believe that educational television shows or smartphone apps or games are helping their infants learn and develop. But truly, there is no evidence that shows that there's any developmental benefits for unsupervised screen-media use.

Host Amber Smith: So this isn't just passive -- the TV being on while you're having dinner at home. This is purposeful.

Danielle Hoose, DPT: Correct. Yes.

Host Amber Smith: Well, why does the American Academy of Pediatrics (AAP) and the World Health Organization recommend avoiding screen-media exposure, then?

Danielle Hoose, DPT: They're recommending it because we know that infants are not able to translate what they learn from a two-dimensional device to their three-dimensional world, and this continues to develop during that first two years of life.

And so for babies, infants, toddlers, that under-2 age, for them to learn, they need real hands-on exploration of their natural environment. They need interactions with their caregivers or family members, and they need opportunities to play in unstructured and creative ways.

So time spent using screen media is time taken away from these important real-life interactions and opportunities for learning.

Host Amber Smith: So you're making me think about these new goggles that we're hearing about that I think Apple has made. That's going to blur the 2D/3D world even more.

Danielle Hoose, DPT: It certainly is. I'm very curious to see what will come of that.

Host Amber Smith: It's crazy. So does screen-media exposure affect the baby's ability to learn faces or recognize faces and social skills like that?

Danielle Hoose, DPT: Yeah, so we are finding that, especially with language, we really need language learning to happen in an active way through interacting with others. We have to talk to our babies for them to develop language. And the (medical) literature is actually supportive that children who started watching television during their first year of life and who watched more than two hours per day are six times more likely to have language delays than those who do not.

And we think it's because screen-media use is taking away those opportunities for children to actively interact with adults.

Host Amber Smith: So are there any exceptions to screen media? Because I'm thinking about FaceTime (video calls) with grandparents, say, who don't live in the same community. Is there some positive use of screens to let the infant get to know faces from afar?

Danielle Hoose, DPT: Yeah, there actually is. And the AAP just recently modified their recommendations to include FaceTiming, or video chatting, as an acceptable use of screen media in this vulnerable population. So once your child is old enough to understand FaceTime and seems interested in it, video chatting is appropriate to build relationships with those long-distance relatives.

And so you can use video chatting to point and label what you're seeing on the screen with your child. You can model how to respond to the person on the screen, and you can play some interactive games like peekaboo or singing songs or making funny noises to facilitate some of that back-and-forth socializing.

Host Amber Smith: Now, for the study you were involved in, you surveyed almost 200 mothers with infants 18 months and younger in Georgia, Pennsylvania and New York.

What sorts of questions were on the surveys?

Danielle Hoose, DPT: So we asked mothers 10 simple questions, and it included statements that they had to rate on a scale from one to five on whether they agreed or disagreed with those statements related to screen time, such as if they believed if screen time was beneficial for their baby, if the pediatrician's office talked to them about screen time and how many minutes per day their child was watching screen time on average.

Host Amber Smith: So what did the study find?

Danielle Hoose, DPT: So we found that 79% of infants exceeded that daily recommendation of zero minutes of screen time. We found that 29% exposed their infant to more than 30 minutes per day, and 61% of moms did not recall receiving any recommendations from their pediatrician regarding screen-time exposure.

We also found that in general, the more education a mother possessed, the less likely they believed that screen-time use was beneficial for the baby.

Host Amber Smith: The more education the mom had, the less likely she was to think that there was benefit?

Danielle Hoose, DPT: Correct.

Host Amber Smith: Did any of these findings surprise you?

Danielle Hoose, DPT: Yeah, it did. I really thought that pediatricians would more routinely educate parents, and it wasn't until I had a baby myself that I saw in my own (baby's) well visits that that piece of education really isn't being shared at well visits.

Host Amber Smith: What role do you see for nurses and physical therapists?

Danielle Hoose, DPT: We understand that pediatricians have a lot on their plate, with limited face-to-face time during these well visits.

And they have a lot of topics to cover. So we're thinking that nurse practitioners could be a health care professional that could share that burden, and they could counsel families on those guidelines during well visits.

As pediatric PTs (physical therapists), we often work in the child's home. And we see firsthand if there are screens being used in the background or for entertainment during our therapy sessions.

And so, we as therapists can use those opportunities to also educate parents on the guidelines and offer some alternatives to promote development.

Host Amber Smith: Well, what is your advice for moms with infants in terms of screen-media exposure? Is it OK to have the television on in the background at home?

Danielle Hoose, DPT: So the problem with early exposure to background television is that quality of parent-child interaction and the distracting nature of the television from whatever activity is ongoing.

Host Amber Smith: What about if you're nursing the baby or holding a sleeping baby? Is that OK to have the TV on then?

Danielle Hoose, DPT: There's actually a term to describe this. I think the media is calling it "brexting," short for "breastfeeding while texting." And so again, the problem with using your phone or having that television in the background is that you're limiting your opportunities to connect with your baby. So often, baby will reach up at you, smile, make noises, and if your attention is on your phone or that TV screen, you miss out on those opportunities to respond back to your baby and create some of those positive social interactions that are so important for babies' development and to build secure connections.

Host Amber Smith: You mentioned, I mean, some of this educational TV, "Sesame Street" and other shows, there's some positive qualities to those, but at what age are, parents recommended to start their children watching those?

Danielle Hoose, DPT: "Sesame Street" is actually a pretty well-studied program, and for preschool-aged children, so that 3-to-5 range, studies have found that when they've been limited to just one hour of exposure to that high-quality programming, they do have some benefits of having larger vocabularies and better readiness for preschool.

But again, the American Academy of Pediatrics still recommends that you limit that screen use to just one hour because those real-life interactions should take priority over that passive screen viewing.

Host Amber Smith: What are some strategies for managing screen time around children of different ages? Because I'm thinking the younger kids in the family inevitably are going to be exposed at earlier ages because of older siblings. Is that right?

Danielle Hoose, DPT: Yeah, that's so true and so difficult for families to manage. So if you truly cannot avoid screen time in your household, the American Academy of Pediatrics recommends that parents try to offset that developmental risk by doing some co-viewing of high-quality educational programming. So that means sitting with the child and having conversations with them about what they're seeing on the screen and trying to have just more interactive engagement with the baby and what they're viewing, so that it's more active versus just passive viewing.

Host Amber Smith: Now, a mobile phone is tempting as a tool for distracting a baby that's getting cranky during a trip to the store. What are alternatives to this? That's got to be very tempting.

Danielle Hoose, DPT: Oh, sure. As a parent of a toddler myself, I get it. It is so hard and stressful sometimes. I'm always trying to plan ahead, so having snacks, toys, I try to keep my child engaged by talking out loud as I shop and interacting with them.

Toddlers have pretty short attention spans, so using redirection is a powerful tool. Giving them choices: Should we buy the green apples or the red apples? Or saying, "Look at that!" to draw their attention away from whatever might be upsetting them. I also try to avoid situations that will trigger meltdowns, like staying away from that toy aisle at the grocery store and try to make sure the baby's well rested or fed before we go shopping.

Host Amber Smith: Well, Dr. Hoose, I appreciate you making time for this interview. Thank you so much.

Danielle Hoose, DPT: Thank you for having me.

Host Amber Smith: My guest has been Dr. Danielle Hoose. She's a pediatric clinical specialist and part of the voluntary clinical faculty in Upstate's department of physical therapy education.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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