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Once the stress of a cancer diagnosis and its intensive treatments have passed, the hope is that life can return to normal. But we know that this is not true for many people who have had treatments for cancer, and sleep is often impacted for a long time after treatment.

Researchers at the American Cancer Society studied responses from 1,903 cancer survivors from across the US. These survivors were diagnosed with cancers such as breast cancer or prostate cancer about nine years before the study. As part of the research, these cancer survivors were asked questions about their sleep and cancer history, and their overall physical, mental, and social health. Even though these men and women had been diagnosed with cancer almost a decade ago, a staggering 51% reported that their sleep had been disturbed over the prior month!

Why do sleep problems continue after cancer?

Findings suggest that the residual effects of cancer may continue to negatively affect a survivor’s sleep. Not surprisingly, poor sleepers were more likely to report that they had more physical and emotional distress. Perhaps more unexpected were results that showed survivors who were sleeping poorly were also more likely to be having some economic hardship, and expressed worries about money and a fear of cancer recurrence.

These are common burdens for cancer survivors. Financially, cancer survivors not only have to shoulder the medical costs associated with their initial treatments, but also ongoing bills from managing the lasting effects of those treatments. Additionally, survivors may have had to change their work situation, or leave their job entirely, in order to manage their health.

Other research has shown that fear of cancer recurrence is common among survivors. Despite having completed their treatments many years prior, people struggle with chronic distress regarding their health and well-being, often at levels equal to that experienced when they were initially diagnosed with cancer.

What can cancer survivors do to improve their sleep?

It is critical that cancer survivors raise the issue with their medical team. There are a number of different sleep disorders that require thorough evaluation and accurate diagnosis. For example, insomnia disorder and obstructive sleep apnea are common among middle-aged and older men and women. If sleep disorders are left untreated, they can lead to a host of negative health outcomes, including cognitive dysfunction, mood disorders, cardiovascular disease, and more.

Medication is a common treatment to help sleep, but it’s not always the best choice, as there are concerns about medication tolerance (needing a larger dose to get the same effect), dependence, and daytime side effects. In the study previously mentioned, 28% of respondents reported using a sleep medication within the past month. While there is certainly a time and a place for medications designed to help with sleep, long-term use is not advised for cancer survivors, especially if the problem is insomnia disorder.

Rather, cognitive behavioral therapy for insomnia (or CBT-I) is recommended as first-line treatment by both the American Academy of Sleep Medicine and the American College of Physicians. Instead of masking the symptom (poor sleep), CBT-I targets the problematic sleep behaviors and thoughts that continue to cause a person to sleep poorly. For example, a patient receiving radiation therapy may be fatigued during the day and take extended naps. During active treatment, this can be helpful. But they may develop a habit of continuing to take naps, which can affect their ability to fall asleep at night. As part of CBT-I, cancer survivors can expect to track their sleep, develop a sleep period that is better aligned with how much sleep they need, learn to avoid problematic sleep behaviors in the bedroom, and change the thoughts that can make it more difficult to fall asleep or stay asleep.

What are the key takeaway messages?

Sleep difficulties are common among cancer survivors, even if they were successfully treated for their cancer years ago. Sleep disorders should be evaluated by a medical provider trained in sleep medicine. There are a number of excellent treatment options that can improve sleep for cancer survivors, such as CBT-I. With increasing virtual access to medical care, telemedicine and online interventions are exciting possibilities for cancer survivors struggling with their sleep.

Topical vitamin C is a science-backed, dermatologist-favorite ingredient that may help slow early skin aging, prevent sun damage, and improve the appearance of wrinkles, dark spots, and acne. Vitamin C is an antioxidant, meaning it fights harmful free radicals (toxins) that come in contact with your skin from external sources like air pollution, or from inside the body as a result of normal processes like your metabolism. Free radicals can damage the skin, and applying topical vitamin C can combat free radicals and may improve the skin’s overall appearance.

Skin benefits of vitamin C

A few clinical studies have demonstrated that vitamin C can improve wrinkles. One study showed that daily use of a vitamin C formulation for at least three months improved the appearance of fine and coarse wrinkles of the face and neck, as well as improved overall skin texture and appearance.

Vitamin C may also help protect the skin from harmful ultraviolet rays when used in combination with a broad-spectrum sunscreen. Clinical studies have shown that combining vitamin C with other topical ingredients, namely ferulic acid and vitamin E, can diminish redness and help protect the skin from long-term damage caused by harmful sun rays.

Further, vitamin C can reduce the appearance of dark spots by blocking the production of pigment in our skin. In clinical trials, the majority of the participants applying topical vitamin C had improvement in their dark spots with very little irritation or side effects, but more studies are needed to confirm the brightening effects of vitamin C.

Additionally, topical vitamin C can help with acne through its anti-inflammatory properties that help control sebum (oil) production within the skin. In clinical trials, twice-daily application of vitamin C reduced acne lesions when compared to placebo. While no serious side effects were reported with vitamin C use in any of these studies, it is important to note that there are only a handful of clinical trials that have studied the effects for vitamin C, and more studies are needed to confirm the findings presented here.

Where to find topical vitamin C and what to look for on the label

Vitamin C can be found in serums or other skincare products. Different formulations of vitamin C can alter its strength and effects in the skin. Consider purchasing vitamin C products from your dermatologist’s office or a verified online retailer, with a clinical formulation that contains an active form of vitamin C (for instance, L-ascorbic acid), has a strength of 10% to 20%, and a pH lower than 3.5, as this combination has been studied in clinical trials. This information can be obtained from the manufacturer’s website under the ingredients section.

Who shouldn’t use Vitamin C products?

Vitamin C has only been studied in adults and is not recommended for children. Always read the ingredient list before purchasing a vitamin C product. If you have sensitivity or a known allergy to any of the ingredients, consider a patch test or consult your doctor before use. If you have acne-prone or oily skin, consider using a formulation that also fights oils, or contains ingredients like salicylic acid that fight breakouts.

How to use topical Vitamin C

During your morning skincare routine

• use a gentle cleanser
• apply a few drops of a vitamin C serum to the face and neck
• apply moisturizer and sunscreen.

You may experience a mild tingling sensation with the use of vitamin C. You may choose to begin applying it every other day, and if tolerated you may apply it daily. It may take up to three months of consistent use to see a noticeable improvement. If you experience substantial discomfort or irritation, please stop using vitamin C and consult with your physician.

Vitamin C does not replace the use of sunscreen or wearing sun-protective clothing. Be sure to use broad-spectrum, tinted sunscreen daily, and limit sun exposure during peak hours.

Follow Dr. Nathan on Twitter @NeeraNathanMD
Follow Dr. Patel on Twitter @PayalPatelMD

The holidays are supposed to be a time of joy and celebration, and the meal is a centerpiece of the occasion. But when you’re a caregiver for an aging parent, the joy can be overshadowed by stress.

Whether you’re observing winter holidays — such as Hanukkah, Christmas, Kwanzaa, or New Year’s Eve — or holidays that fall during another time of year, take steps in advance to ensure that you and your loved one can enjoy the meal together with as little stress as possible. These tips can help.

Consider the dining schedule

Your mom or dad might normally eat at a different time than the planned holiday meal. If the meal times don’t match, give your parent a nutritious snack to stave off hunger, or find out if it’s possible to serve the holiday meal at a time that’s good for your parent. If other festivities are on the docket, consider that timing as well. Your parent likely has a limited amount of energy to spend visiting with others, so allow plenty of time to eat.

Serve your parent easy-to-eat food

Holiday meals often feature special-occasion foods that may be overly rich or hard for your parent to cut, chew, swallow, or keep on a fork or spoon. Talk about this beforehand, if that’s possible. Know which foods your parent should avoid, such as nuts. Serve safer choices in small amounts, and help by cutting up hard-to-eat foods before they come to the table or arrive on a plate.

Another option is serving something simple for your parent to eat that won’t need much supervision and won’t make a mess. Rice or fine pasta with vegetables, pureed beef or fish stew (no bones!), or mashed root vegetables and beans are some examples. If you’re not hosting the holiday event, ask if it’s okay to bring a meal that’s right for your parent.

Remember medicines

If your parent normally takes prescribed drugs at meals, don’t let this holiday be a time to get off schedule. Go over the medication list in advance and set a timer on your phone to remind you of dosing times.

Work in shifts with other guests

Have a conversation ahead of time with other guests who can help. When assisting a parent during a meal, you may not get much of a chance to eat your own food or chat with people at the table. Build in a break by arranging for another guest (perhaps a sibling) to take a turn helping out.

Plan the bathroom break

When you have to go, you have to go. And aging parents, like young children, sometimes need to excuse themselves mid-bite. A bathroom trip before the meal might reduce that risk, but it’s no guarantee. Work out in advance who’s going to assist your parent if nature’s call arrives during the meal.

Keep fluids handy

Make sure your parent is staying hydrated and getting enough fluids before, during, and after the meal. Also, keep an extra glass of water handy, and a straw if necessary, in case your parent is having a hard time swallowing food. Note also that moistened food is easier to swallow, so consider adding a little extra sauce to a parent’s meal.

Watch alcohol intake

While alcohol may be offered at the holiday meal, it doesn’t mean it will be safe for your parent. Alcohol consumption can lead to falls in older adults, and can interfere with medications. Ask your parent’s doctor if a little libation is allowed. such as a half-glass of wine. If not, consider offering your parent non-alcoholic beer, wine, or champagne if they’d like it. And mind your own alcohol intake: while you’re acting as a caregiver you’ll need to stay in control.

Arrange your parent’s exit well in advance

Gatherings can be tiring and stressful for older adults, and your parent might be ready to leave before the holiday meal officially concludes, especially if guests linger. Decide on a realistic exit time and let other guests know about it in advance, so everyone can plan accordingly.

If all goes well, you and your parent will both enjoy the holiday meal and wind up feeling the glow of meaningful family connection, sharing, and love — all of which are great for health.

For years, products containing acetaminophen, such as the pain reliever Tylenol, were largely viewed as safe to take during pregnancy. Hundreds of widely available over-the-counter remedies, including popular cold, cough, and flu products, contain acetaminophen. Not surprisingly, some 65% of women in the US report taking it during pregnancy to relieve a headache or to ease an aching back.

But recently, a group of doctors and scientists issued a consensus statement in Nature Reviews Endocrinology urging increased caution around acetaminophen use in pregnancy. They noted growing evidence of its potential to interfere with fetal development, possibly leaving lingering effects on the brain, reproductive and urinary systems, and genital development. And while the issue they raise is important, it’s worth noting that the concerns come from studies done in animals and human observational studies. These types of studies cannot prove that acetaminophen is the actual cause of any of these problems.

An endocrine disruptor

Acetaminophen is known to be an endocrine disruptor. That means it can interfere with chemicals and hormones involved in healthy growth, possibly throwing it off track.

According to the consensus statement, some research suggests that exposure to acetaminophen during pregnancy — particularly high doses or frequent use — potentially increases risk for early puberty in girls, or male fertility problems such as low sperm count. It is also associated with other issues such as undescended testicles, or a birth defect called hypospadias where the opening in the tip of the penis is not in the right place. It might play a role in attention deficit disorder and negatively affect IQ.

Risks for ill effects are low

If you took acetaminophen during a current or past pregnancy, this might sound pretty scary — especially since you’ve probably always considered this medicine harmless. But while experts agree it’s important to consider potential risks when taking any over-the-counter or prescription medicines during pregnancy, you shouldn’t panic.

“The risk for an individual is low,” says Dr. Kathryn M. Rexrode, chief of the Division of Women’s Health, Department of Medicine at Harvard-affiliated Brigham and Women’s Hospital.

Chances are pretty good that if you took acetaminophen during a pregnancy, your baby likely did not, or will not, suffer any ill effects.

The research on this topic is not conclusive. Some information used to inform the consensus statement was gathered from studies on animals, or human studies with significant limitations. More research is needed to confirm that this medicine is truly causing health problems, and to determine at what doses, and at what points during a pregnancy, exposure to acetaminophen might be most harmful.

Sensible steps if you’re pregnant

Three common-sense steps can help protect you and your baby until more is known on this topic:

• Avoid acetaminophen during pregnancy when possible. Previously during preconception and pregnancy counseling, Dr. Rexrode had warned patients against using NSAID drugs, such as Advil and Aleve, and suggested taking acetaminophen instead. “Now I also tell people that some concerns have been raised about acetaminophen use during pregnancy, and explain that its use should be limited to situations where it is really needed,” says Dr. Rexrode. In short, always consider whether you really need it before you swallow a pill.
• Consult with your doctor. Always clear acetaminophen use with your doctor, particularly if you are going to be using the medicine for a long period of time. They might agree that taking it is the best option — or suggest a safer alternative.
• Minimize use. If you do need to take acetaminophen during pregnancy, take it for the shortest amount of time possible and at the lowest effective dose to reduce fetal exposure. “This advice about the lowest necessary dose for the shortest period of time is generally good counseling for all over-the-counter medication use, especially during pregnancy,” says Dr. Rexrode.

While all of this is good advice for using acetaminophen, there are times when it’s riskier not to take it. For example, if you have a high fever during pregnancy — which can harm your baby — acetaminophen may be needed to bring your fever down. Provided it’s advised by your doctor, the benefits of acetaminophen use in this case outweigh the potential risks.

In all aspects of our lives, we rely on experts, from home repairs to weather forecasting to food safety, and just about everything else that’s part of modern society. There’s just no way to know everything about everything. Yet when it comes to medicine, people seem to be taking their health in their hands in ways they’d never consider if, say, their car brakes needed repairs and they weren’t auto mechanics.

What if your brakes were shot?

Suppose a well-recommended car mechanic tells you your brakes need repair. Hopefully, they explain why this is necessary and review the pros and cons of your options, including no repairs. You certainly could get additional opinions and estimates. But to make a decision, you’d have to accept that a mechanic has specialized knowledge and that their advice is sound. Quite likely, you’d get the brakes fixed rather than risk injury.

Would you berate the mechanic personally because they told you something you didn’t want to hear about your beloved car? Let's hope not. And unless you knew a lot about cars, you probably wouldn’t tinker with the brakes yourself, or take the advice of a neighbor to spray the tires with vegetable oil because a friend of his cousin said it worked for his car. And you wouldn’t take your car to a veterinarian — it just wouldn’t make sense, right?

Yet hundreds of thousands of people in the US are rejecting advice on getting a COVID vaccine from well-respected health authorities like the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA). Healthcare providers have somehow become the target of taunts, hostility, and even death threats for encouraging people to protect themselves and others.

Fear of the proven and an embrace of the unproven

What’s driving this? It seems to be some combination of distrust ("these so-called experts don’t know what they’re talking about"; "they rushed the vaccines just to help the drug companies") and unfounded suspicion ("they’re trying to control us, experiment on us, inject microchips in us"). Some people see recommendations regarding COVID-19 as attacks on American values ("mask and vaccine mandates infringe on my personal freedom").

At the same time, many who dismiss the advice of true experts are embracing unproven and potentially dangerous remedies, such as ivermectin pills and betadine gargles.

How did we get here?

Some reasons we’ve seen erosion in trust placed in public health experts are

• Politics. COVID-19 quickly became a political issue in the US. For example, trust in the CDC varies markedly by political affiliation, with Democrats giving much higher marks to the CDC, FDA, and NIH than Republicans.
• Social media. Misinformation spread through social media is rampant, and much of it has been linked to a small number of people.
• "Pseudo-experts." Even impressive credentials don’t automatically qualify everyone to be experts in a pandemic disease. Recent examples include radiologists, cardiologists, and chiropractors who have made headlines with their controversial views.
• Personal gain. Some have profited financially, politically, or otherwise by deliberately spreading health disinformation and denouncing expert advice.

Confusing changes in message

Public health messaging about protecting ourselves from COVID-19 also affects trust. For example, recommendations around wearing masks were inconsistent early on, and have continued to change since then.

While some confusing, seemingly contradictory messages were true missteps, most are simply changes in recommendations based on a change in circumstances, such as spiking virus cases or a more easily spread variant causing severe illness, hospitalizations, and deaths.

Particularly in the early months, no one had all the answers. But as we have accumulated information from research and real-world experience, changes in recommendations should not only be expected but embraced. It’s usually a reflection of the close attention experts are paying to changing circumstances.

Doing your own research?

A wait-and-see policy can be risky — and not just when it comes to fixing your car brakes. The virus that causes COVID-19 was only discovered 18 months ago, and vaccines have been in use for less than a year. Yet already we have an enormous amount of data from research and real-world experience from many millions of people.

So, when someone says they want to "wait and see" or "do their own research" rather than accept the advice of their own doctors or public health experts, what exactly does that mean? Are they waiting to see if something bad will happen to those who were vaccinated? How long is long enough?

Unless you’re a cutting-edge virologist, immunologist, epidemiologist, or public health expert, doing your own research isn’t likely to provide more reliable data than studies published in peer-reviewed medical journals that guide the CDC and FDA. Of course, most people "doing their own research" are relying on others who are also not doing actual research, yet they discount the findings and recommendations of true experts.

It’s important to ask questions. But pose them to your doctor. Rely less on people who tell you what you want to hear, and more on those who trained in science and whose careers have been devoted to improving health.

Each time a wave of COVID-19 engulfs a community, overwhelmed hospitals wind up postponing elective surgeries. The schedule changes are needed to make room for COVID patients, allow all hands on deck for crisis care, and shield people in the community from unnecessary COVID exposure. This scenario may grow worse if the flu season isn’t mild this year –– a good reason to get that flu shot!

Postponement of an elective surgery is upsetting, and automatically presents you with two dilemmas:

• You’ll have to cope with your ailment while you wait for the all-clear.
• You’ll have to be prepared for your surgery when you get the call that’s it’s back on.

Read on for steps you can take to cope with both situations.

First, what’s considered elective surgery?

All surgical procedures involve cutting skin and tissue using a variety of tools and techniques. But unlike heart surgery done in response to blocked arteries, elective surgery is not an emergency. It’s a procedure that can be safely scheduled in advance. That’s not to say it isn’t important.

An elective surgery could be

• major, such as a hip or knee replacement, or surgery to repair a prolapsed (fallen) uterus
• minor, such as surgery to relieve carpal tunnel syndrome (an entrapped nerve in the wrist), or surgery to remove a cataract (cloudy lens) in the eye.

The determination of whether surgery is elective isn’t always clear-cut. Sometimes it depends on your health circumstances. For example, surgery to replace a heart valve might or might not be an emergency, depending on the person’s condition.

Coping while you wait for elective surgery

Waiting for your surgery has potential consequences. Maybe you won’t be able to work, or maybe your condition, pain, or anxiety about the situation — or all three — will get worse.

While you’re in limbo, here are four steps you can take:

• Keep lines of communication open with your health care providers. That could mean having important phone numbers for your physician on hand, or logging onto your patient portal and emailing your doctor or nurse. Ask your doctor how often you should check in. 
• Report changes in symptoms. When you scheduled your surgery, your condition wasn’t life-threatening. But things can change. Don’t wait until you experience an emergency; report symptom changes as soon as you notice them.
• Get prescriptions refilled. You don’t want to be without medications when you need them, especially if you’ll need your doctor to sign off on refills.
• Arrange for additional help. Perhaps a friend or family member can assist you with grocery shopping, meal preparation, housekeeping, or getting through daily activities. If you can afford it, consider hiring someone to assist you temporarily. Prices average about $25 per hour in the US, with a minimum of several hours per week.

When surgery is back on schedule

Eventually, you’ll get the call that your surgery is a go. That doesn’t mean it will occur soon. Most likely there will be a backlog of postponed surgeries, which may add more time to your wait. Prepare for the possibility that you’ll need to extend the arrangements that have been getting you through your waiting period.

It’s equally wise to prepare for the chance that your surgery will happen with little notice. Alert friends, family members, or your private-duty care agency about this possibility, so they can arrange to jump in to help when you need them.

And make sure you have the answers to these questions ready well in advance:

• How will you get to and from surgery? (Will you count on a friend, a ride service, or a hired health aide?) 
• How will you obtain medications prescribed after surgery?
• Which equipment (if any) will you need after your surgery? For example, if you’re going to have a joint replacement, you’ll need a walker and shower chair afterward. See if you can arrange to get it now, so you’ll have it ready.

It may not be easy dealing with your condition until your surgery takes place, but at least you’ll have both a plan A and a plan B. That preparation may give you a little peace of mind and a feeling of some control over your situation.

As the holiday season approaches, there’s a lot to keep in mind. Let’s just start with the easy questions: Who’s hosting Thanksgiving? Who’s making the turkey? The stuffing? Dessert?

But as we embark on our second round of holidays during the COVID-19 pandemic, we all have additional questions and decisions to make about how to keep everyone safe:

• Inside or outside? While outside is safer, it may be too cold where you are to consider dining outdoors.
• Is it necessary to wear masks or keep a physical distance? That depends on everyone’s vaccination status, recent exposures, and risk tolerance.
• Must everyone be vaccinated? For many, this one’s a dealbreaker. Some hosts may insist. And some family and friends may come only if everyone is vaccinated.

The role of COVID testing could be changing

We know a lot more about testing for COVID-19 than at this time last year:

• PCR tests. This is still the most accurate test of current infection. It detects small amounts of genetic material from the virus that causes COVID-19. But it often takes days to get the result back.
• Rapid tests. This is typically an antigen test. It detects small bits of viral protein using similar technology to that used in pregnancy tests. An advantage of this type of testing is that the results are back in minutes. And while these tests have a higher rate of false negatives than a PCR test, getting a negative result strongly suggests you aren’t contagious. Even if you are infected, a negative result suggests there’s too little virus to infect others, at least at the time of the test. So, rapid COVID tests could be used as a way to screen people just before an activity during which exposure is possible — like Thanksgiving or other holiday gatherings.

One approach is to offer testing for each person as they arrive. It might slow the reunion process down a bit, but only for a few minutes. If a visiting friend or family member tests positive, they should leave along with anyone else they might have already exposed. The next step for them would to be to quarantine while waiting for results from a PCR test.

Cost, availability, and other limits of rapid testing before gatherings

While rapid testing may be a useful way to reduce your risk as holiday gatherings approach, it’s not perfect. Cost per test is high, generally $10 to $40 in the US. That’s especially hard for people with limited resources and those at higher risk for infection and complications from COVID-19. Rapid tests may be hard to find, too, although the Biden administration has vowed to address lack of availability by pledging several billion dollars to expand rapid testing. The health department in your community may be able to help you find test sites.

The FDA has given emergency use authorization to nearly 40 different tests, and research suggests that different brands vary widely in their accuracy. Currently, there are no specific recommendations from experts about which rapid test is best.

Additionally:

• Results only apply to the time that the test is performed. You could have a negative test today despite being infected and a positive test tomorrow. These false-negative results may occur because it’s so early in the infection that there isn’t much viral protein present. Or it could be because of how the sample was obtained — maybe the swab wasn’t inserted deeply enough into the nose or wasn’t twirled around for long enough. Repeated testing can be helpful to address the concern of false-negative results; in fact, some tests specifically recommend repeat testing within a few days.
• False-positive results may occur. A test may indicate infection when no such infection is present. It’s what happened on a now-infamous episode of The View. Two hosts quickly exited the set during a live broadcast because their COVID tests were positive. Soon after, their results were declared incorrect after further testing was done. Although false-positive results should be quite rare, manufacturing problems may make them more likely. In fact, some tests have been recalled because of an unexpectedly high rate of false-positive results.
• Be prepared to download an app and follow instructions carefully. Rapid tests for COVID-19 typically require you to download an app and connect your phone or computer to the testing device through the app. Then you need to use a swab to collect a sample from inside your nose, apply the swab to the chemicals from the kit, and wait 15 minutes or so for your device to tell you the result. It’s not a particularly intuitive or consumer-friendly process. Many people may find it challenging.

The bottom line

Despite its limitations, rapid testing for COVID-19 is a strategy worth considering for holiday gatherings or group activities during which exposure to the virus is possible. Ideally, simplified rapid testing will become readily available at low (or no) cost soon. So, think about putting rapid COVID testing on your holiday to-do list, and consider offering tests to guests before you sit down for the turkey. It doesn’t take long, and the turkey probably won’t be ready on time anyway.

All parents want their children to be successful in life — and by successful, we mean not just having a good job and a good income, but also being happy. And all parents wonder how they can make that happen.

According to Harvard’s Center on the Developing Child, it’s less about grades and extracurricular activities, and more about a core set of skills that help children navigate life’s challenges as they grow. These skills all fall under what we call executive function skills that we use for self-regulation. Developing strong executive function skills, and finding ways to strengthen those skills, can help people feel successful and happy in life.

What are five important core skills?

• Planning: being able to make and carry out concrete goals and plans
• Focus: the ability to concentrate on what’s important at a given time
• Self-control: controlling how we respond to not just our emotions but stressful situations
• Awareness: not just noticing the people and situations around us, but also understanding how we fit in
• Flexibility: the ability to adapt to changing situations.

While these are skills that children (and adults) can and do learn throughout their lifetimes, there are two time periods that are particularly important: early childhood (ages 3 to 5) and adolescence/early adulthood (ages 13 to 26). During these windows of opportunity, learning and using these skills can help set children up for success. In this post, we’ll talk about that first window of early childhood.

The best way to learn any skill is by practicing — and we are all more likely to want to practice something if it is fun and we feel motivated. Here are some ways that parents can help their children learn and strengthen executive function skills.

Planning

It’s natural for parents and caregivers to do the planning for young children, but there are absolutely ways to get them involved, such as:

• Planning the day’s activities with them, whether it be a school day or a play day. Talk about all the day’s tasks, including meals, dressing, bathing, and other things; help them see it as part of a whole, and something that they can help manage.
• Cook or bake something together. Put together the shopping list, go shopping, go over the recipe together, and help them understand all the steps.
• When getting ready for a holiday or a party, include them in thinking about what everyone would like to do and how to do it.

Focus

The explosion of device use has definitely caused all sorts of problems with focus in both children and adults. There is an instant gratification to screens that makes it hard to put them aside and focus on less stimulating tasks. Now, more than ever, it’s important to:

• Enforce screen-free time, even if they complain (parents need to abide by this too).
• Have the materials on hand to make or build things. Find projects that will take an hour or two. Do it with them!
• Read print books out loud together, including chapter books. Having to picture things themselves rather than seeing it on a screen helps children learn to focus.

Self-control

This is one where being mindful of your own reactions to situations is important. How do you react to anger and frustration? Is road rage a problem for you? Remember that children always pay more attention to what we do than what we say. To help your child learn self-control, you can:

• Talk about feelings, and about strategies for managing strong emotions — like taking a deep breath, stepping away from the situation, screaming into a pillow, etc.
• Help them understand how their behavior affects others, and why it’s important to be mindful of that (which also teaches awareness).
• Debrief after tantrums or upsets. What could everyone have done differently?

Awareness

This one can be fun to teach.

• Go for walks. Visit places together. Listen and watch. Imagine together what people might be doing or thinking.
• Join community service activities; show children that anyone can make a difference.
• Have rituals of checking in as a family, like at dinner. Give people a chance to talk about the best and worst parts of their day, and talk about ways you can work better as a family and treat each other well.

Flexibility

We tend to cater to our children and their needs, making our schedules and plans around them. Some of that is pure parenting survival. But ultimately, it’s not always helpful; life has a way of messing up even the most careful plans. Kids need structure, sure, but they also need to be able to adjust to the inevitable curve balls.

• Don’t always say no to something that might happen during a naptime or mealtime. It’s okay if schedules occasionally vary.
• Be spontaneous when you can. Go for an unplanned outing, and otherwise make last-minute plans sometimes.
• When plans change or fall through, be upbeat about it and make the most of it. Be a role model.

In helping your children learn these skills, you might just learn something about yourself — and learn some new skills too.

Follow me on Twitter @drClaire

Lately it seems like everywhere I look, someone is vaping as they walk by, stand outside a store, or roll up in the car next to me at a stoplight. It’s not surprising: e-cigarette use, or vaping, has become remarkably popular in recent years. About 6% of adults in the US now report vaping. That’s about 15 million people, double the number from just three years ago. Of course, regular cigarettes are known to cause cancer and a host of other health problems.

While considered less harmful than smoking tobacco, vaping isn’t risk-free. We know some, but not all, of its risks. We also know vaping is increasingly popular among teens and young adults, and this makes the recent FDA announcement authorizing sales of three additional vaping products surprising.

A surprise announcement from the FDA

In its announcement, the FDA authorized the R. J. Reynolds Vapor Company to market and sell its Vuse Solo device with tobacco-flavored vaping liquid to adults.

The FDA denied marketing authorization for 10 flavored products made by the same company. It also reports having denied more than a million flavored vaping products from other companies.

By the way, the agency emphasizes it is not actually approving these vaping products, or declaring them safe. The announcement states that marketing authorization will be reversed if

• the company directs advertising to younger audiences
• there is evidence of “significant” new use by teens or by people who did not previously smoke cigarettes
• R. J. Reynolds does not comply with extensive monitoring requirements.

Why did the FDA take this action?

The decision was reportedly based on data from the company — unfortunately not provided in the press release — demonstrating these products would benefit individuals and public health. How? By helping smokers quit.

Some studies have suggested that e-cigarette use can be modestly helpful for smokers trying to quit. For example, an analysis of 61 studies found that e-cigarette use was more effective than other approaches to quitting smoking. The study authors estimated that out of every 100 people who tried to quit smoking by vaping, nine to 14 might be successful. When only using other methods, such as nicotine patches or behavioral counselling, only four to seven smokers out of 100 might quit. A separate study suggests vaping may help smokers who aren’t able to quit reduce the number of cigarettes smoked per day — at least for six months, the duration of the study.

Does vaping harm health less than smoking cigarettes?

Despite claims that vaping is less harmful than smoking cigarettes and that it might help smokers quit, concern about its risks is well deserved.

• Nicotine addiction. Whether in cigarettes or vapes, nicotine is highly addictive. And the amount of nicotine in many vaping products is much higher than in regular cigarettes. Side effects include reduced appetite, increased heart rate and blood pressure, nausea, and diarrhea.
• Harm to lungs and heart. Vapors from e-cigarettes may contain cancer-causing toxins, metals, and lung irritants. Vaping raises risk for lung diseases, such as emphysema, asthma, chronic bronchitis, and chronic obstructive pulmonary disease. It’s also linked to an increased risk of heart attacks. Even secondhand exposure to e-cigarette vapors may trigger asthma.
• Severe, potentially fatal lung injury. In 2019, doctors began seeing people who had recently vaped and developed shortness of breath, cough, fever, and extensive lung damage. Dubbed EVALI (e-cigarette or vaping product use-associated lung injury), more than 2,800 cases and 68 deaths were reported. The condition has been linked to vapors containing THC and a form of vitamin E (called vitamin E acetate) used as a thickening agent when vaping THC. Cases have fallen markedly since 2020. Possibly because of falling case numbers, the FDA announcement of new vaping products didn’t even mention EVALI, which seems odd. If you do vape, see these recommendations to reduce the risk of EVALI.
• Health risks during pregnancy. Nicotine can damage a baby’s developing brain and lungs; some flavorings may be harmful as well. As a result, experts recommend that people who are pregnant not vape.

For teens and children, vaping has additional risks

An alarming number of middle-school and high-school age kids report vaping, despite the nationwide prohibition against selling e-cigarette products to anyone under age 18 (21 in some states). Its popularity is partly related to the marketing of flavors known to appeal to minors, such as bubblegum and berry-flavored products. According to one national survey, approximately 85% of teen vaping involved non-tobacco flavored products.

It’s important to know that

• nicotine negatively affects the developing brain
• the high exposure to nicotine and other toxic chemicals through vaping may be particularly harmful to kids because of their smaller body size
• the addictive potential of nicotine may mean that kids who vape are more likely to become cigarette smokers.

The bottom line

For nonsmokers and teens, there is no controversy: don’t start smoking and don’t vape.

If you’re an adult smoker trying to quit, be aware that the balance of risks and benefits and the long-term health consequences of vaping are uncertain. We need more solid research to help people make decisions. Meanwhile, the FDA has come down on the side of a limited authorization to help adult smokers quit. We’ll know only in retrospect if that was the right move.

If a screening test for prostate cancer produces an abnormal result, the next step is typically a biopsy. In the United States, this is almost always done by threading a biopsy needle into the prostate through the rectum. By watching on an ultrasound machine, doctors can see where the needle is going. Called a transrectal ultrasound (TRUS) biopsy, this procedure comes with a small but growing risk of infections that are in turn increasingly resistant to current antibiotics.

To minimize infection risk, doctors can also thread the biopsy needle through a patch of skin between the anus and scrotum called the perineum, thus bypassing rectal bacteria. These so-called transperineal (TP) biopsies offer a further advantage in that they provide better access to the tip (or apex) of the prostate, which is where 30% of cancers occur. However, they are also more painful for the patient. Until recently, they were done only in hospital operating rooms under general anesthesia.

Today, technical advances are making it possible for doctors to perform TP biopsies under local anesthesia in their own offices. And with this development, pressure to limit infections by adopting this approach is growing.

During a recent study, Harvard scientists looked at how the two methods compare in terms of cancer detection and complication rates. In all, 260 men were included in the study, each closely matched in terms of age, race, prostate-specific antigen levels, and other diagnostic findings. Half the men got TRUS biopsies and the other half got TP biopsies, and all the procedures were performed at a single medical practice between 2014 and 2020. Per standard clinical protocols, all the men in the TRUS group took prophylactic antibiotics to prepare. By contrast, just 43% of men in the TP group took antibiotics, in accordance with physician preferences.

Results showed minimal differences in the cancer detection rate, which was 62% in the TP group and 74% among men who got TRUS biopsies. But importantly, 15% of men with cancer in the TP group had apex tumors that the TRUS biopsies "may have missed," the study authors wrote.

More complications with the TP approach

As far as complications go, one man in the TRUS group developed an infection that was treated with multiple rounds of oral antibiotics. None of the TP-biopsied men got an infection, but eight of them had other complications: one had urinary blood clots that were treated in the hospital, two were catheterized for acute urinary retention, three were medically evaluated for dizziness, and two had temporary swelling of the scrotum.

Why were the TP noninfectious complication rates higher? That's not entirely clear. For various reasons, doctors wound up taking more prostate samples (called cores) on average from men in the TP group than they did from men in the TRUS group. The authors suggest if an equivalent number of cores had been taken from men in either group, then the complication rates might have been more similar. (In fact, larger comparative studies performed in hospital-based settings show no difference in complication rates when equal numbers of cores are obtained). But doctors in the current study also had more experience with TRUS biopsies, and that might also explain the discrepancy, the authors suggest. And as doctors in general become experienced with the TP method, complication rates might fall.

In an editorial comment, Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, acknowledged positive findings from the study, particularly a reduced need for antibiotics with the TP method, and the discovery of apex tumors TRUS biopsies could have missed. Garnick also highlighted a "steep learning curve" with TP biopsies, and how some of the noninfectious complications required hospital-based care. "The ability to perform TP biopsies in an office setting should enable future comparisons with TRUS to help answer whether this new TP technology has enduring value," he wrote.