Pediatrics

In one my recent Letters, I concluded with the concern that infant-led weaning, which makes some sense, can be confused with child-led family meals, which make none. I referred to an increasingly popular style of parenting overemphasizing child autonomy that seems to be a major contributor to the mealtime chaos that occurs when pleasing every palate at the table becomes the goal.

In the intervening weeks, I have learned that this parenting style is called “gentle parenting.” Despite its growing popularity, possibly fueled by the pandemic, it has not been well-defined nor its effectiveness investigated. In a recent paper published in PLOS ONE, two professors of developmental psychology have attempted correct this deficit in our understanding of this parenting style, which doesn’t appear to make sense to many of us with experience in child behavior and development. 

 

Gentle Parents

By surveying a group of 100 parents of young children, the investigators were able to sort out a group of parents (n = 49) who self-identified as employing gentle parenting. Their responses emphasized a high level of parental affection and emotional regulation by both their children and themselves.

Investigators found that 40% of the self-defined gentle parents “had negative difference scores indicating misbehavior response descriptions that included more child directed responses. I interpret this to mean that almost half of the time the parents failed to evenly include themselves in a solution to a conflict, which indicates incomplete or unsuccessful emotional regulation on their part. The investigators also observed that, like many other parenting styles, gentle parenting includes an emphasis on boundaries “yet, enactment of those boundaries is not uniform.”

More telling was the authors’ observation that “statements of parenting uncertainty and burnout were present in over one third of the gentle of the gentle parenting sample.” While some parents were pleased with their experience, the downside seems unacceptable to me. When asked to explain this finding, Annie Pezalla, PhD, one of the coauthors, has said “gentle parenting practices work best when a parent is emotionally regulated and unconstrained for time — commodities that parents struggle with the most.”

 

Abundance Advice on Parenting Styles

I find this to be a very sad story. Parenting can be difficult. Creating and then gently and effectively policing those boundaries is often the hardest part. There is no shortage of “experts” willing to tell the throngs of anxious parents how to do it. It is not surprising to me that of the four books I have written for parents, the one titled How to Say No to Your Toddler is the only one popular enough to be published in four languages.

Of course I am troubled, as I suspect you may be, with the label “gentle parenting.” It implies that the rest of us are doing something terrible, “harsh” maybe, “cruel” maybe. We can dispense with the “affectionate” descriptor immediately because gentle parenting can’t claim sole ownership to it. Every, behavior management scheme I am aware of touts being caring and loving at its core.

I completely agree that emotional regulation for both parent and child are worthy goals, but I’m not hearing much on how that is to be achieved other than by trying to avoid the inevitable conflict by failing to even say “No” when poorly crafted boundaries are breached. 

There are scores of parenting styles out there. And there should be, because we are all different. Parents have strengths and weaknesses and they have begotten children with different personalities and vulnerabilities. And, families come from different cultures and socioeconomic backgrounds. 

Across all of these differences there are two primary roles for every parent. The first is to lead by example. If a parent wants his/her child to be kind and caring and polite, then the parent has no choice but to behave that way. If the parent can’t always be present, the environment where the child spends most of his/her day should model the desired behavior. I’m not talking about teaching because you can’t preach good behavior. It must be modeled.

The second role for the parent is to keep his/her child safe from dangers that exist in every environment. This can mean accepting vaccines and seeking available medical care. But, it also means creating some limits — the current buzzword is “guardrails” — to keep the child from veering into the ditch.

 

Setting Limits

Limits will, of necessity, vary with the environment. The risks of a child growing on a farm differ from those of child living in the city. And they must be tailored to the personality and developmental stage of the child. A parent may need advice from someone experienced in child behavior to create individualized limits. You may be able to allow your 3-year-old to roam freely in an environment in which I would have to monitor my risk-taking 3-year-old every second. A parent must learn and accept his/her child’s personality and the environment they can provide.

Limits should be inanimate objects whenever possible. Fences, gates, doors with latches, and locked cabinets to keep temptations out of view, etc. Creative environmental manipulations should be employed to keep the annoying verbal warnings, unenforceable threats, and direct child-to-parent confrontations to a minimum.

 

Consequences

Challenges to even the most carefully crafted limits are inevitable, and this is where we get to the third-rail topic of consequences. Yes, when prevention has failed for whatever reason, I believe that an intelligently and affectionately applied time-out is the most efficient and most effective consequence. This is not the place for me to explore or defend the details, but before you write me off as an octogenarian hard-ass (or hard-liner if you prefer) I urge you to read a few chapters in How to Say No to Your Toddler.

Far more important than which consequence a parent chooses are the steps the family has taken to keep both parent and child in a state of balanced emotional regulation. Is everyone well rested and getting enough sleep? Sleep deprivation is one of the most potent triggers of a tantrum; it also leaves parents vulnerable to saying things and making threats they will regret later. Does the child’s schedule leave him or her enough time to decompress? Does the parent’s schedule sync with a developmentally appropriate schedule for the child? Is he/she getting the right kind of attention when it makes the most sense to him/her?

 

Intelligent Parenting

If a family has created an environment in which limits are appropriate for the child’s personality and developmental stage, used physical barriers whenever possible, and kept everyone as well rested as possible, both challenges to the limits and consequences can be kept to a minimum.

But achieving this state requires time as free of constraints as possible. For the few families that have the luxury of meeting these conditions, gentle parenting might be the answer. For the rest of us, intelligent parenting that acknowledges the realities and limits of our own abilities and our children’s vulnerabilities is the better answer.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]. 

In one my recent Letters, I concluded with the concern that infant-led weaning, which makes some sense, can be confused with child-led family meals, which make none. I referred to an increasingly popular style of parenting overemphasizing child autonomy that seems to be a major contributor to the mealtime chaos that occurs when pleasing every palate at the table becomes the goal.

In the intervening weeks, I have learned that this parenting style is called “gentle parenting.” Despite its growing popularity, possibly fueled by the pandemic, it has not been well-defined nor its effectiveness investigated. In a recent paper published in PLOS ONE, two professors of developmental psychology have attempted correct this deficit in our understanding of this parenting style, which doesn’t appear to make sense to many of us with experience in child behavior and development. 

 

Gentle Parents

By surveying a group of 100 parents of young children, the investigators were able to sort out a group of parents (n = 49) who self-identified as employing gentle parenting. Their responses emphasized a high level of parental affection and emotional regulation by both their children and themselves.

Investigators found that 40% of the self-defined gentle parents “had negative difference scores indicating misbehavior response descriptions that included more child directed responses. I interpret this to mean that almost half of the time the parents failed to evenly include themselves in a solution to a conflict, which indicates incomplete or unsuccessful emotional regulation on their part. The investigators also observed that, like many other parenting styles, gentle parenting includes an emphasis on boundaries “yet, enactment of those boundaries is not uniform.”

More telling was the authors’ observation that “statements of parenting uncertainty and burnout were present in over one third of the gentle of the gentle parenting sample.” While some parents were pleased with their experience, the downside seems unacceptable to me. When asked to explain this finding, Annie Pezalla, PhD, one of the coauthors, has said “gentle parenting practices work best when a parent is emotionally regulated and unconstrained for time — commodities that parents struggle with the most.”

 

Abundance Advice on Parenting Styles

I find this to be a very sad story. Parenting can be difficult. Creating and then gently and effectively policing those boundaries is often the hardest part. There is no shortage of “experts” willing to tell the throngs of anxious parents how to do it. It is not surprising to me that of the four books I have written for parents, the one titled How to Say No to Your Toddler is the only one popular enough to be published in four languages.

Of course I am troubled, as I suspect you may be, with the label “gentle parenting.” It implies that the rest of us are doing something terrible, “harsh” maybe, “cruel” maybe. We can dispense with the “affectionate” descriptor immediately because gentle parenting can’t claim sole ownership to it. Every, behavior management scheme I am aware of touts being caring and loving at its core.

I completely agree that emotional regulation for both parent and child are worthy goals, but I’m not hearing much on how that is to be achieved other than by trying to avoid the inevitable conflict by failing to even say “No” when poorly crafted boundaries are breached. 

There are scores of parenting styles out there. And there should be, because we are all different. Parents have strengths and weaknesses and they have begotten children with different personalities and vulnerabilities. And, families come from different cultures and socioeconomic backgrounds. 

Across all of these differences there are two primary roles for every parent. The first is to lead by example. If a parent wants his/her child to be kind and caring and polite, then the parent has no choice but to behave that way. If the parent can’t always be present, the environment where the child spends most of his/her day should model the desired behavior. I’m not talking about teaching because you can’t preach good behavior. It must be modeled.

The second role for the parent is to keep his/her child safe from dangers that exist in every environment. This can mean accepting vaccines and seeking available medical care. But, it also means creating some limits — the current buzzword is “guardrails” — to keep the child from veering into the ditch.

 

Setting Limits

Limits will, of necessity, vary with the environment. The risks of a child growing on a farm differ from those of child living in the city. And they must be tailored to the personality and developmental stage of the child. A parent may need advice from someone experienced in child behavior to create individualized limits. You may be able to allow your 3-year-old to roam freely in an environment in which I would have to monitor my risk-taking 3-year-old every second. A parent must learn and accept his/her child’s personality and the environment they can provide.

Limits should be inanimate objects whenever possible. Fences, gates, doors with latches, and locked cabinets to keep temptations out of view, etc. Creative environmental manipulations should be employed to keep the annoying verbal warnings, unenforceable threats, and direct child-to-parent confrontations to a minimum.

 

Consequences

Challenges to even the most carefully crafted limits are inevitable, and this is where we get to the third-rail topic of consequences. Yes, when prevention has failed for whatever reason, I believe that an intelligently and affectionately applied time-out is the most efficient and most effective consequence. This is not the place for me to explore or defend the details, but before you write me off as an octogenarian hard-ass (or hard-liner if you prefer) I urge you to read a few chapters in How to Say No to Your Toddler.

Far more important than which consequence a parent chooses are the steps the family has taken to keep both parent and child in a state of balanced emotional regulation. Is everyone well rested and getting enough sleep? Sleep deprivation is one of the most potent triggers of a tantrum; it also leaves parents vulnerable to saying things and making threats they will regret later. Does the child’s schedule leave him or her enough time to decompress? Does the parent’s schedule sync with a developmentally appropriate schedule for the child? Is he/she getting the right kind of attention when it makes the most sense to him/her?

 

Intelligent Parenting

If a family has created an environment in which limits are appropriate for the child’s personality and developmental stage, used physical barriers whenever possible, and kept everyone as well rested as possible, both challenges to the limits and consequences can be kept to a minimum.

But achieving this state requires time as free of constraints as possible. For the few families that have the luxury of meeting these conditions, gentle parenting might be the answer. For the rest of us, intelligent parenting that acknowledges the realities and limits of our own abilities and our children’s vulnerabilities is the better answer.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]. 

In one my recent Letters, I concluded with the concern that infant-led weaning, which makes some sense, can be confused with child-led family meals, which make none. I referred to an increasingly popular style of parenting overemphasizing child autonomy that seems to be a major contributor to the mealtime chaos that occurs when pleasing every palate at the table becomes the goal.

In the intervening weeks, I have learned that this parenting style is called “gentle parenting.” Despite its growing popularity, possibly fueled by the pandemic, it has not been well-defined nor its effectiveness investigated. In a recent paper published in PLOS ONE, two professors of developmental psychology have attempted correct this deficit in our understanding of this parenting style, which doesn’t appear to make sense to many of us with experience in child behavior and development. 

 

Gentle Parents

By surveying a group of 100 parents of young children, the investigators were able to sort out a group of parents (n = 49) who self-identified as employing gentle parenting. Their responses emphasized a high level of parental affection and emotional regulation by both their children and themselves.

Investigators found that 40% of the self-defined gentle parents “had negative difference scores indicating misbehavior response descriptions that included more child directed responses. I interpret this to mean that almost half of the time the parents failed to evenly include themselves in a solution to a conflict, which indicates incomplete or unsuccessful emotional regulation on their part. The investigators also observed that, like many other parenting styles, gentle parenting includes an emphasis on boundaries “yet, enactment of those boundaries is not uniform.”

More telling was the authors’ observation that “statements of parenting uncertainty and burnout were present in over one third of the gentle of the gentle parenting sample.” While some parents were pleased with their experience, the downside seems unacceptable to me. When asked to explain this finding, Annie Pezalla, PhD, one of the coauthors, has said “gentle parenting practices work best when a parent is emotionally regulated and unconstrained for time — commodities that parents struggle with the most.”

 

Abundance Advice on Parenting Styles

I find this to be a very sad story. Parenting can be difficult. Creating and then gently and effectively policing those boundaries is often the hardest part. There is no shortage of “experts” willing to tell the throngs of anxious parents how to do it. It is not surprising to me that of the four books I have written for parents, the one titled How to Say No to Your Toddler is the only one popular enough to be published in four languages.

Of course I am troubled, as I suspect you may be, with the label “gentle parenting.” It implies that the rest of us are doing something terrible, “harsh” maybe, “cruel” maybe. We can dispense with the “affectionate” descriptor immediately because gentle parenting can’t claim sole ownership to it. Every, behavior management scheme I am aware of touts being caring and loving at its core.

I completely agree that emotional regulation for both parent and child are worthy goals, but I’m not hearing much on how that is to be achieved other than by trying to avoid the inevitable conflict by failing to even say “No” when poorly crafted boundaries are breached. 

There are scores of parenting styles out there. And there should be, because we are all different. Parents have strengths and weaknesses and they have begotten children with different personalities and vulnerabilities. And, families come from different cultures and socioeconomic backgrounds. 

Across all of these differences there are two primary roles for every parent. The first is to lead by example. If a parent wants his/her child to be kind and caring and polite, then the parent has no choice but to behave that way. If the parent can’t always be present, the environment where the child spends most of his/her day should model the desired behavior. I’m not talking about teaching because you can’t preach good behavior. It must be modeled.

The second role for the parent is to keep his/her child safe from dangers that exist in every environment. This can mean accepting vaccines and seeking available medical care. But, it also means creating some limits — the current buzzword is “guardrails” — to keep the child from veering into the ditch.

 

Setting Limits

Limits will, of necessity, vary with the environment. The risks of a child growing on a farm differ from those of child living in the city. And they must be tailored to the personality and developmental stage of the child. A parent may need advice from someone experienced in child behavior to create individualized limits. You may be able to allow your 3-year-old to roam freely in an environment in which I would have to monitor my risk-taking 3-year-old every second. A parent must learn and accept his/her child’s personality and the environment they can provide.

Limits should be inanimate objects whenever possible. Fences, gates, doors with latches, and locked cabinets to keep temptations out of view, etc. Creative environmental manipulations should be employed to keep the annoying verbal warnings, unenforceable threats, and direct child-to-parent confrontations to a minimum.

 

Consequences

Challenges to even the most carefully crafted limits are inevitable, and this is where we get to the third-rail topic of consequences. Yes, when prevention has failed for whatever reason, I believe that an intelligently and affectionately applied time-out is the most efficient and most effective consequence. This is not the place for me to explore or defend the details, but before you write me off as an octogenarian hard-ass (or hard-liner if you prefer) I urge you to read a few chapters in How to Say No to Your Toddler.

Far more important than which consequence a parent chooses are the steps the family has taken to keep both parent and child in a state of balanced emotional regulation. Is everyone well rested and getting enough sleep? Sleep deprivation is one of the most potent triggers of a tantrum; it also leaves parents vulnerable to saying things and making threats they will regret later. Does the child’s schedule leave him or her enough time to decompress? Does the parent’s schedule sync with a developmentally appropriate schedule for the child? Is he/she getting the right kind of attention when it makes the most sense to him/her?

 

Intelligent Parenting

If a family has created an environment in which limits are appropriate for the child’s personality and developmental stage, used physical barriers whenever possible, and kept everyone as well rested as possible, both challenges to the limits and consequences can be kept to a minimum.

But achieving this state requires time as free of constraints as possible. For the few families that have the luxury of meeting these conditions, gentle parenting might be the answer. For the rest of us, intelligent parenting that acknowledges the realities and limits of our own abilities and our children’s vulnerabilities is the better answer.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]. 

TOPLINE:

Exposure to fine particulate matter (PM_2.5) during pregnancy is associated with an increased risk for spontaneous preterm birth, with peak vulnerability in the second trimester. Lower socioeconomic status, limited green space exposure, and extreme heat amplify this risk, whereas living around more trees provides protective effects.

METHODOLOGY:

• The researchers conducted a population-based retrospective cohort study to examine the associations of exposures to total PM_2.5 and five constituents (black carbon, nitrate, organic matter, and sulfate) during pregnancy with spontaneous preterm birth.
• They included 409,037 singleton live births from the Kaiser Permanente Southern California health care system between 2008 and 2018, with mothers having a mean age of 30.3 years at delivery (51% Hispanic).
• Daily total PM_2.5 concentrations and monthly data on the constituents in California were obtained; mean exposures during the entire pregnancy and in each trimester were calculated.
• Spontaneous preterm births were identified through the evaluation of preterm labor visits and were defined as a delivery occurring before 37 weeks following the onset of spontaneous labor, without pregnancy complications, and within 7 days of the last preterm labor visit.
• The analysis also examined the effect of factors such as race and ethnicity, education, median household income, exposure to green spaces, wildfire smoke, and temperature.

TAKEAWAY:

• Each 2.76 µg/m³ increase in total PM_2.5 exposure during pregnancy raised the risk for spontaneous preterm birth by 15% (P < .001), with black carbon showing the highest risk (adjusted odds ratio [aOR], 1.15; 95% CI, 1.12-1.18; P < .001).
• Exposure to PM_2.5 during the second trimester showed the highest association with spontaneous preterm birth (aOR, 1.10; P < .001), followed by that during the third (aOR, 1.09; P < .001) and first (aOR, 1.07; P < .001) trimesters.
• Individuals with lower education levels showed a higher risk for spontaneous preterm birth than those with more than 4 years of college education (P = .003).
• Exposure to extreme heat (P < .001) and lower exposure to total green space (P = .003) increased the risk for spontaneous preterm abortion.

IN PRACTICE:

“Targeted and preventive public health interventions among these subpopulations with high risk may be critical for minimizing the burden of spontaneous preterm birth,” the authors wrote.

SOURCE:

The study was led by Anqi Jiao of the program in public health at the Department of Environmental and Occupational Health at the University of California, Irvine. It was published online in JAMA Network Open.

LIMITATIONS:

According to the authors, exposure misclassification was inevitable as individual exposure to PM_2.5 was estimated according to census tract-level data without considering personal activity patterns. Only five major PM_2.5 constituents were measured due to data availability. Additionally, street-view green space data were considered spatial snapshots, which cannot capture temporal variations, possibly leading to exposure misclassification and biased associations in either direction.

DISCLOSURES:

The study was supported by the National Institute of Environmental Health Sciences and the California Air Resources Board. One author reported receiving research funding from pharmaceutical and biopharmaceutical companies, which was paid to the institute. Another author reported receiving grants from a medical technology company outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Exposure to fine particulate matter (PM_2.5) during pregnancy is associated with an increased risk for spontaneous preterm birth, with peak vulnerability in the second trimester. Lower socioeconomic status, limited green space exposure, and extreme heat amplify this risk, whereas living around more trees provides protective effects.

METHODOLOGY:

• The researchers conducted a population-based retrospective cohort study to examine the associations of exposures to total PM_2.5 and five constituents (black carbon, nitrate, organic matter, and sulfate) during pregnancy with spontaneous preterm birth.
• They included 409,037 singleton live births from the Kaiser Permanente Southern California health care system between 2008 and 2018, with mothers having a mean age of 30.3 years at delivery (51% Hispanic).
• Daily total PM_2.5 concentrations and monthly data on the constituents in California were obtained; mean exposures during the entire pregnancy and in each trimester were calculated.
• Spontaneous preterm births were identified through the evaluation of preterm labor visits and were defined as a delivery occurring before 37 weeks following the onset of spontaneous labor, without pregnancy complications, and within 7 days of the last preterm labor visit.
• The analysis also examined the effect of factors such as race and ethnicity, education, median household income, exposure to green spaces, wildfire smoke, and temperature.

TAKEAWAY:

• Each 2.76 µg/m³ increase in total PM_2.5 exposure during pregnancy raised the risk for spontaneous preterm birth by 15% (P < .001), with black carbon showing the highest risk (adjusted odds ratio [aOR], 1.15; 95% CI, 1.12-1.18; P < .001).
• Exposure to PM_2.5 during the second trimester showed the highest association with spontaneous preterm birth (aOR, 1.10; P < .001), followed by that during the third (aOR, 1.09; P < .001) and first (aOR, 1.07; P < .001) trimesters.
• Individuals with lower education levels showed a higher risk for spontaneous preterm birth than those with more than 4 years of college education (P = .003).
• Exposure to extreme heat (P < .001) and lower exposure to total green space (P = .003) increased the risk for spontaneous preterm abortion.

IN PRACTICE:

“Targeted and preventive public health interventions among these subpopulations with high risk may be critical for minimizing the burden of spontaneous preterm birth,” the authors wrote.

SOURCE:

The study was led by Anqi Jiao of the program in public health at the Department of Environmental and Occupational Health at the University of California, Irvine. It was published online in JAMA Network Open.

LIMITATIONS:

According to the authors, exposure misclassification was inevitable as individual exposure to PM_2.5 was estimated according to census tract-level data without considering personal activity patterns. Only five major PM_2.5 constituents were measured due to data availability. Additionally, street-view green space data were considered spatial snapshots, which cannot capture temporal variations, possibly leading to exposure misclassification and biased associations in either direction.

DISCLOSURES:

The study was supported by the National Institute of Environmental Health Sciences and the California Air Resources Board. One author reported receiving research funding from pharmaceutical and biopharmaceutical companies, which was paid to the institute. Another author reported receiving grants from a medical technology company outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Exposure to fine particulate matter (PM_2.5) during pregnancy is associated with an increased risk for spontaneous preterm birth, with peak vulnerability in the second trimester. Lower socioeconomic status, limited green space exposure, and extreme heat amplify this risk, whereas living around more trees provides protective effects.

METHODOLOGY:

• The researchers conducted a population-based retrospective cohort study to examine the associations of exposures to total PM_2.5 and five constituents (black carbon, nitrate, organic matter, and sulfate) during pregnancy with spontaneous preterm birth.
• They included 409,037 singleton live births from the Kaiser Permanente Southern California health care system between 2008 and 2018, with mothers having a mean age of 30.3 years at delivery (51% Hispanic).
• Daily total PM_2.5 concentrations and monthly data on the constituents in California were obtained; mean exposures during the entire pregnancy and in each trimester were calculated.
• Spontaneous preterm births were identified through the evaluation of preterm labor visits and were defined as a delivery occurring before 37 weeks following the onset of spontaneous labor, without pregnancy complications, and within 7 days of the last preterm labor visit.
• The analysis also examined the effect of factors such as race and ethnicity, education, median household income, exposure to green spaces, wildfire smoke, and temperature.

TAKEAWAY:

• Each 2.76 µg/m³ increase in total PM_2.5 exposure during pregnancy raised the risk for spontaneous preterm birth by 15% (P < .001), with black carbon showing the highest risk (adjusted odds ratio [aOR], 1.15; 95% CI, 1.12-1.18; P < .001).
• Exposure to PM_2.5 during the second trimester showed the highest association with spontaneous preterm birth (aOR, 1.10; P < .001), followed by that during the third (aOR, 1.09; P < .001) and first (aOR, 1.07; P < .001) trimesters.
• Individuals with lower education levels showed a higher risk for spontaneous preterm birth than those with more than 4 years of college education (P = .003).
• Exposure to extreme heat (P < .001) and lower exposure to total green space (P = .003) increased the risk for spontaneous preterm abortion.

IN PRACTICE:

“Targeted and preventive public health interventions among these subpopulations with high risk may be critical for minimizing the burden of spontaneous preterm birth,” the authors wrote.

SOURCE:

The study was led by Anqi Jiao of the program in public health at the Department of Environmental and Occupational Health at the University of California, Irvine. It was published online in JAMA Network Open.

LIMITATIONS:

According to the authors, exposure misclassification was inevitable as individual exposure to PM_2.5 was estimated according to census tract-level data without considering personal activity patterns. Only five major PM_2.5 constituents were measured due to data availability. Additionally, street-view green space data were considered spatial snapshots, which cannot capture temporal variations, possibly leading to exposure misclassification and biased associations in either direction.

DISCLOSURES:

The study was supported by the National Institute of Environmental Health Sciences and the California Air Resources Board. One author reported receiving research funding from pharmaceutical and biopharmaceutical companies, which was paid to the institute. Another author reported receiving grants from a medical technology company outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

For decades I have suspected that there is a strong association between sleep deprivation and pediatric attention disorders. More recently I have wondered whether screen time, particularly at bedtime might be a significant contributor to sleep quantity and quality in both children and adults. There is a growing body of research that combines my two observations and suggests that bedtime screen time through its effect on sleep may be linked to pediatric attention problems. However, most of this work is preliminary and needs to be confirmed.

Stumbling across a paper from England titled “Toddler Screen Use Before Bed and Its Effect on Sleep and Attention” renewed my hope that we finally have evidence to close that knowledge gap. My bubble burst quickly however when I jumped ahead and read the conclusion portion of the abstract and learned that authors observed “no clear difference in parent reported attention” in the group of children in which screen time before bedtime had been eliminated. The authors wonder if their small study sample may be to blame.

 

Disappointed, I persisted and read the paper in its entirety and found that despite their failure to link bedtime screen time with attention disorders, the investigators have made a significant contribution to our understanding of how we can better encourage good pediatric sleep hygiene. 

 

The Study

One hundred and five families with a toddler who was being exposed to a video screen in the hour before bedtime were divided into three groups. One group received guidance and advice from a pediatric team about the potential benefit of eliminating bedtime screen time. They were also given a box of activities that contained “activity cards and age appropriate toys” to replace the screen use. The family also received periodic support and follow-up contacts. A second group received only the “bedtime box.” And the third received no intervention.

It is important to note that the investigators modeled their intervention on one developed in a previous study using older children that was “co-created with caregivers and early years practitioners”(my italics). 

The intervention resulted in reductions in parent-reported screen time, sleep efficiency, night awakenings, and daytime sleep. The decrease in nap time was a surprise to the investigators. 

These reductions were small. However, the investigators were most impressed (and I share in their sentiment) with the finding that 99% (104/105) of the families stayed with the study until completion, demonstrating that future studies using this format were highly feasible. The authors of the study were pleased also and possibly surprised that 94% (33/35) of the families who received the intervention adhered to the recommendations. 

 

One Suggestion: ‘Just Shut the TV Off’

If you are a cynic, you might be tempted to explain the investigators’ (and my) excitement over the feasibility and adherence numbers as an attempt to pump up the importance of a set of otherwise lackluster numbers regarding sleep and the failure to find any association between the intervention and attention. However, having spent a large part of my career trying to encourage parents to improve their child’s sleep hygiene, often with little success, I am encouraged by this study’s success in getting families to accept and then adhere to the intervention.

I must admit that when presented with a child who appeared to be having some attention difficulties and was watching television as part of his or her bedtime ritual, there’s a good chance I would have simply told the parents, “Just shut the TV off.” This certainly worked with some families, particularly those who had already bought into my preaching about the importance of sleep. However, my acceptance and adherence rates were no where near the 99% and 94% these investigators where achieving. 

I did try to make follow-up phone calls, as these investigators did, but generally only to the most seriously effected families or in situations in which felt I was going to have the greatest chance of success. I am sorry to say that I didn’t involve the parents in crafting my overly simplistic intervention. Had I been more open to parental input, I suspect my results would have improved.

 

An Alternative

I think another reason for these investigators’ success was the clever ploy of offering a replacement (in this case the bedtime box of alternative activities) when they asked the parents to remove the screen time. Getting anyone to break an unhealthy habit, be they parents or patients, it often helps to offer them an alternative. The activity may not be as appealing as their current behavior but it can fill the gap until a new even healthier behavior develops.

Building an efficient and effective bedtime ritual begins in the first months of life. The initial challenge could be separating nursing or a bottle from the settling in process. Later on it could mean helping a parent who is out of the home all day understand that they may have to suppress their natural urge to engage in vigorous play with his/her child at a time that is best devoted to winding down into a healthy bedtime ritual. Although screen time may not be physically stimulating, there is increasing evidence that it shouldn’t be part of a pre-bedtime ritual. The question of if and how it contributes to attention problems will have to wait until another day. 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

For decades I have suspected that there is a strong association between sleep deprivation and pediatric attention disorders. More recently I have wondered whether screen time, particularly at bedtime might be a significant contributor to sleep quantity and quality in both children and adults. There is a growing body of research that combines my two observations and suggests that bedtime screen time through its effect on sleep may be linked to pediatric attention problems. However, most of this work is preliminary and needs to be confirmed.

Stumbling across a paper from England titled “Toddler Screen Use Before Bed and Its Effect on Sleep and Attention” renewed my hope that we finally have evidence to close that knowledge gap. My bubble burst quickly however when I jumped ahead and read the conclusion portion of the abstract and learned that authors observed “no clear difference in parent reported attention” in the group of children in which screen time before bedtime had been eliminated. The authors wonder if their small study sample may be to blame.

 

Disappointed, I persisted and read the paper in its entirety and found that despite their failure to link bedtime screen time with attention disorders, the investigators have made a significant contribution to our understanding of how we can better encourage good pediatric sleep hygiene. 

 

The Study

One hundred and five families with a toddler who was being exposed to a video screen in the hour before bedtime were divided into three groups. One group received guidance and advice from a pediatric team about the potential benefit of eliminating bedtime screen time. They were also given a box of activities that contained “activity cards and age appropriate toys” to replace the screen use. The family also received periodic support and follow-up contacts. A second group received only the “bedtime box.” And the third received no intervention.

It is important to note that the investigators modeled their intervention on one developed in a previous study using older children that was “co-created with caregivers and early years practitioners”(my italics). 

The intervention resulted in reductions in parent-reported screen time, sleep efficiency, night awakenings, and daytime sleep. The decrease in nap time was a surprise to the investigators. 

These reductions were small. However, the investigators were most impressed (and I share in their sentiment) with the finding that 99% (104/105) of the families stayed with the study until completion, demonstrating that future studies using this format were highly feasible. The authors of the study were pleased also and possibly surprised that 94% (33/35) of the families who received the intervention adhered to the recommendations. 

 

One Suggestion: ‘Just Shut the TV Off’

If you are a cynic, you might be tempted to explain the investigators’ (and my) excitement over the feasibility and adherence numbers as an attempt to pump up the importance of a set of otherwise lackluster numbers regarding sleep and the failure to find any association between the intervention and attention. However, having spent a large part of my career trying to encourage parents to improve their child’s sleep hygiene, often with little success, I am encouraged by this study’s success in getting families to accept and then adhere to the intervention.

I must admit that when presented with a child who appeared to be having some attention difficulties and was watching television as part of his or her bedtime ritual, there’s a good chance I would have simply told the parents, “Just shut the TV off.” This certainly worked with some families, particularly those who had already bought into my preaching about the importance of sleep. However, my acceptance and adherence rates were no where near the 99% and 94% these investigators where achieving. 

I did try to make follow-up phone calls, as these investigators did, but generally only to the most seriously effected families or in situations in which felt I was going to have the greatest chance of success. I am sorry to say that I didn’t involve the parents in crafting my overly simplistic intervention. Had I been more open to parental input, I suspect my results would have improved.

 

An Alternative

I think another reason for these investigators’ success was the clever ploy of offering a replacement (in this case the bedtime box of alternative activities) when they asked the parents to remove the screen time. Getting anyone to break an unhealthy habit, be they parents or patients, it often helps to offer them an alternative. The activity may not be as appealing as their current behavior but it can fill the gap until a new even healthier behavior develops.

Building an efficient and effective bedtime ritual begins in the first months of life. The initial challenge could be separating nursing or a bottle from the settling in process. Later on it could mean helping a parent who is out of the home all day understand that they may have to suppress their natural urge to engage in vigorous play with his/her child at a time that is best devoted to winding down into a healthy bedtime ritual. Although screen time may not be physically stimulating, there is increasing evidence that it shouldn’t be part of a pre-bedtime ritual. The question of if and how it contributes to attention problems will have to wait until another day. 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

For decades I have suspected that there is a strong association between sleep deprivation and pediatric attention disorders. More recently I have wondered whether screen time, particularly at bedtime might be a significant contributor to sleep quantity and quality in both children and adults. There is a growing body of research that combines my two observations and suggests that bedtime screen time through its effect on sleep may be linked to pediatric attention problems. However, most of this work is preliminary and needs to be confirmed.

Stumbling across a paper from England titled “Toddler Screen Use Before Bed and Its Effect on Sleep and Attention” renewed my hope that we finally have evidence to close that knowledge gap. My bubble burst quickly however when I jumped ahead and read the conclusion portion of the abstract and learned that authors observed “no clear difference in parent reported attention” in the group of children in which screen time before bedtime had been eliminated. The authors wonder if their small study sample may be to blame.

 

Disappointed, I persisted and read the paper in its entirety and found that despite their failure to link bedtime screen time with attention disorders, the investigators have made a significant contribution to our understanding of how we can better encourage good pediatric sleep hygiene. 

 

The Study

One hundred and five families with a toddler who was being exposed to a video screen in the hour before bedtime were divided into three groups. One group received guidance and advice from a pediatric team about the potential benefit of eliminating bedtime screen time. They were also given a box of activities that contained “activity cards and age appropriate toys” to replace the screen use. The family also received periodic support and follow-up contacts. A second group received only the “bedtime box.” And the third received no intervention.

It is important to note that the investigators modeled their intervention on one developed in a previous study using older children that was “co-created with caregivers and early years practitioners”(my italics). 

The intervention resulted in reductions in parent-reported screen time, sleep efficiency, night awakenings, and daytime sleep. The decrease in nap time was a surprise to the investigators. 

These reductions were small. However, the investigators were most impressed (and I share in their sentiment) with the finding that 99% (104/105) of the families stayed with the study until completion, demonstrating that future studies using this format were highly feasible. The authors of the study were pleased also and possibly surprised that 94% (33/35) of the families who received the intervention adhered to the recommendations. 

 

One Suggestion: ‘Just Shut the TV Off’

If you are a cynic, you might be tempted to explain the investigators’ (and my) excitement over the feasibility and adherence numbers as an attempt to pump up the importance of a set of otherwise lackluster numbers regarding sleep and the failure to find any association between the intervention and attention. However, having spent a large part of my career trying to encourage parents to improve their child’s sleep hygiene, often with little success, I am encouraged by this study’s success in getting families to accept and then adhere to the intervention.

I must admit that when presented with a child who appeared to be having some attention difficulties and was watching television as part of his or her bedtime ritual, there’s a good chance I would have simply told the parents, “Just shut the TV off.” This certainly worked with some families, particularly those who had already bought into my preaching about the importance of sleep. However, my acceptance and adherence rates were no where near the 99% and 94% these investigators where achieving. 

I did try to make follow-up phone calls, as these investigators did, but generally only to the most seriously effected families or in situations in which felt I was going to have the greatest chance of success. I am sorry to say that I didn’t involve the parents in crafting my overly simplistic intervention. Had I been more open to parental input, I suspect my results would have improved.

 

An Alternative

I think another reason for these investigators’ success was the clever ploy of offering a replacement (in this case the bedtime box of alternative activities) when they asked the parents to remove the screen time. Getting anyone to break an unhealthy habit, be they parents or patients, it often helps to offer them an alternative. The activity may not be as appealing as their current behavior but it can fill the gap until a new even healthier behavior develops.

Building an efficient and effective bedtime ritual begins in the first months of life. The initial challenge could be separating nursing or a bottle from the settling in process. Later on it could mean helping a parent who is out of the home all day understand that they may have to suppress their natural urge to engage in vigorous play with his/her child at a time that is best devoted to winding down into a healthy bedtime ritual. Although screen time may not be physically stimulating, there is increasing evidence that it shouldn’t be part of a pre-bedtime ritual. The question of if and how it contributes to attention problems will have to wait until another day. 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

New recommendations on rescuing adults and children who have drowned include an important update for healthcare professionals, trained rescuers, and untrained lay rescuers. 

The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have issued recommendations that highlight delivering rescue breaths as well as calling 911 and performing chest compressions in cardiopulmonary resuscitation (CPR) as first steps when a person pulled from the water is in cardiac arrest.

This is the first collaboration between the two organizations on resuscitation after drowning. The recommendations were published simultaneously in Circulation and Pediatrics.

Included in the recommendations are two key principles:

• Anyone pulled from the water who has no signs of normal breathing or consciousness should be presumed to be in cardiac arrest.
• Rescuers should immediately start CPR that includes rescue breathing in addition to chest compressions. Multiple large studies show more people with cardiac arrest from noncardiac causes such as drowning survive when CPR includes rescue breaths, compared with hands-only CPR (calling 911 and pushing hard and fast in the center of the chest).

If someone is untrained, unwilling, or unable to give breaths, they can perform chest compressions until help arrives, the recommendations advise.

 

Reasoning Behind the Update

The authors, led by writing group cochair Tracy E. McCallin, MD, associate professor in the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland , Ohio, explained that drowning generally advances from initial respiratory arrest from submersion-related hypoxia to cardiac arrest, and therefore it can be difficult to distinguish respiratory arrest from cardiac arrest because pulses are difficult to accurately palpate within the recommended 10-second window.

“Therefore, resuscitation from cardiac arrest due to this specific circumstance must focus on restoring breathing as much as it does circulation,” the authors wrote.

Resuscitation after drowning may begin in the water with rescue breathing when safely provided by trained rescuers and should continue with chest compressions, once the drowned person and the rescuer are on land or in a boat, the report authors wrote.

“The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned,” McCallin states in a press release.

In addition to the new guidance on rescue breaths, the update includes new topics that the AHA has not previously addressed with treatment recommendations, such as oxygen administration after drowning; automated external defibrillator use in cardiac arrest after drowning and public-access defibrillation programs.

 

Pediatricians Can Help Spread the Word

Alexandra Stern, MD, assistant professor in the Department of Pediatrics at University of Florida, Gainesville, who was not part of the update, said pediatricians can help disseminate this new information.

“Water safety is a topic frequently discussed as a pediatrician, with focus often being on primary prevention of drowning,” she said. “We stress the importance of the multiple layers of protection against drowning, such as touch supervision (staying within arm’s length); secure fencing, access to appropriate life jackets, and teaching our children to swim. Learning CPR is a large part of these measures and continuing these discussions with our patients and families is important.”

She added that updating the recommended procedures will likely require changes to all forms of education and community outreach regarding drowning from basic life support classes to more advanced lifeguard training. She noted that the update provides practical guidance not just for trained rescuers and healthcare professionals, but also for family members. 

The paper notes that drowning is the third leading cause of death from unintentional injury globally, accounting for 7% of all injury-related deaths. In the United States, drowning is the leading cause of death in children aged 1-4 years and the second leading cause of death from unintentional injury in children aged 5-14 years.

The update is based on systematic reviews from 2021 to 2023 performed by the International Liaison Committee on Resuscitation related to the resuscitation of drowning.

The authors and Stern reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

New recommendations on rescuing adults and children who have drowned include an important update for healthcare professionals, trained rescuers, and untrained lay rescuers. 

The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have issued recommendations that highlight delivering rescue breaths as well as calling 911 and performing chest compressions in cardiopulmonary resuscitation (CPR) as first steps when a person pulled from the water is in cardiac arrest.

This is the first collaboration between the two organizations on resuscitation after drowning. The recommendations were published simultaneously in Circulation and Pediatrics.

Included in the recommendations are two key principles:

• Anyone pulled from the water who has no signs of normal breathing or consciousness should be presumed to be in cardiac arrest.
• Rescuers should immediately start CPR that includes rescue breathing in addition to chest compressions. Multiple large studies show more people with cardiac arrest from noncardiac causes such as drowning survive when CPR includes rescue breaths, compared with hands-only CPR (calling 911 and pushing hard and fast in the center of the chest).

If someone is untrained, unwilling, or unable to give breaths, they can perform chest compressions until help arrives, the recommendations advise.

 

Reasoning Behind the Update

The authors, led by writing group cochair Tracy E. McCallin, MD, associate professor in the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland , Ohio, explained that drowning generally advances from initial respiratory arrest from submersion-related hypoxia to cardiac arrest, and therefore it can be difficult to distinguish respiratory arrest from cardiac arrest because pulses are difficult to accurately palpate within the recommended 10-second window.

“Therefore, resuscitation from cardiac arrest due to this specific circumstance must focus on restoring breathing as much as it does circulation,” the authors wrote.

Resuscitation after drowning may begin in the water with rescue breathing when safely provided by trained rescuers and should continue with chest compressions, once the drowned person and the rescuer are on land or in a boat, the report authors wrote.

“The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned,” McCallin states in a press release.

In addition to the new guidance on rescue breaths, the update includes new topics that the AHA has not previously addressed with treatment recommendations, such as oxygen administration after drowning; automated external defibrillator use in cardiac arrest after drowning and public-access defibrillation programs.

 

Pediatricians Can Help Spread the Word

Alexandra Stern, MD, assistant professor in the Department of Pediatrics at University of Florida, Gainesville, who was not part of the update, said pediatricians can help disseminate this new information.

“Water safety is a topic frequently discussed as a pediatrician, with focus often being on primary prevention of drowning,” she said. “We stress the importance of the multiple layers of protection against drowning, such as touch supervision (staying within arm’s length); secure fencing, access to appropriate life jackets, and teaching our children to swim. Learning CPR is a large part of these measures and continuing these discussions with our patients and families is important.”

She added that updating the recommended procedures will likely require changes to all forms of education and community outreach regarding drowning from basic life support classes to more advanced lifeguard training. She noted that the update provides practical guidance not just for trained rescuers and healthcare professionals, but also for family members. 

The paper notes that drowning is the third leading cause of death from unintentional injury globally, accounting for 7% of all injury-related deaths. In the United States, drowning is the leading cause of death in children aged 1-4 years and the second leading cause of death from unintentional injury in children aged 5-14 years.

The update is based on systematic reviews from 2021 to 2023 performed by the International Liaison Committee on Resuscitation related to the resuscitation of drowning.

The authors and Stern reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

New recommendations on rescuing adults and children who have drowned include an important update for healthcare professionals, trained rescuers, and untrained lay rescuers. 

The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have issued recommendations that highlight delivering rescue breaths as well as calling 911 and performing chest compressions in cardiopulmonary resuscitation (CPR) as first steps when a person pulled from the water is in cardiac arrest.

This is the first collaboration between the two organizations on resuscitation after drowning. The recommendations were published simultaneously in Circulation and Pediatrics.

Included in the recommendations are two key principles:

• Anyone pulled from the water who has no signs of normal breathing or consciousness should be presumed to be in cardiac arrest.
• Rescuers should immediately start CPR that includes rescue breathing in addition to chest compressions. Multiple large studies show more people with cardiac arrest from noncardiac causes such as drowning survive when CPR includes rescue breaths, compared with hands-only CPR (calling 911 and pushing hard and fast in the center of the chest).

If someone is untrained, unwilling, or unable to give breaths, they can perform chest compressions until help arrives, the recommendations advise.

 

Reasoning Behind the Update

The authors, led by writing group cochair Tracy E. McCallin, MD, associate professor in the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland , Ohio, explained that drowning generally advances from initial respiratory arrest from submersion-related hypoxia to cardiac arrest, and therefore it can be difficult to distinguish respiratory arrest from cardiac arrest because pulses are difficult to accurately palpate within the recommended 10-second window.

“Therefore, resuscitation from cardiac arrest due to this specific circumstance must focus on restoring breathing as much as it does circulation,” the authors wrote.

Resuscitation after drowning may begin in the water with rescue breathing when safely provided by trained rescuers and should continue with chest compressions, once the drowned person and the rescuer are on land or in a boat, the report authors wrote.

“The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned,” McCallin states in a press release.

In addition to the new guidance on rescue breaths, the update includes new topics that the AHA has not previously addressed with treatment recommendations, such as oxygen administration after drowning; automated external defibrillator use in cardiac arrest after drowning and public-access defibrillation programs.

 

Pediatricians Can Help Spread the Word

Alexandra Stern, MD, assistant professor in the Department of Pediatrics at University of Florida, Gainesville, who was not part of the update, said pediatricians can help disseminate this new information.

“Water safety is a topic frequently discussed as a pediatrician, with focus often being on primary prevention of drowning,” she said. “We stress the importance of the multiple layers of protection against drowning, such as touch supervision (staying within arm’s length); secure fencing, access to appropriate life jackets, and teaching our children to swim. Learning CPR is a large part of these measures and continuing these discussions with our patients and families is important.”

She added that updating the recommended procedures will likely require changes to all forms of education and community outreach regarding drowning from basic life support classes to more advanced lifeguard training. She noted that the update provides practical guidance not just for trained rescuers and healthcare professionals, but also for family members. 

The paper notes that drowning is the third leading cause of death from unintentional injury globally, accounting for 7% of all injury-related deaths. In the United States, drowning is the leading cause of death in children aged 1-4 years and the second leading cause of death from unintentional injury in children aged 5-14 years.

The update is based on systematic reviews from 2021 to 2023 performed by the International Liaison Committee on Resuscitation related to the resuscitation of drowning.

The authors and Stern reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

LAS VEGAS — No matter which treatment regimen is recommended for patients with acne, it should always include a topical retinoid, according to dermatologist Hilary Baldwin, MD.

Patients with successfully treated acne typically use an average of 2.53 different medications, Baldwin, director of the Acne Treatment & Research Center, Brooklyn, New York, said at the Society of Dermatology Physician Associates (SDPA) 22nd Annual Fall Dermatology Conference.

 

“Combination treatment is the name of the game, but how do we convince our patients that what we chose is carefully orchestrated?” she said. “Combination therapy is much more effective, yet we’re always told, ‘keep it simple.’ The trick is to use combination products that have two or three medications in them — fixed combinations and products with excellent vehicles.”

No matter what treatment regimen is recommended for patients with acne, she continued, it should always include a topical retinoid. Tretinoin was the first topical retinoid approved for acne treatment in 1971, followed by adapalene in 1996, tazarotene in 1997, and trifarotene in 2019. According to a review article , topical retinoids inhibit the formation of microcomedones, reduce mature comedones and inflammatory lesions, enhance penetration of other drugs, reduce and prevent scarring, reduce hyperpigmentation, and maintain remission of acne.

More recently, authors of the 2024 American Academy of Dermatology guidelines of care for the management of acne vulgaris strongly recommended the use of topical retinoids based on moderate certainty evidence in the medial literature. Strong recommendations are also made for benzoyl peroxide, topical antibiotics, and oral doxycycline.

Baldwin noted that the benefits of retinoids include their comedolytic and anti-comedogenic properties, their effectiveness in treating inflammatory lesions, and their suitability for long-term maintenance. However, their drawbacks involve the potential for irritancy, which can be concentration- and vehicle-dependent.

Irritancy “maxes out at 1-2 weeks, but the problem is you lose the patient at 2 weeks unless they know it’s coming,” she said, noting that she once heard the 2-week mark characterized as a “crisis of confidence.” Patients “came in with a bunch of pimples, and now they’re red and flaky and burning and stinging [from the retinoid], yet they still have pimples,” Baldwin said. “You really need to talk them through that 2-week mark [or] they’re going to stop the medication.”

To improve retinoid tolerability, Baldwin offered the following tips:

• Use a pea-sized amount for the entire affected area and avoid spot treatments.
• Start with every other day application.
• Moisturize regularly, possibly applying moisturizer before the retinoid.
• Consider switching to a different formulation with an alternative vehicle or retinoid delivery system. Adapalene and tazarotene are the only retinoids that have proven to be stable in the presence of benzoyl peroxide, she said.
• Be persistent. “There is no such thing as a patient who cannot tolerate a retinoid,” said Baldwin, the lead author of a review on the evolution of topical retinoids for acne. “It’s because of a provider who failed to provide a sufficient amount of information to allow the patient to eventually be able to tolerate a retinoid.”

Baldwin also referred to an independent meta-analysis of 221 trials comparing the efficacy of pharmacological therapies for acne in patients of any age, which found that the percentage reduction in total lesion count, compared with placebo, was the highest with oral isotretinoin (mean difference [MD], 48.41; P = 1.00), followed by triple therapy containing a topical antibiotic, a topical retinoid, and benzoyl peroxide (MD, 38.15; P = .95), and by triple therapy containing an oral antibiotic, a topical retinoid, and benzoyl peroxide (MD, 34.83; P = .90).

Baldwin is a former president of the American Acne & Rosacea Society and is the SDPA conference medical director. She disclosed being a speaker, consultant, and/or an advisory board member for Almirall, Arcutis, Bausch, Beiersdorf, Cutera, Galderma, Journey, Kenvue, La Roche-Posay, L’Oreal, Sanofi, Sun Pharma, and Tarsus Pharmaceuticals.

 

A version of this article appeared on Medscape.com.

LAS VEGAS — No matter which treatment regimen is recommended for patients with acne, it should always include a topical retinoid, according to dermatologist Hilary Baldwin, MD.

Patients with successfully treated acne typically use an average of 2.53 different medications, Baldwin, director of the Acne Treatment & Research Center, Brooklyn, New York, said at the Society of Dermatology Physician Associates (SDPA) 22nd Annual Fall Dermatology Conference.

 

“Combination treatment is the name of the game, but how do we convince our patients that what we chose is carefully orchestrated?” she said. “Combination therapy is much more effective, yet we’re always told, ‘keep it simple.’ The trick is to use combination products that have two or three medications in them — fixed combinations and products with excellent vehicles.”

No matter what treatment regimen is recommended for patients with acne, she continued, it should always include a topical retinoid. Tretinoin was the first topical retinoid approved for acne treatment in 1971, followed by adapalene in 1996, tazarotene in 1997, and trifarotene in 2019. According to a review article , topical retinoids inhibit the formation of microcomedones, reduce mature comedones and inflammatory lesions, enhance penetration of other drugs, reduce and prevent scarring, reduce hyperpigmentation, and maintain remission of acne.

More recently, authors of the 2024 American Academy of Dermatology guidelines of care for the management of acne vulgaris strongly recommended the use of topical retinoids based on moderate certainty evidence in the medial literature. Strong recommendations are also made for benzoyl peroxide, topical antibiotics, and oral doxycycline.

Baldwin noted that the benefits of retinoids include their comedolytic and anti-comedogenic properties, their effectiveness in treating inflammatory lesions, and their suitability for long-term maintenance. However, their drawbacks involve the potential for irritancy, which can be concentration- and vehicle-dependent.

Irritancy “maxes out at 1-2 weeks, but the problem is you lose the patient at 2 weeks unless they know it’s coming,” she said, noting that she once heard the 2-week mark characterized as a “crisis of confidence.” Patients “came in with a bunch of pimples, and now they’re red and flaky and burning and stinging [from the retinoid], yet they still have pimples,” Baldwin said. “You really need to talk them through that 2-week mark [or] they’re going to stop the medication.”

To improve retinoid tolerability, Baldwin offered the following tips:

• Use a pea-sized amount for the entire affected area and avoid spot treatments.
• Start with every other day application.
• Moisturize regularly, possibly applying moisturizer before the retinoid.
• Consider switching to a different formulation with an alternative vehicle or retinoid delivery system. Adapalene and tazarotene are the only retinoids that have proven to be stable in the presence of benzoyl peroxide, she said.
• Be persistent. “There is no such thing as a patient who cannot tolerate a retinoid,” said Baldwin, the lead author of a review on the evolution of topical retinoids for acne. “It’s because of a provider who failed to provide a sufficient amount of information to allow the patient to eventually be able to tolerate a retinoid.”

Baldwin also referred to an independent meta-analysis of 221 trials comparing the efficacy of pharmacological therapies for acne in patients of any age, which found that the percentage reduction in total lesion count, compared with placebo, was the highest with oral isotretinoin (mean difference [MD], 48.41; P = 1.00), followed by triple therapy containing a topical antibiotic, a topical retinoid, and benzoyl peroxide (MD, 38.15; P = .95), and by triple therapy containing an oral antibiotic, a topical retinoid, and benzoyl peroxide (MD, 34.83; P = .90).

Baldwin is a former president of the American Acne & Rosacea Society and is the SDPA conference medical director. She disclosed being a speaker, consultant, and/or an advisory board member for Almirall, Arcutis, Bausch, Beiersdorf, Cutera, Galderma, Journey, Kenvue, La Roche-Posay, L’Oreal, Sanofi, Sun Pharma, and Tarsus Pharmaceuticals.

 

A version of this article appeared on Medscape.com.

LAS VEGAS — No matter which treatment regimen is recommended for patients with acne, it should always include a topical retinoid, according to dermatologist Hilary Baldwin, MD.

Patients with successfully treated acne typically use an average of 2.53 different medications, Baldwin, director of the Acne Treatment & Research Center, Brooklyn, New York, said at the Society of Dermatology Physician Associates (SDPA) 22nd Annual Fall Dermatology Conference.

 

“Combination treatment is the name of the game, but how do we convince our patients that what we chose is carefully orchestrated?” she said. “Combination therapy is much more effective, yet we’re always told, ‘keep it simple.’ The trick is to use combination products that have two or three medications in them — fixed combinations and products with excellent vehicles.”

No matter what treatment regimen is recommended for patients with acne, she continued, it should always include a topical retinoid. Tretinoin was the first topical retinoid approved for acne treatment in 1971, followed by adapalene in 1996, tazarotene in 1997, and trifarotene in 2019. According to a review article , topical retinoids inhibit the formation of microcomedones, reduce mature comedones and inflammatory lesions, enhance penetration of other drugs, reduce and prevent scarring, reduce hyperpigmentation, and maintain remission of acne.

More recently, authors of the 2024 American Academy of Dermatology guidelines of care for the management of acne vulgaris strongly recommended the use of topical retinoids based on moderate certainty evidence in the medial literature. Strong recommendations are also made for benzoyl peroxide, topical antibiotics, and oral doxycycline.

Baldwin noted that the benefits of retinoids include their comedolytic and anti-comedogenic properties, their effectiveness in treating inflammatory lesions, and their suitability for long-term maintenance. However, their drawbacks involve the potential for irritancy, which can be concentration- and vehicle-dependent.

Irritancy “maxes out at 1-2 weeks, but the problem is you lose the patient at 2 weeks unless they know it’s coming,” she said, noting that she once heard the 2-week mark characterized as a “crisis of confidence.” Patients “came in with a bunch of pimples, and now they’re red and flaky and burning and stinging [from the retinoid], yet they still have pimples,” Baldwin said. “You really need to talk them through that 2-week mark [or] they’re going to stop the medication.”

To improve retinoid tolerability, Baldwin offered the following tips:

• Use a pea-sized amount for the entire affected area and avoid spot treatments.
• Start with every other day application.
• Moisturize regularly, possibly applying moisturizer before the retinoid.
• Consider switching to a different formulation with an alternative vehicle or retinoid delivery system. Adapalene and tazarotene are the only retinoids that have proven to be stable in the presence of benzoyl peroxide, she said.
• Be persistent. “There is no such thing as a patient who cannot tolerate a retinoid,” said Baldwin, the lead author of a review on the evolution of topical retinoids for acne. “It’s because of a provider who failed to provide a sufficient amount of information to allow the patient to eventually be able to tolerate a retinoid.”

Baldwin also referred to an independent meta-analysis of 221 trials comparing the efficacy of pharmacological therapies for acne in patients of any age, which found that the percentage reduction in total lesion count, compared with placebo, was the highest with oral isotretinoin (mean difference [MD], 48.41; P = 1.00), followed by triple therapy containing a topical antibiotic, a topical retinoid, and benzoyl peroxide (MD, 38.15; P = .95), and by triple therapy containing an oral antibiotic, a topical retinoid, and benzoyl peroxide (MD, 34.83; P = .90).

Baldwin is a former president of the American Acne & Rosacea Society and is the SDPA conference medical director. She disclosed being a speaker, consultant, and/or an advisory board member for Almirall, Arcutis, Bausch, Beiersdorf, Cutera, Galderma, Journey, Kenvue, La Roche-Posay, L’Oreal, Sanofi, Sun Pharma, and Tarsus Pharmaceuticals.

 

A version of this article appeared on Medscape.com.

PARIS — “My child is a poor eater” is a complaint frequently heard during medical consultations. Such concerns are often unjustified but a source of much parental frustration. 

Marc Bellaïche, MD, a pediatrician at Robert-Debré Hospital in Paris, addressed this issue at France’s annual general medicine conference (JNMG 2024). His presentation focused on distinguishing between parental perception, typical childhood behaviors, and feeding issues that require intervention.

In assessing parental worries, tools such as The Montreal Children’s Hospital Feeding Scale for children aged 6 months to 6 years and the Baby Eating Behavior Questionnaire for those under 6 months can help identify and monitor feeding issues. Observing the child eat, when possible, is also valuable.

 

Key Phases and Development

Bellaïche focused on children under 6 years, as they frequently experience feeding challenges during critical development phases, such as weaning or when the child is able to sit up.

A phase of neophilia (interest in new foods) typically occurs before 12 months, followed by a phase of neophobia (fear of new foods) between ages 1 and 3 years. This neophobia is a normal part of neuropsychological, sensory, and taste development and can persist if a key developmental moment is marked by a choking incident, mealtime stress, or forced feeding. “Challenges differ between a difficult 3-year-old and a 6- or 7-year-old who still refuses new foods,” he explained.

 

Parental Pressure and Nutritional Balance

Nutritional balance is essential, but “parental pressure is often too high.” Parents worry because they see food as a “nutraceutical.” Bellaïche recommended defusing anxiety by keeping mealtimes calm, allowing the child to eat at their pace, avoiding force-feeding, keeping meals brief, and avoiding snacks. While “it’s important to stay vigilant — as it’s incorrect to assume a child won’t let themselves starve — most cases can be managed in general practice through parental guidance, empathy, and a positive approach.”

Monitoring growth and weight curves is crucial, with the Kanawati index (ratio of arm circumference to head circumference) being a reliable indicator for specialist referral if < 0.31. A varied diet is important for nutritional balance; when this isn’t achieved, continued consumption of toddler formula after age 3 can prevent iron and calcium deficiencies.

When eating difficulties are documented, healthcare providers should investigate for underlying organic, digestive, or extra-digestive diseases (neurologic, cardiac, renal, etc.). “It’s best not to hastily diagnose cow’s milk protein allergy,” Bellaïche advised, as cases are relatively rare and unnecessarily eliminating milk can complicate a child’s relationship with food. Similarly, gastroesophageal reflux disease should be objectively diagnosed to avoid unnecessary proton pump inhibitor treatment and associated side effects.

For children with low birth weight, mild congenital heart disease, or suggestive dysmorphology, consider evaluating for a genetic syndrome.

 

Avoidant/Restrictive Food Intake Disorder (ARFID)

ARFID is marked by a lack of interest in food and avoidance due to sensory characteristics. Often observed in anxious children, ARFID is diagnosed in approximately 20% of children with autism spectrum disorder, where food selectivity is prevalent. This condition can hinder a child’s development and may necessitate nutritional supplementation.

Case Profiles in Eating Issues

Bellaïche outlined three typical cases among children considered “picky eaters”:

• The small eater: Often near the lower growth curve limits, this child “grazes and doesn’t sit still.” These children are usually active and have a family history of similar eating habits. Parents should encourage psychomotor activities, discourage snacks outside of mealtimes, and consider fun family picnics on the floor, offering a mezze-style variety of foods. 
• The child with a history of trauma: Children with trauma (from intubation, nasogastric tubes, severe vomiting, forced feeding, or choking) may develop aversions requiring behavioral intervention. 
• The child with high sensory sensitivity: This child dislikes getting the hands dirty, avoids mouthing objects, or resists certain textures, such as grass and sand. Gradual behavioral approaches with sensory play and visually appealing new foods can be beneficial. Guided self-led food exploration (baby-led weaning) may also help, though dairy intake is often needed to prevent deficiencies during this stage. 

Finally, gastroesophageal reflux disease or constipation can contribute to appetite loss. Studies have shown that treating these issues can improve appetite in small eaters.

 

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

PARIS — “My child is a poor eater” is a complaint frequently heard during medical consultations. Such concerns are often unjustified but a source of much parental frustration. 

Marc Bellaïche, MD, a pediatrician at Robert-Debré Hospital in Paris, addressed this issue at France’s annual general medicine conference (JNMG 2024). His presentation focused on distinguishing between parental perception, typical childhood behaviors, and feeding issues that require intervention.

In assessing parental worries, tools such as The Montreal Children’s Hospital Feeding Scale for children aged 6 months to 6 years and the Baby Eating Behavior Questionnaire for those under 6 months can help identify and monitor feeding issues. Observing the child eat, when possible, is also valuable.

 

Key Phases and Development

Bellaïche focused on children under 6 years, as they frequently experience feeding challenges during critical development phases, such as weaning or when the child is able to sit up.

A phase of neophilia (interest in new foods) typically occurs before 12 months, followed by a phase of neophobia (fear of new foods) between ages 1 and 3 years. This neophobia is a normal part of neuropsychological, sensory, and taste development and can persist if a key developmental moment is marked by a choking incident, mealtime stress, or forced feeding. “Challenges differ between a difficult 3-year-old and a 6- or 7-year-old who still refuses new foods,” he explained.

 

Parental Pressure and Nutritional Balance

Nutritional balance is essential, but “parental pressure is often too high.” Parents worry because they see food as a “nutraceutical.” Bellaïche recommended defusing anxiety by keeping mealtimes calm, allowing the child to eat at their pace, avoiding force-feeding, keeping meals brief, and avoiding snacks. While “it’s important to stay vigilant — as it’s incorrect to assume a child won’t let themselves starve — most cases can be managed in general practice through parental guidance, empathy, and a positive approach.”

Monitoring growth and weight curves is crucial, with the Kanawati index (ratio of arm circumference to head circumference) being a reliable indicator for specialist referral if < 0.31. A varied diet is important for nutritional balance; when this isn’t achieved, continued consumption of toddler formula after age 3 can prevent iron and calcium deficiencies.

When eating difficulties are documented, healthcare providers should investigate for underlying organic, digestive, or extra-digestive diseases (neurologic, cardiac, renal, etc.). “It’s best not to hastily diagnose cow’s milk protein allergy,” Bellaïche advised, as cases are relatively rare and unnecessarily eliminating milk can complicate a child’s relationship with food. Similarly, gastroesophageal reflux disease should be objectively diagnosed to avoid unnecessary proton pump inhibitor treatment and associated side effects.

For children with low birth weight, mild congenital heart disease, or suggestive dysmorphology, consider evaluating for a genetic syndrome.

 

Avoidant/Restrictive Food Intake Disorder (ARFID)

ARFID is marked by a lack of interest in food and avoidance due to sensory characteristics. Often observed in anxious children, ARFID is diagnosed in approximately 20% of children with autism spectrum disorder, where food selectivity is prevalent. This condition can hinder a child’s development and may necessitate nutritional supplementation.

Case Profiles in Eating Issues

Bellaïche outlined three typical cases among children considered “picky eaters”:

• The small eater: Often near the lower growth curve limits, this child “grazes and doesn’t sit still.” These children are usually active and have a family history of similar eating habits. Parents should encourage psychomotor activities, discourage snacks outside of mealtimes, and consider fun family picnics on the floor, offering a mezze-style variety of foods. 
• The child with a history of trauma: Children with trauma (from intubation, nasogastric tubes, severe vomiting, forced feeding, or choking) may develop aversions requiring behavioral intervention. 
• The child with high sensory sensitivity: This child dislikes getting the hands dirty, avoids mouthing objects, or resists certain textures, such as grass and sand. Gradual behavioral approaches with sensory play and visually appealing new foods can be beneficial. Guided self-led food exploration (baby-led weaning) may also help, though dairy intake is often needed to prevent deficiencies during this stage. 

Finally, gastroesophageal reflux disease or constipation can contribute to appetite loss. Studies have shown that treating these issues can improve appetite in small eaters.

 

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

PARIS — “My child is a poor eater” is a complaint frequently heard during medical consultations. Such concerns are often unjustified but a source of much parental frustration. 

Marc Bellaïche, MD, a pediatrician at Robert-Debré Hospital in Paris, addressed this issue at France’s annual general medicine conference (JNMG 2024). His presentation focused on distinguishing between parental perception, typical childhood behaviors, and feeding issues that require intervention.

In assessing parental worries, tools such as The Montreal Children’s Hospital Feeding Scale for children aged 6 months to 6 years and the Baby Eating Behavior Questionnaire for those under 6 months can help identify and monitor feeding issues. Observing the child eat, when possible, is also valuable.

 

Key Phases and Development

Bellaïche focused on children under 6 years, as they frequently experience feeding challenges during critical development phases, such as weaning or when the child is able to sit up.

A phase of neophilia (interest in new foods) typically occurs before 12 months, followed by a phase of neophobia (fear of new foods) between ages 1 and 3 years. This neophobia is a normal part of neuropsychological, sensory, and taste development and can persist if a key developmental moment is marked by a choking incident, mealtime stress, or forced feeding. “Challenges differ between a difficult 3-year-old and a 6- or 7-year-old who still refuses new foods,” he explained.

 

Parental Pressure and Nutritional Balance

Nutritional balance is essential, but “parental pressure is often too high.” Parents worry because they see food as a “nutraceutical.” Bellaïche recommended defusing anxiety by keeping mealtimes calm, allowing the child to eat at their pace, avoiding force-feeding, keeping meals brief, and avoiding snacks. While “it’s important to stay vigilant — as it’s incorrect to assume a child won’t let themselves starve — most cases can be managed in general practice through parental guidance, empathy, and a positive approach.”

Monitoring growth and weight curves is crucial, with the Kanawati index (ratio of arm circumference to head circumference) being a reliable indicator for specialist referral if < 0.31. A varied diet is important for nutritional balance; when this isn’t achieved, continued consumption of toddler formula after age 3 can prevent iron and calcium deficiencies.

When eating difficulties are documented, healthcare providers should investigate for underlying organic, digestive, or extra-digestive diseases (neurologic, cardiac, renal, etc.). “It’s best not to hastily diagnose cow’s milk protein allergy,” Bellaïche advised, as cases are relatively rare and unnecessarily eliminating milk can complicate a child’s relationship with food. Similarly, gastroesophageal reflux disease should be objectively diagnosed to avoid unnecessary proton pump inhibitor treatment and associated side effects.

For children with low birth weight, mild congenital heart disease, or suggestive dysmorphology, consider evaluating for a genetic syndrome.

 

Avoidant/Restrictive Food Intake Disorder (ARFID)

ARFID is marked by a lack of interest in food and avoidance due to sensory characteristics. Often observed in anxious children, ARFID is diagnosed in approximately 20% of children with autism spectrum disorder, where food selectivity is prevalent. This condition can hinder a child’s development and may necessitate nutritional supplementation.

Case Profiles in Eating Issues

Bellaïche outlined three typical cases among children considered “picky eaters”:

• The small eater: Often near the lower growth curve limits, this child “grazes and doesn’t sit still.” These children are usually active and have a family history of similar eating habits. Parents should encourage psychomotor activities, discourage snacks outside of mealtimes, and consider fun family picnics on the floor, offering a mezze-style variety of foods. 
• The child with a history of trauma: Children with trauma (from intubation, nasogastric tubes, severe vomiting, forced feeding, or choking) may develop aversions requiring behavioral intervention. 
• The child with high sensory sensitivity: This child dislikes getting the hands dirty, avoids mouthing objects, or resists certain textures, such as grass and sand. Gradual behavioral approaches with sensory play and visually appealing new foods can be beneficial. Guided self-led food exploration (baby-led weaning) may also help, though dairy intake is often needed to prevent deficiencies during this stage. 

Finally, gastroesophageal reflux disease or constipation can contribute to appetite loss. Studies have shown that treating these issues can improve appetite in small eaters.

 

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.