Abstract
The issue of electronic media use by young children is increasingly important in pediatrics, a major risk factor for numerous chronic conditions. Despite guidelines in place since 1999, screen time is on the rise, aided by new formats removing practically all barriers of use. Key drivers are technological allure, confusion about developmental readiness, and perception of educational value, fueled by potent marketing. This article describes the development of Baby Unplugged™, a series of children’s board books celebrating “old-school,” screen-free childhood. Written by a pediatrician who also owns a children’s bookstore, the books were inspired and informed by advocacy projects in the areas of media use and early literacy as a pediatric resident. They reinforce AAP Electronic Media Guidelines, notably discouraging screen-based media under 2 years old, largely by encouraging healthy, fun alternatives. Examples include Pets, Book, and Yard. Multi-sensorial exploration and parent-child engagement are emphasized in a non-prescriptive way, featuring gender and ethnic diversity and activities that are accessible and inexpensive. The author describes challenges faced by pediatricians providing anticipatory guidance for media use, given limited time and resources and the perception that we are out of touch. This is heightened by oft-deceptive marketing of screen-based products more likely to be perceived as “cool.” Reach Out and Read is cited as an example of a successful, “cool” intervention, though limited to select populations. Baby Unplugged™ takes advocacy to the marketplace, where the screen time battle is being lost.
Keywords
As far as I know, I am the only pediatrician in the world also owning and operating a children’s bookstore. Foolhardy though it often seems, this perspective has enabled me to answer the call of the American Academy of Pediatrics (AAP) to be a physician advocate in a unique and timely way.
Balancing bookselling, medicine, and fatherhood is a challenge, rife with existential crises. Pediatrics does, however, offer far more synergy than other specialties, and books are among our most potent therapeutic tools. In addition to wise counsel from Wild Things, caterpillars, and Harry Potter, I have learned the magic of incorporating books into clinic visits, used evidence-based medicine to explain why we refuse to carry cartoon-based books or videos at our bookstore, and in distinct settings interviewed parents regarding the current media morass.
During residency at Cincinnati Children’s, we were required to complete advocacy and research projects for graduation. Predictably, I focused mine on literacy and the health effects of electronic media. Thus, after 30 hours on-call (a bygone era), a blur of family-centered, evidence-based care excepting bedroom television for patients of all ages, I would collapse on our story time stage for children’s literature review. I also immersed myself in the grown-up kind, including AAP guidelines. This culminated in my PGY-3 Chairman’s Rounds presentation, “Analog Kids in a Digital Age, “ which I have since adapted for school and community groups, inspiring a heightened sense of mission for my work outside of the hospital.
Though statistics and studies are emerging, some more robust than others, it is clear that media plays a starring role in major epidemics we pediatricians face, including obesity, aggression, and sleep, attention, and learning problems. 1 . As from a meteor (media-or?) strike, the landscape of childhood has transformed at a rate unprecedented in human history and not for the better. Despite evidence-based guidelines in place since the 1990s, children are consuming more than ever—literally starting before they can babble 2 —with little time for much else. 3 An emergency room attending added anecdotal evidence during a busy residency shift, lamenting how chief complaints had morphed from acute to chronic, falling out of trees, bike crashes, and bee stings sublimating into a haze of behavioral problems, atopy, and BMI.
How has this happened?
Despite common accusations that “the electronic babysitter did it,” education4,5—and the anxieties and misplaced expectations that go with it—is the major influence on parental media choices. A stroll through the toy section of any big box store corroborates this, with almost every product marketed to young children bearing a “learning” tag. This explains the phenomenal success of Baby Einstein and copycat videos (muted by a 2007 study 6 associating them with language delay and a successful recall campaign) and million-unit sales of surreal products like Your Baby Can Read! (recently defunct thanks largely to aggressive advocacy efforts) and why popular cartoon characters rake in big bucks moonlighting as teachers, for example, Lightning McQueen Learn and Go.
Clearly, our peer review and that of parents are not the same.
“Smart baby” products are a large, lucrative, and growing industry, backed by vast advertising dollars. 7 We pediatricians are among the only lines of defense for our patients, yet are increasingly outmatched, our methods largely the same as in the predigital era. Though perhaps it should, our training does not include marketing and sales. We do not have R&D teams, theme parks, or budgets for infomercials. Thus, we often express a sense of futility, 8 succumbing to a “new normal.” Pressures to see patients faster, with so much anticipatory ground to cover, give us no choice but to pick a few key battles and move on. This explains recent studies finding that only 15% of parents of children younger than 2 had ever discussed e-media with providers 9 and confusion among parents regarding screen time reduction 10 —unfortunate, because media increasingly defines key risk factors and how children live their lives.
If education is why parents buy what they do, it stands to reason that we would have more influence. We epitomize educational. We have degrees, organize committees, publish peer-reviewed studies, and write recommendations. Why don’t parents listen to us?
Because we’re not cool.
It’s an age-old, tragic story: the smart kid labors in obscurity, the cool one is popular. Parents buy in to Baby Einstein because Einstein was a cool genius, and the videos have cool packaging, with names like Baby Neptune, backed by cool marketing. They bought Your Baby Can Read! because babies reading on TV are super cool, and founder Dr Titzer offered a secret uncool doctors will not share. The word “app” is cool. iPads transcend cool. And all these promise to make babies smarter via buying something—what’s cooler and more American than that?
We know that e-media is not cool for young children. Every few months or so at checkups, just before poking said children with needles, 15% of the time we make our case like party-pooping, diet-and-exercise data-coddling killjoys; our handouts utterly 1.0, our over-the-spectacles advice akin to Charlie Brown’s teacher: “1-2 hours per day of pro-social programming, no TV in the bedroom, wah-wah-wah . . .” Thus, may be 15% of that 15% of the time, parents listen.
There are exceptions, of course. Notable among them is Reach Out and Read* (ROAR). By design, this program incorporates actual books into well-child visits in low-income clinics from ages 6 months to 5 years. Motivation is bidirectional: families are excited by the prospect of a free, brand new book to take home, and pediatricians are inspired by this “teachable moment” to discuss the importance of reading, which goes hand in hand with screen time reduction. As a result, ROAR is very successful on many levels, including language and literacy, school readiness, and clinic compliance and its evidence base among the strongest for interventions in general pediatrics. 11
ROAR effectively addresses a population at high risk for the negative effects of excessive screen time. Unfortunately, the vast majority of pediatric clinics are non-ROAR, lacking its infrastructure and resources, alongside pressures cited earlier. Thus, despite socioeconomic advantages, including books in the home, 12 higher-income families tend to receive media guidance informally (and with no cool, free book) or not at all, turning largely to the marketplace where sound guidance is lacking. 13
All parents want to make healthy choices for their children. They want to buy them healthy products. They want them to learn. They are also susceptible to an unprecedented vortex of peer pressure, deceptive marketing, and misinformation. 14 They do respect our clinical acumen—rashes, ears, auscultation—but whether via a rushed aside after uvula inspection in the clinic or in guideline-citing magazine articles, perhaps we’re perceived as out of touch in the media space, whence cool wins the day. Fusion of credibility and cool is rare in the marketplace, perhaps unique to Sesame Street, though in my opinion Elmo et al are too often used “off-label” by kids under 2.
And so, not long after graduation 2 years ago, with advocacy and audience in mind, an idea struck: wage the media battle in the marketplace, where we are losing it. Rather than just criticizing and restricting unhealthy media, we needed to develop and promote healthy alternatives. If parents want educational and cool, we need to create something educational and cool or, more important, something their children think is cool (kids could not care less if it is educational), inspiring them to share it with peers.
My experience as a children’s bookseller afforded me insight into what parents buy, what children like, and why. It also afforded me a platform, a network, and ample idealistic craziness endemic in independent booksellers to make it happen. And so, after a year of hard yet exciting work, we created a new publishing imprint, and Baby Unplugged was born.
Baby Unplugged is a board book series celebrating “old-school” experiences and icons of childhood, aka how most grown-ups spent theirs. Each title (7 to date) features children of diverse gender and ethnicity reinforcing the value of shared reading, creative play, and grown-up–child engagement. Each is educational as a natural by-product of a child’s drive to explore and connect in the real world, not via academics, marketing claim, or screen-based tie-ins. For example, Pets conveys the joy of relationships with real, as opposed to the expanding menagerie of virtual, pets. Yard invites children to explore and interact with nature. Blanket encourages imagination and reflection. Book cheers real pages to turn and laps to sit on. The others are Box, Ball, and Beach. None promise mastery of vocabulary, emotions, snacking, or anything explicit. They are simple, fun, and cool.
And their logo was created by a cool 5-year-old—my daughter.
Though market-based, Baby Unplugged is backed by mission and evidence. It is consistent with AAP media guidelines 15 reaffirmed in 2011: avoiding screen media for children younger than 2 years, encouraging healthy alternatives such as their subject matter, and representing advocacy by pediatricians, given our “unique position to relay information about media to parents and children.” It targets the population most vulnerable to consequences of excessive screen media. It invites dialogic discussion of a child’s world, past and present. And rather than restricting and potentially alienating parents, it promotes inclusive, accessible activities, fostering analog skill development during critical developmental stages.
In essence, the series is anticipatory guidance, though you’d never know it—and that’s cool.
The response to Baby Unplugged has been positive so far, with strong sales, enthusiastic reviews, and national awards. Grandparents in particular seem to resonate with our mission, recalling simpler, analog times. Educators have embraced the books, sharing concerns about impaired readiness in basic, real-world skills once taken for granted. Parents convey a sense of relief that apps and flash cards aren’t necessary and that it’s ok to unplug and play. Most important, babies love them. One mom told me that her son chewed and kissed Pets so much that she had to buy a new one, and another told me that her toddler insisted on holding Blanket for her birthday photo.
It’s that kind of cool that is needed.
Our next objective is to introduce Baby Unplugged to a wider audience. We are distributing our first national catalog, dialoguing with potential major publishing partners, and hope to further engagement with ROAR, including developing titles for urban settings. Our supporting blog, BabyUnplugged.com, highlights relevant statistics and studies in a family-friendly way, with a mission to be “screen-free until three.” It is hoped that by building a recognizable, credible, mission-driven brand, Baby Unplugged will be a useful adjunct to media advocacy efforts, market pressures helping pediatricians make “old-school” cool again.
Footnotes
Acknowledgements
Special thanks to Dr Victor Strasburger, MD, who encouraged Dr Hutton to write and submit this article and provided valuable insights into preparation for submission.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Though the author is the author and publisher of books mentioned, this does not represent a conflict of interest because these books were explicitly developed in accordance with and to reinforce AAP Media Use Guidelines and derived from advocacy projects as a pediatric resident.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
*
ROAR is a cool program, involving cool market-based products distributed by smart, cool doctors.