For the more than 11.4 million infants and toddlers living in the United States,1 life is filled with health and safety dos and don'ts. For their caregivers, these practices often seem limited to the infant/toddler stage of development. In some cases — such as placing infants on their backs to sleep as a safeguard against Sudden Infant Death Syndrome (SIDS) and never putting a child to bed with a milk- or juice-filled bottle — they are. Many other practices, however, should be promoted during these early years and viewed as part of a continuum of healthy habits for a lifetime. This article highlights some of those habits, their links to healthy behaviors later in life, and their potential impact on overall health over the course of a lifetime.
The science of early childhood reveals that early relationships with nurturing caregivers sets "both the foundation and the scaffold on which cognitive, linguistic, emotional, and moral development unfold."2 Since nearly all health and safety practices are accomplished in the context of a relationship with an adult caregiver, the healthy habits described below do not apply simply to the infant or toddler; they involve the interaction of a child and caregiver, and, in some cases, the caregiver alone. The promotion and practice of early healthy habits presents numerous opportunities for developing quality nurturing early relationships between the caregiver and child as part of developing a secure, confident person.
What are "Healthy Habits" and Why are They Important from the Start?
Healthy habits are health, nutrition and safety practices that, when performed regularly, over a prolonged period of time, contribute to improved overall physical, social, emotional and mental health. Some examples include sensible sleep practices, proper oral hygiene, car safety (such as use of car seats and seat belts), healthy eating, and regular physical activity. The healthy habits described below comprise the beginning of the healthy habits continuum and, when promoted and practiced during infancy and early childhood, may contribute to physical, social, emotional and mental health for a lifetime.
Healthy eating habits, for example, are key to a lifetime of healthy eating and better overall health: learning to like a variety of healthy foods sets the stage for the generous consumption of fruits and vegetables and other low-fat, nutrient dense foods. In a study examining the relationship between various psychosocial factors and fruit and vegetable consumption, one of the most important factors in determining someone's fruit and vegetable intake was whether they had been in the habit of eating many fruits and vegetables since childhood.3 Recent reviews of the literature regarding the health benefits of fruits and vegetables show their consumption to be associated with reduced risks of adult onset diseases such as some cancers, heart disease, diabetes, and stroke.4,5
But just like young children, healthy habits need continued nurturing. While infants are often started early on a diet including fruits and vegetables, their caregiver's ability to maintain diets rich in vegetables and fruits is quickly put to the challenge as they become "picky eating" toddlers. Picky eating toddlers can grow up to be picky eating children6 and perhaps picky eating young adults.
Sensible Sleep Practices
Adequate sleep is an important component of an overall healthy lifestyle. Sleep factors tremendously into the lives of very young children and their caregivers: from the first week of life, when new parents struggle with their own change in schedule and lack of sleep, to the inevitable questions about normal versus abnormal sleep patterns, to parents eventually asking exasperatedly, "When will she sleep through the night?" Sleep, and issues connected to sleep, play an early, prominent, and perpetual role in the healthy habits continuum. The early establishment of healthy sleep habits — such as a consistent bedtime routine and going to bed without a sweet-fluid-filled bottle — is important for immediate and future physical, social, emotional and mental health. Healthy sleep habits for infants and toddlers can help them with self-regulation, serve as a wonderful time for promoting quality relationships between caregiver and child, and serve as a time to reinforce other healthy habits. With respect to sleep position, early healthy sleep habits can even be life saving.
Perhaps the most critical of all sleep time early healthy habits is the practice of placing a young infant on their back to sleep, as a Sudden Infant Death (SIDS) prevention measure. In 1996, as part of a modification of a previous statement on infant sleep position, the American Academy of Pediatrics (AAP) Task Force on Infant Positioning and SIDS recommended that healthy "infants should be placed for sleep in a nonprone position."7 The Task Force went on to state that "a supine position (wholly on the back) confers the lowest risk and is preferred." Assuring this early healthy habit is initiated is particularly vital for African-American families, who are at twice the risk for SIDS and are less likely to be informed by health care providers about the recommendation to place infants on their back to sleep.8
Early Exposure to Books
The importance of early exposure to books and the elements of the interactions that occur around the sharing of books with infants and toddlers are key in developing a foundation for learning and education success. According to ZERO TO THREE: National Center for Infants, Toddlers, and Families, early language and literacy (reading and writing) development begins in the first three years of life and is closely linked to a child's earliest experiences with books and stories.9 As part of regular bedtime routines, or any time where caregiver and child can interact positively around the sharing of books, this activity also helps set the stage for quality interpersonal interactions throughout life by providing an opportunity for furthering attachment and the nurturing relationship between caregiver and child.
Reading aloud by parents may be the single most critical factor in a child's reading success later in life. Children who live in print-rich environments and who are read to during the first years of life are more likely to learn to read on schedule. Children in households where there is little exposure to reading are at risk for reading problems even before entering school.10 Reading difficulty may lead to increases in school failure, delinquency, substance abuse and teenage pregnancy. Early exposure to books is particularly important for low-income families, who face the greatest risks and have the least resources.
Reach Out and Read is a program that promotes early exposure to books at well-child visits by giving parents of children at risk age-appropriate tips on literacy development and a developmentally appropriate children's book for them to keep. The program has been especially successful in getting books into the hands of very young children and promoting reading activity to parents, leading to changes in parental attitudes toward reading to their young children and enhanced language development.11,12,13 Reach Out and Read is endorsed by the American Academy of Pediatrics and serves 1.5 million children annually.
Other Healthy Habits
It should be obvious that routine health care maintenance visits for infants and toddlers is an important general early healthy habit to establish. Of course, caregivers must remember to set the example and see their provider regularly as well. The following are additional general healthy habits that should be initiated early.
As a health care professional, I am reminded regularly of the importance of hand washing. This is also an important healthy habit for infants and toddlers to develop, particularly from the perspective of illness prevention. Specifically, hand washing can be the most effective way to prevent the spread of communicable disease and to keep from getting sick. For instance, a recent study of 341 children's day care centers revealed that infrequent washing of children's or providers' hands after nose wiping, after diapering, before meals, and before food preparation was clearly associated with a higher frequency of illness.14
Counsel families to wash their hands:
- After sneezing or coughing
- After toileting
- Upon leaving places with high a likelihood of exposure to illness causing germs (doctor's offices, large multi-child use play equipment or pens, day care centers, etc.)
- Upon arriving home
- Before, during, and after preparing food
- Before eating
- After handling animals or animal waste
- More frequently when someone in the home is sick
- And of course, when their hands are dirty
Hand washing can become a fun activity. Again, it is an opportunity to promote the relationship between the caregiver and the infant and toddler. Caregivers may sing to the child and/or have the child sing a 10-15 second song such as "Yankee Doodle" or "Twinkle, Twinkle, Little Star" while washing to assure adequate time is spent at the task. See the Centers for Disease Control and Prevention's National Center for Infectious Diseases web site at www.cdc.gov/ounceofprevention/ for more information on the importance of hand washing.
A daily oral health regimen should begin soon after birth. This regimen should continue throughout life. Begin with washing the gums with a wet cloth prior to teeth appearing and proceed to soft brushing once teeth appear. Important adjuncts include use of fluoride and dental floss. Early childhood dental caries has been reported by the Centers for Disease Control and Prevention to be perhaps the most prevalent infectious disease of our nation's children.15 Yet, it is largely preventable. One of the most effective early healthy oral health habits for prevention of early caries is to never put a child to bed with a bottle containing juice, milk, or other sugary liquid. Recommendations for early oral hygiene include prenatal oral health counseling for parents and oral consultation and evaluation with a dentist within 6 months of the eruption of the first tooth and not later than 1 year of age; these healthy habits should last a lifetime.16
Creating A Safe and Healthy Environment
All children deserve to grow up in safe, non-disease or illness and injury provoking environments. Five specific practices that constitute healthy habits for creating a safe and healthy environment include creating smoke free environments, protection from overexposure to the sun, using protective headgear when indicated, appropriately using car seats and seat belts, and using caution around animals.
Create a Smoke Free Environment
One of the most critical healthy habits benefiting an infant or toddler (and their caregiver) is to create a smoke free environment. That means no tobacco smoking by caregivers or others in the presence of the infant and toddler. The benefits are legion. It is long known that children of smokers have increased respiratory problems. A 2002 review evaluating studies from the mid 1960's to October 2000 on the effects of (early) exposure to environmental tobacco smoke on the respiratory health of children found strong and consistent evidence that exposure in childhood causes chronic respiratory symptoms (e.g., cough, phlegm, and wheezing) and induces asthma in children.17 By not smoking caregivers not only preserve the health of their infants and toddlers, they also promote a healthy habit. In fact, children are less likely to become smokers themselves if they grow up in a home with non-smokers.18
Protection from Overexposure to the Sun
In addition to prevention of potential injury and illness, early attention to prevention of overexposure to sun through the use of sunscreens, hats and use of shade will promote a lifetime of awareness of the risks of overexposure and reduce the risk for developing certain cancers. Approximately 80% of lifetime sun exposure occurs before the age of 18.19 The AAP recommends that infants under 6 months should
be kept out of direct sunlight, use sunscreen when skin is not adequately protected by physical means, and protect the eyes using a hat with a brim.20 While many parents recognize the benefits of sunscreen, they often neglect to employ other "physical" means of sun protection, such as use of shade and brimmed hats.21
This is by no means a prescription to limit time outside for very young children. On the contrary, the point is to make sure caregivers are taking the proper care to protect against over exposure to the sun so that time outside can be prolonged, more enjoyable, and safe.
Appropriately Using Car Seats and Seat Belts
As is the case for nearly all of the early healthy habits, caregivers should practice the adult version of the habit as an example for the young child. With respect to car safety, this includes appropriate use of restraint devises. An important resource for families is the AAP Car Safety Seats: A Guide for Families 2003 . We know that child safety seats reduce the risk of death in passenger cars by about 70% for infants and by about 55% for toddlers ages 1 to 4. For children ages 9 years and older, car seat belts reduce injury risk by about 50%.22 This is one of the best examples of a healthy habit for a lifetime as the reduction in risk associated with the use of appropriate seats and restraints in cars continues throughout the lifetime.
Use of Protective Headgear
From the moment a child is placed in a moving vehicle where there is increased chance of head injury, they should wear a helmet. This includes bike baby carriers, walker runners, etc. The AAP advises that infants younger than 12 months are too young to sit in a rear bike seat and should not be carried on a bicycle, nor should they be carried in backpacks or frontpacks on a bike. Children who are old enough (12 months to 4 years) to sit well unsupported and whose necks are strong enough to support a lightweight helmet may be carried in a child-trailer or rear-mounted seat (http://www.aap.org/family/tippadultbike.htm). Caregivers should be aware that the evidence supporting the use of helmets to prevent head injury is overwhelming. Bicycle helmets have been shown to reduce the risk of head and brain and severe brain injury by as much as 88% for all ages of bicyclists involved in crashes.23 A substantial portion of bicycle-related fatalities among children could be prevented with a bicycle helmet, particularly where there is legislation regarding the use of helmets.24 Most importantly perhaps, they need to know that children are more likely to judge helmet use as important if parents and older siblings also use helmets.25
Safety Around Animals
A momentary lapse in vigilance could lead to a lifetime of regret with respect to injuries due to animals. Children should learn early to have a healthy respect for the beauty, companionship, loyalty and yet potential danger of animals. Derived from the Beginnings Parents Guide26 and the AAP Caring for Your Child Birth to Age 5, Table 1 lists tips for early healthy habits that caregivers should practice and teach to their infant and toddler to protect them for a lifetime.27
Developing an Atmosphere of Sound Mental Health
Sound mental health in an infant and toddler is characterized by what I call a child's social and emotional fitness. A child who is socially and emotionally fit is physically well, confident in their abilities, curious and derives pleasure from finding out about things, desires to have an impact on the environment and those around them, is self-controlled, is able to socially engage others, has the ability and derives pleasure from communicating with others, and is able to cooperate in a group setting. According to Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents the interaction between parent and infant is central to the infant's physical, cognitive, social and emotional development, as well as to his or her self-regulation abilities. The child will build on the secure, trusting relationships established in the first year to develop an emerging sense of self in the toddler years.28
Taking Care of Yourself
Parents want to provide their children with a loving, safe, nurturing home environment. This is difficult at best, however, when parents themselves are not feeling loved, safe or nurtured. An adult caregiver's attention to their own mental health needs is the first step in being able to carefully attune to the mental health needs of their infant or toddler. Healthy habits associated with this include: regular time for relaxation and solitude, regular contact with peers, and being nurtured. These habits should be shared between caregiver and child to prevent stress, promote sound early mental health, and prevent
or relieve stress.
Stress in Infants and Toddlers
Even young infants and toddlers experience stress and have stressors that can be prevented and/or blunted. Some questions you can ask to determine if a child is stressed are: Is she extra fussy, cranky or easily upset? Is she regressing in behaviors? Has she stopped playing with her favorite toys? Does she look away when you talk to her? Does she cover her ears, back up, or try to hide when someone talks loudly? Does she withdraw and become silent? Answering yes to one or more of these questions may indicate that there is too much stress in the child's life. Stress can take many forms: busy schedule, change in routine, change in family, change in diet, illness or injury of the child or other family member. Children can read their parents. They pick up on their stress level and whether they are happy or sad. Stress may be unavoidable, but we can help parents develop healthy responses to stressful situations.
Electronic Media Exposure
The media, from television, computers, hand held games and more bombard today's infant and toddler. In addition, all present a risk for potential easy access to content that is often inappropriate. Furthermore, numerous studies have demonstrated an association between excess television watching and overweight/obesity. Therefore, television should be limited for all members of the household. The American Academy of Pediatrics specifically recommends discouraging "television viewing for children younger than 2 years, and encourage(ing) more interactive activities that will promote proper brain development, such as talking, playing, singing, and reading together."29 There is no substitute for interaction with a live and reacting adult caregiver for learning and developing appropriate social behavior.
Physical Activity and Play
Physical activity and play as healthy habits for a lifetime serve important roles in the health and development of children. Play for infants and toddlers is exercise of the mind and body. During play, children learn patience and persistence, how to focus on what's important and follow directions, to take small steps to work toward larger goals and to work with others.
Play sets the stage for a lifetime of physical activity. This is critical in today's world of increasingly sedentary lifestyles and ever-increasing incidence of obesity. General physical activity is important for babies, toddlers, and preschoolers. Babies and young children are confined too much in their strollers, play pens, and car and infant seats, according to the National Association for Sport and Physical Education (NASPE). This confinement can lead to sedentary habits and childhood obesity, the NASPE warns. In response, the NASPE has released its first physical activity guidelines for infants, toddlers, and preschoolers30 (Table 2). Children who later participate in sports as adolescents were more likely to drink milk and have a healthy self-image, and were less likely to suffer emotional distress, have suicidal behavior, have family substance abuse problems, and suffer physical and sexual abuse.31
Leading by Example
It is the caregivers, in most cases the parents, who set the stage for initiation and promotion of healthy habits in their children. While this article has focused on infancy and toddlerhood, bear in mind that a caregiver's adoption and maintenance of healthy habits starting prenatally (healthy eating, no smoking, adequate exercise) set the stage for continued good health after the baby is born. Most learning occurs through "modeling", in essence, watching another perform a behavior and receive positive reinforcement for doing it. Nutrition researchers, for example, have found that modeling plays a significant role in children's healthy food habits. Mother's own food behaviors (time of eating, types of foods they like or dislike, and the places they choose to eat food in the home) are significantly correlated with their children's eating behaviors.32 Children tend to sample an unfamiliar food more readily when an adult is eating it than when it is merely offered,33 and their food neophobia seems to resemble their parents'.34 Child-care providers also influence young children's food preferences and consumption.35 A caregiver's first challenge in cultivating early healthy habits may be demonstrating the habits themselves. However, as young children become adolescents, the family's ability to influence healthy behavior through modeling gives way to peer modeling.36-40 Therefore it is very important for families to establish healthy habits before their children are subject to the vagaries of peer pressure in adolescence.
Importantly, as a health care provider, you are a role model for healthy habits in your office and in your community. Families that see you actively washing your hands, engaged in physical activity, avoiding tobacco smoke, eating healthy, using bicycle helmets and safety belts, etc., will be further convinced of the utility of these habits in their own lives. Moreover, a recent study found that disclosing your own healthy habits in conversations with parents can enhance a family's motivation for adopting healthy habits themselves.41
Many of the health and safety practices promoted during the infant and toddler years can be viewed as a set of healthy habits that exist on a continuum of healthy habits for a lifetime. Our success in aiding parents in instilling these early healthy habits in infants and toddlers, and promoting the practice of the adult versions of the habits will be reflected in the lifetime well being of the infants, toddlers and families we serve.
Caregivers' responsibility of initiating early healthy habits in and for infants and toddlers can serve as a positive motivator that leads to improved healthy habits of caregivers. In an ideal world, adult caregiver behaviors should reflect the later stages of the continuum of healthy habits started in infancy and toddlerhood.
George L. Askew is the Founder and Executive Director of Docs For Tots, and an Assistant Clinical Professor of Pediatrics at George Washington University School of Medicine in Washington, DC. Dr. Askew has devoted his professional primary care clinical service to low-income children and their families. Prior to launching Docs For Tots, he was a Fellow in the Soros Open Society Institute, Medicine as a Profession, Advocacy Fellowship for Physicians, working with ZERO TO THREE (National Center for Infants, Toddlers, and Families) in Washington, D.C.