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Do I Really Have to Follow That Health Rule?

Melanie Acevedo
Melanie Acevedo

How many episodes of My Little Pony: Friendship Is Magic can a preschooler watch before it curdles her brain? What’s the safe upper limit for feeding your kid boxed mac ’n’ cheese?

In moments when you’re asking yourself these kinds of questions, it’s a relief to turn to the guidelines put out by the American Academy of Pediatrics (AAP), whose research-backed recommendations on stuff like screen time and nutrition are truly the closest thing parents have to an official set of “rules” for raising kids. But nearly 80 percent of our Parents Panel of AAP Moms admit they have trouble following at least one of the AAP health rules at home.

Here’s how they push past the struggle and make it work.

Screen Time Rules for Kids

The recommendations: Children under 18 months should have no screen use (other than video chatting); for kids 18 to 24 months, watch together in moderation; for ages 2 to 5 years, limit screen use to one hour per day of high-quality programming; for ages 6 and up, place consistent limits, and ensure media doesn’t interfere with adequate sleep and physical activity.

Why they’re hard: Screens are absolutely everywhere—in our pockets, in the seat backs of our minivans, and even on the tables and walls at restaurants. Placing limits on screen time is, by far, the rule our pediatrician-mom panelists say they have the most trouble with. But screens can be helpful too:

“As a working mom, I use them to provide time for me to get things done like making dinner or putting clothes away,” says Rhonda Graves Acholonu, M.D., vice chair for education at The Children’s Hospital at Montefiore, in Bronx, New York.

How to stick with them: Set up simple expectations from the start—and then follow through. (The AAP urges parents to create a family media plan that lays out clear rules about when and where screen time happens. Design your own at healthychildren.org/mediauseplan.)

“We don’t try to find substitutes for TV, but instead think of other things we like to do,” says Rupal Gupta, M.D., a pediatrician at Children’s Mercy Kansas City. “When I’m getting ready in the morning or doing chores, my kids love listening to podcasts, like Story Pirates or Wow in the World, or audiobooks. They’ve listened to the Ramona series more times than I can count.” Many of the doctor-moms also credited Legos, books, and an arts-and-crafts station as great solo-play activities to occupy their kids.

Toothbrushing Rules for Kids

The recommendations: Kids should brush twice a day with fluoridated toothpaste, using a smear the size of a grain of rice before age 3 and a pea-size dollop after that, with parental supervision until age 8 or so. The AAP doesn’t have time recommendations for brushing, but the American Academy of Pediatric Dentistry advises that kids brush for a full two minutes, twice a day.

Why they’re hard: It’s easy to skip or forget when you’re pressed for time, and a lot of kids truly hate it.

“My son used to bite!” says Silvia Pereira-Smith, M.D., a pediatrician at The Medical University of South Carolina, in Charleston. “It would take us more like five minutes to brush instead of two, but I’d remind myself that putting in the extra effort was worth it.”

Twenty-one percent of kids ages 5 and under have at least one cavity, as do more than half of grade school–age children, according to the Centers for Disease Control and Prevention. Decay in baby teeth can lead to root problems as kids get older, so it’s just as important to get your crew into the lifelong brushing habit, says AAP spokesperson Shelly Flais, M.D., author of Raising Twins.

“The sooner they start doing it regularly, the more it becomes part of their routine and just how they live.”

How to stick with them: “I tell my kids to roar like a lion while I brush their teeth, or I have them practice using a toothbrush on a stuffed animal or even me first. I’ve also tried a special light-up toy that turns on only if they open their mouth—because I press the button! Good timing is necessary for this one,” says Jessica Lazerov, M.D., a pediatrician at Children’s National in Washington, D.C. “Toddlers love praise, so if they open their mouth and let me brush, I make a big deal about how amazing that was—even if it was just for a few hurried seconds.”

But Dr. Lazerov admits, “Sometimes you end up at a stalemate. Rather than force it, you may need to just try again later. Besides, getting them to chew the toothbrush is still better than nothing.”

Nutrition Rules for Kids

The recommendations: The AAP suggests limiting sweets and sugary drinks and following the USDA dietary daily intake recommendations for kids: 1 to 1 1/2 cups of fruit, 1 to 2 1/2 cups of veggies, and 2 to 3 cups of dairy (cheese, yogurt, milk), depending on their age. While the AAP doesn’t put specific limits on sugar, the American Heart Association recommends that kids eat or drink less than 6 teaspoons (25 grams) of added sugar daily. (That doesn’t include naturally occurring sugars like fructose and lactose in whole foods like fruit and milk.)

Why they’re hard: Let us count the ways! Picky palates, busy schedules, toddler food jags (all bread, all the time), stubborn veggie haters ... we could go on.

“It’s hard to work up the energy and set aside the time to prepare and enforce healthy meals when my kids put up a fuss,” admits Brenda Anders Pring, M.D., a pediatrician in Boston. And even when you regularly plan and prep healthy meals and snacks at home, you can’t always control what your kids are offered outside the house.

“Snacks and sugary treats have become a part of every activity. In a single day my girls might have something sweet at school, fruit snacks at Girl Scouts, and then birthday cupcakes at soccer practice,” says Erika Crane, M.D., a pediatrician in Detroit.

How to stick with them: Don’t force kids to clean their plate or eat food they hate, says Dr. Flais. “There’s no surer way to turn a child off healthy foods than making him feel that they’re a punishment.”

However, a simple three-bite rule has helped Dr. Gupta’s kids, age 5 and 8. “No matter what, they have to have at least three veggie bites at a meal,” she says. As a snack, her kids love “apple fries and ketchup”—she cuts apples into matchstick shapes, sprinkles them with cinnamon, and offers strawberry jelly as the ketchup-like dip. For go-to prepackaged options, many of the doctors turn to pretzels, cheese sticks, applesauce pouches, Annie’s crackers, and protein bars like Clif Kid Zbars, LÄRABAR bars, and KIND bars.

Exercise Rules for Kids

The recommendations: Daily active play for preschoolers and at least 60 minutes of moderate-to-vigorous physical activity for kids ages 6 and older.

Why they’re hard: Only a quarter of school-age kids in the U.S. get the recommended hour of exercise per day. Screen time often infringes on other kinds of activity, says Dr. Flais, and kids aren’t getting as much movement at school as in the past. Only 65 percent of U.S. school districts require regularly scheduled recess for elementary schools, and even in states where P.E. is required by law, kids get only between 60 and 100 minutes per week.

How to stick with them: Team sports and active after-school activities are a good way to build exercise into your child’s daily life. However, don’t underestimate the benefit of shorter chunks of activity, says Dr. Flais. “Even in the cold Midwest winters, we bundle up, smear some Vaseline on the kids’ faces, and get outside for family walks.” A 20-minute stroll around the neighborhood, 30-minute climb at the playground, and ten-minute stint of active play at home adds up to an hour.

“We try to find small ways to incorporate movement as a family,” says Jamaiya James, M.D., a pediatrician in Castle Rock, Colorado. “My kids’ favorite is having a dance party. Nothing gets them laughing and moving like putting on our favorite songs and bopping around with Mom and Dad after dinner. I’m sure we look ridiculous, but it’s so much fun.”

Sleep Rules for Kids

The recommendations: The AAP says infants should be put down on their back on a firm sleep surface without soft bedding until age 1. They should also share their parents’ bedroom (but not their bed) for the first six to 12 months. These guidelines—most of which were introduced in 1992 to reduce the risk of sudden unexpected infant deaths (SUID) including SIDS, accidental suffocation in bed, and other unknown causes—have proven effective. In 1990, the SUID rate was 154 deaths per 100,000 infants. By 2016, it was 91 per 100,000.

Why they’re hard: That being said, we know sticking to these guidelines isn’t always easy, especially when your baby won’t stop crying and you’re absolutely exhausted. “I give you permission to walk away,” says Amanda Montalbano, M.D., a pediatrician at Children’s Mercy East, in Independence, Missouri. “If you have changed, fed, and rocked your baby but nothing is working, put him down on his back, alone in the crib, and go two closed doors away. You won’t hear his cries, so you can take a few minutes to calm down. Crying won’t hurt a baby, but a frustrated parent might.”

How to stick with them: While most of the pediatrician-moms in our survey followed the safe-sleep rules closely, many found that the “rooming in” recommendation took a toll on their own ability to fall or stay asleep. Plus, research has found that babies get less sleep at night and sleep for shorter stretches when they’re in their parents’ room after 4 months of age. What’s most important is that your infant doesn’t share your bed.

If you have an older child who wants to crawl in with you (which can be annoying but is considered safe), Dr. Montalbano suggests this strategy to prevent it from becoming a habit: “Kids are welcome to stay in your room when they’re sick or scared or they want to be close, but they’re not allowed in bed. Instead, create a nest of pillows and blankets for them on the floor. They may stay one or two nights but will eventually want to go back to their own comfortable bed.”