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A previous study of a reading aloud intervention in Brazil, called Universidade do Bebê (UBB), demonstrated impacts on parenting and child outcomes for families with toddlers and preschoolers, even for parents with low literacy, and cognitive stimulation mediated effects on child outcomes. In a new study, we sought to determine whether similar results would be found when UBB was provided beginning in pregnancy through early toddlerhood, including (1) impacts on parenting and child development, (2) variation in impact on parenting and child outcomes by parent literacy level, and (3) indirect impacts on child outcomes through cognitive stimulation.Women with low income who were either pregnant or with children aged 0 to 24 months were randomized to UBB or control groups. UBB consisted of monthly workshops focused on reading aloud complemented by a book-lending library. Participants were evaluated at baseline and approximately 11 months later (M = 11.0, SD = 0.4; range 9.9-12.2 months) on parenting (cognitive stimulation, beliefs about early reading, screen time, and discipline) and child development.Four hundred families (n = 200 UBB) were randomized; 286 (71.5%; n = 150 UBB) received 11-month follow-up. UBB families showed increased cognitive stimulation (Cohen's d = 0.92) and awareness about the importance of early reading ( d = 0.90) than controls, with no differences by parent literacy level. UBB was associated with reduced screen time and increased vocabulary, but only for families with low parent literacy. UBB effects on child outcomes were mediated by cognitive stimulation.The findings support implementation of reading aloud programs beginning in pregnancy and early childhood.

Poverty-related disparities appear early in life in cognitive, language, and social-emotional development, and in growth, especially obesity, and have long-term consequences across the life course. It is essential to develop effective strategies to promote healthy behaviors in pregnancy and the early years of parenthood that can mitigate disparities. Primary preventive interventions within the pediatric primary care setting offer universal access, high engagement, and population-level impact at low cost. While many families in poverty or with low income would benefit from preventive services related to both development and growth, most successful interventions have tended to focus on only one of these domains. In this manuscript, we suggest that it may be possible to address both development and growth simultaneously and effectively. In particular, current theoretical models suggest alignment in mechanisms by which poverty can create barriers to parent-child early relational health (i.e., parenting practices, creating structure, and parent-child relationship quality), constituting a final common pathway for both domains. Based on these models and related empirical data, we propose a strength-based, whole child approach to target common antecedents through positive parenting and prevent disparities in both development and growth; we believe this approach has the potential to transform policy and practice. Achieving these goals will require new payment systems that make scaling of primary prevention in health care feasible, research funding to assess efficacy/effectiveness and inform implementation, and collaboration among early childhood stakeholders, including clinicians across specialties, scientists across academic disciplines, and policy makers.

To determine feasibility and explore effects of literacy promotion using e-books versus board books on the home reading environment, book reading, television use, and child development.Randomized controlled trial comparing digital literacy promotion (DLP) using e-books to standard literacy promotion (SLP) using board books among Medicaid-eligible infants. DLP participants received e-books on home digital devices, while SLP participants received board books at well visits between 6 and 12 months of age. Differences in StimQ Read Subscale (StimQ-Read) scores, parent-reported reading and television use, and Bayley Scales of Infant Development-3rd Edition (Bayley-3) scores between groups were assessed using intention-to-treat analysis.A total of 104 Medicaid-eligible infants were enrolled and randomized from 3 pediatric practices. There were no differences in sociodemographic characteristics between groups at baseline. Children in the DLP group initially had lower StimQ-Read scores but showed similar increases in StimQ-Read scores over time as children in the SLP group. Parents in the DLP group reported greater use of digital devices to read or engage their child (65% vs 23%, P.001) but similar board book reading and television viewing. There were no differences between groups in cognitive or motor scale scores, but DLP participants had marginally lower language scales scores (DLP 85.7 vs SLP 89.7; P = .10) at the 6-month follow-up.Literacy promotion using e-books was feasible and associated with greater e-book usage but no difference in board book reading, television viewing, or home reading environment scores. A potential adverse impact of e-books on language development should be confirmed in future study.

OBJECTIVE: To determine the effect of adding a video and text messages to Reach Out and Read (ROR) on parent-reported literacy activities compared to the standard version. STUDY DESIGN: We conducted a mixed methods hybrid type I effectiveness-implementation randomized trial in a community health center that serves low-income Latino families. We assessed shared reading frequency and the StimQ Reading subscale, at enrollment and 6-month follow up and the StimQ Parent Verbal Responsivity subscale, Parent Reading Belief Inventory, and Survey of Wellbeing of Young Children-Milestones at follow up. We randomized 160 parent-child dyads to ROR or ROR plus video and text messages (enhanced ROR). We collected process data on ROR and engagement with texts. We interviewed 15 enhanced ROR participants. We analyzed quantitative data using regression and qualitative data using immersion/crystallization. RESULTS: 137 parent-child dyads completed the study (87% Latino, mean child age 9 months). We found differences in the StimQ Reading subscale (B=0.32; p=0.034) and marginal differences in attitudes about reading favoring enhanced ROR. Between-group differences for shared reading frequency, verbal responsivity, and developmental delay were not significant. Qualitative themes provided insight into the enhanced ROR including how it encouraged parents, remaining barriers like competing priorities and lack of social support, and unanticipated benefits (i.e., parent appreciation for attention on their families’ wellbeing). CONCLUSIONS: A video and text message enhancement to ROR resulted in modest improvements in the home literacy environment over ROR alone. Additional strategies are needed to overcome potent barriers faced by low-income families. TRIAL REGISTRATION: ClinicalTrials.gov NCT03242850

To examine whether (1) a parent-child reading program (Universidade do Bebê [UBB]), conducted in Brazil pre-pandemic can support parenting and parent-child reading 6 months into the pandemic, (2) cognitive stimulation at pandemic onset mediates effects of UBB on these outcomes, and (3) UBB pre-pandemic buffers associations between COVID-19-related distress and parenting/parent-child reading 6 months into the pandemic.400 women, either pregnant or with children 0-24 months, were randomized to UBB (n = 200) or control groups. UBB consisted of monthly parent workshops focusing on parent-child reading and a book-lending library. Assessments pre-pandemic (June-2019) and at pandemic onset (April-2020) included cognitive stimulation. Assessments 6 months into the pandemic (October-2020) included COVID-19 exposure/impact/distress, as well as parenting and parent-child reading.133 families (n = 69 UBB) contributed data 6 months into the pandemic. Participation in UBB pre-pandemic was associated with parent-child reading but not parenting 6 months into the pandemic. Indirect effects of UBB through cognitive stimulation at pandemic onset were observed for both outcomes. Increased COVID-19-related distress was significantly associated with reduced parenting/parent-child reading 6 months into the pandemic in the control group only.Promotion of cognitive stimulation pre-pandemic may have reduced risk for effects of the pandemic on parenting/parent-child reading.The trial has been registered with the Brazilian Clinical Trials Registry RBR-29RZDH on 05/28/2018.This is the first study showing sustained impacts of a reading aloud intervention beginning in pregnancy and early infancy implemented pre-pandemic. Findings suggest that participation in a reading-aloud intervention buffered associations between COVID-19 distress and parenting/parent-child reading 6 months into the pandemic. Novel empirical evidence suggests that promotion of cognitive stimulation prior to the pandemic may buffer its impacts on parenting and parent-child book reading following onset in low- and middle-income countries. Findings provide important new support for implementation of parent-child reading aloud programs and likely have implications for early childhood development beyond the COVID-19 pandemic for disasters generally.

Objectives In this study, we examined (1) whether a reading aloud intervention, Universidade do Bebe (UBB), had impacts on self-regulation; (2) whether effects on child outcomes were mediated by self-regulation; and (3) whether effects of UBB were explained through a sequential pathway of impact, including cognitive stimulation in the home, parent-child interactive reading, and self-regulation. Methods We performed a cluster randomized controlled trial of UBB in child care centers serving low-income children (mean age 37.4 months; SD = 6.5) in Northern Brazil. The child care centers were randomized to receive UBB or standard care (control). Families in UBB could borrow children's books weekly and participate in monthly workshops focused on reading aloud. Parent-child dyads (n = 484, intervention = 232, control = 252) were evaluated at baseline and 9 months later on: child self-regulation, vocabulary, intelligence quotient (IQ), working memory, and phonological memory and measures of cognitive stimulation in the home and parent-child interactive reading. Multilevel analyses accounted for baseline performance, sociodemographics, and clustering within centers and sites. Results The UBB group showed significantly higher self-regulation (Cohen's d = 0.25), compared with the control group, particularly in the subdomains of Attention (d = 0.24) and Impulse Control (d = 0.21). Previously shown impacts of UBB on receptive vocabulary, IQ, and working memory were mediated by self-regulation. Effects of UBB on self-regulation and child outcomes were partially explained through cognitive stimulation in the home and parent-child interactive reading. Conclusion Self-regulation represents an important mechanism by which reading aloud interventions affect language and cognitive outcomes. Investigators should consider the role of self-regulation when refining interventions, seeking to prevent poverty-related disparities.

Poverty remains a critical predictor of children’s school readiness, health and longer term outcomes. Early relational health (ERH) (i.e., parenting practices and relationship quality) mediates the impact of poverty on child development, and thus has been the focus of many parenting interventions. Despite the documented efficacy of parenting interventions at reducing poverty-related disparities in child health and development, several key barriers prevent achieving population-level reach to families with young children. In the current paper we highlight several of these barriers including gaining population-level access to young children and families, reaching families only through single points of access, addressing the significant heterogeneity of risk that exists among families living in poverty, as well as addressing each of these barriers in combination. We suggest that understanding and confronting these barriers will allow family-centered interventions to more effectively address issues related to ERH at a population level, which in turn will reduce poverty-related disparities in child development.

Background: Research exploring associations between exposure to social determinants of health and breastfeeding is needed to identify breastfeeding barriers. Housing insecurity and household conditions (chaos and crowding) may affect breastfeeding by increasing maternal stress and discomfort and decreasing time available to breastfeed. Research Aim: We aimed to examine the relationships between housing insecurity, breastfeeding exclusivity intention during the early postnatal period, and breastfeeding exclusivity at 6 months postpartum among a sample “at risk” for suboptimal breastfeeding rates. Methods: This study is a secondary data analysis of a longitudinal study at two time periods. Data were collected from English- and Spanish-speaking, Medicaid-eligible mother-infant dyads ( N = 361) at near-birth and child aged 6 months, in New York City and Pittsburgh. Structural equation modeling was used to examine direct and indirect effects of housing insecurity on breastfeeding exclusivity at child aged 6 months. Results: The path model showed that experiencing more markers of housing insecurity (i.e., foreclosure/eviction threat, history of homelessness, late rent) was predictive of significantly lower breastfeeding exclusivity at 6 months. This was partially mediated through less exclusive breastfeeding intention during the early postnatal period. Greater household crowding was associated with 6-month breastfeeding exclusivity when mediated by intention. Household crowding had differential effects by study site and participant race/ethnicity. Conclusion: Refinement of housing insecurity as a multi-dimensional construct can lead to the development of standardized data collection instruments, inform future methodological decisions in research addressing social determinants of health, and can inform the development of responsive individual- and structural-level interventions. The data used in this study were collected as part of the SMART Beginnings Randomized Controlled Trial (NCT02459327 registered at ClinicalTrials.gov).

Objective Literacy promotion is a pediatric standard of care in which clinicians provide guidance on shared reading. Latino parents are more likely to hear advice to read with children but are less likely to do so. We sought to understand literacy promotion from the perspective of Latino parents and to identify facilitators and barriers. Methods We purposively sampled Latino parents who participated in Reach Out and Read (ROR) for a qualitative, semistructured interview study. We identified themes using immersion/crystallization and achieved thematic saturation after 21 interviews. Results Two thirds of participants had less than high school education; half of whom had not completed eighth grade. The mean child age was 16.4 months. Primary facilitators of engagement were advice from a pediatrician during a clinical encounter and receipt of the ROR book. Barriers identified included: 1) parents' perceptions that their children were not developmentally ready and that their children's behavior (eg, activity) indicated they were not interested in shared reading; 2) self-perceived limited literacy and/or English proficiency; 3) parenting demands occurring in the context of poverty; and 4) continued child media use despite advice from pediatricians to choose alternate activities such as shared reading instead. Conclusions Parent-clinician relationships are central to ROR's impact but clinicians need to pay more attention to factors in a child's broader environment to strengthen literacy promotion. Specifically clinicians should emphasize skill building during the clinical encounter (eg, sharing knowledge about child development and modeling) and work collaboratively with other stakeholders to address poverty-related stressors.

To test the impact of the fully integrated Smart Beginnings model on parental support of cognitive stimulation from 6-24 months across infancy and toddlerhood.Single-blind, two-site randomized clinical trial of the SB intervention. Enrollment took place at birth in postpartum units of hospitals in New York City and Pittsburgh, PA with a consecutive sample of 403 mother-infant dyads. SB combines Video Interaction Project (VIP) - 14-session universal primary prevention program delivered in the pediatric clinic at the time of well-child visits birth-36 months - with potential for Family Check-Up (FCU) - 3-4-session targeted secondary prevention home-visiting program. The principal outcome was parental support of cognitive stimulation assessed via parent survey and video-recorded observations of parent-child interactions. Ordinary least squares and mixed effects regressions were conducted.Families were mostly Black/African-American (50%) or Latinx (42%); all were Medicaid eligible (100%). SB significantly promoted cognitive stimulation during infancy and toddlerhood for most survey outcomes across time, including StimQ common total (Effect Size [ES]=.25, p=.01) and READ Quantity (ES=.19, p=.04) and Quality (ES=.30, p=.001). For the observations, the impact of SB varied by time, with significant impacts at 6 (ES=.37-.40, p.001) and 24 (ES=.27-.30, p.001) months, but not 18 months.SB positively promotes cognitive stimulation from infancy through toddlerhood using the integrated model. This study adds to the body of research showing preventive interventions in pediatric primary care and home visiting can support early relational health including parental support of cognitive stimulation.

This paper describes the Smart Beginnings Integrated Model, an innovative, tiered approach for addressing school readiness disparities in low-income children from birth to age 3 in the United States through universal engagement of low-income families and primary prevention in pediatric primary care integrated with secondary/tertiary prevention in the home. We build on both public health considerations, in which engagement, cost and scalability are paramount, and a developmental psychopathology framework (Cicchetti & Toth, Journal of Child Psychology and Psychiatry, and Allied Disciplines 50:16-25, 2009), in which the child is considered within the context of the proximal caregiving environment. Whereas existing early preventive models have shown promise in promoting children's school readiness, the Smart Beginnings model addresses three important barriers that have limited impacts at the individual and/or population level: (1) identification and engagement of vulnerable families; (2) the challenges of scalability at low cost within existing service systems; and (3) tailoring interventions to address the heterogeneity of risk among low-income families. Smart Beginnings takes advantage of the existing platform of pediatric primary care to provide a universal primary prevention strategy for all families (Video Interaction Project) and a targeted secondary/tertiary prevention strategy (Family Check-Up) for families with additional contextual factors. We describe the theory underlying the Smart Beginnings model, some initial findings from its recent application in two cities, and implications for changing social policy to promote school readiness beginning during very early childhood.

Parent use of technology to manage child health issues has the potential to improve access and health outcomes. Few studies have examined how parent health literacy affects usage of Internet and cell phone technologies for health management.Cross-sectional analysis of data collected as part of a randomized controlled experiment in 3 urban pediatric clinics. English- and Spanish-speaking parents (n = 858) of children ≤8 years answered questions regarding use of and preferences related to Internet and cell phone technologies. Parent health literacy was measured using the Newest Vital Sign.The majority of parents were high Internet (70.2%) and cell phone (85.1%) users (multiple times a day). A total of 75.1% had limited health literacy (32.1% low, 43.0% marginal). Parents with higher health literacy levels had greater Internet and cell phone use (adequate vs low: adjusted odds ratio [AOR], 1.7 [confidence interval, 1.2-2.5]) and were more likely to use them for health management (AOR, 1.5 [confidence interval, 1.2-1.8]); those with higher health literacy levels were more likely to use the Internet for provider communication (adequate vs marginal vs low: 25.0% vs 18.0% vs 12.0%, P = .001) and health-related cell phone apps (40.6% vs 29.7% vs 16.4%, P.001). Overall preference for using technology for provider communication was high (∼70%) and did not differ by health literacy, although Internet and cell phone apps were preferred by higher literacy parents; no differences were seen for texting.Health literacy-associated disparities in parent use of Internet and cell phone technologies exist, but parents' desire for use of these technologies for provider communication was overall high and did not differ by health literacy.

Children from low-income families are more likely than their higher income peers to show delays in language and literacy skills, both at school entry and across the lifespan. Programs aimed at promoting language and literacy activities in the home, particularly programs that combine distribution of print materials with support and guidance for using them, have been effective in decreasing the word gap, leading to increased school readiness and early literacy. The current study examined the impact of such a program based in pediatric healthcare, Reach Out and Read (ROR), on parents’ use of community resources that also provide access to print—namely, the public library—in the context of a citywide initiative to link literacy resources for low-income families. Effects of both ROR and the library, both individually and combined, on parents’ literacy activities at home were then examined. Significant associations between receiving ROR, using the public library, and parent–child book sharing were found. Implications for intervention and policy are discussed.

Children in low- and middle-income countries (LMICs) are at risk for adverse early development and school readiness outcomes; low parent literacy is common and an important contributing factor. While prevention programs have sought to improve child outcomes by promoting positive parenting practices such as reading aloud, there has been limited evidence of whether such programs have impacts for parents with low literacy in LMICs. This study investigated: (1) whether parent literacy is associated with parent–child reading aloud interactions, the overall cognitive home environment, and child language and cognitive outcomes; and (2) whether impacts of a toddler/preschool reading aloud program differ depending on parent literacy among low-income families in northern Brazil. We performed a secondary analysis of a single-blind cluster randomized controlled trial (RCT) of a parenting intervention (Universidade do Bebe [UBB]) implemented in educational childcare centers in Boa Vista, Brazil. UBB consisted of: (1) a lending library in which children’s books were borrowed weekly; and (2) monthly parent workshops focused on reading aloud. Control families received usual care without the reading aloud program. Five hundred and six mother-infant dyads (279 intervention; 287 control) were enrolled at mean (SD) child age 37.4 (6.5) months. Parents and children were evaluated at baseline/enrollment and approximately 6–9 months later. Measures: (1) Predictor/moderator: parent literacy; (2) Parent outcomes: parent–child interaction during shared storybook reading; cognitive home environment; (3) Child outcomes: expressive and receptive vocabulary; IQ; working memory and short-term phonological memory. Analyses accounted for baseline performance, sociodemographics, and clustering within centers and sites. Parent literacy was positively associated with parent–child verbal/reading interactions and child developmental outcomes, supporting our first hypothesis, that low parent literacy would be associated with lower quantity and quality of parent–child reading and lower scores on assessments of child development. UBB had positive impacts on parent–child interaction, cognitive stimulation, IQ, and receptive vocabulary for both high and low literacy parents, contrary to our second hypothesis, that low parent literacy would be associated with reductions in impacts of the reading aloud intervention. The comparable impacts of a reading aloud program on parent–child verbal/reading interactions and child cognitive outcomes regardless of parent literacy level suggest that preventive interventions in LMICs should consider promotion of shared reading even for low-literacy families.

Feeding concerns are common in the first 2 years of life and typically reflect maternal perceptions occurring within the larger context of the parent-child relationship. We aimed to determine whether (1) maternal depressive systems predicted perceived picky eating, mediated by maternal negative perceptions; (2) receipt of the Video Interaction Project (VIP) parenting intervention impacted perceived picky eating through this pathway; and (3) perceived picky eating was associated with child growth or subsequent dietary patterns.We performed a partial longitudinal analysis of 187 low-income, predominantly Hispanic mother-child dyads enrolled in a randomized controlled trial of the VIP. Mother-infant dyads were enrolled postpartum in an urban public hospital. Participants randomized to the VIP met with an interventionist on days of well-child visits; sessions were designed to facilitate interactions in play and shared reading through provision of learning materials and review of videotaped parent-child interaction; the curriculum did not contain feeding-specific elements. We used structural equation modeling to determine direct, indirect, and total effects of maternal depressive symptoms, maternal negative perceptions, and the VIP on perceived picky eating. We then tested associations between perceived picky eating and (1) child growth, using multivariable linear regression and multilevel modeling; and (2) subsequent child dietary consumption, using multivariable multinomial logistic regression.Maternal depressive symptoms had significant total effects on negative maternal perceptions (β = 0.32, p0.001) and perceived picky eating (β = 0.21, p0.01) after controlling for potential confounders. This effect was partially mediated by maternal negative perceptions (indirect effect: β = 0.06, p = 0.04). When used in the model as the predictor, the VIP had a significant total effect on perceived picky eating (β = -0.16, p = 0.02), which was partially mediated by maternal depressive symptoms and negative perceptions (indirect effect: β = -0.05, p = 0.02). Perceived picky eating was not associated with child diet at age 2 years or adiposity from 6 months to 3 years.Maternal concerns about picky eating may reflect deeper depressive symptoms and negative perceptions of her child's behavior. Interventions designed to facilitate positive parenting in general may lessen feeding-specific concerns, such as picky eating. Although reassurance about growth and nutritional outcomes for children perceived as picky eaters is appropriate, clinicians should also consider probing for underlying symptoms of depression that could lead to eating concerns.

We sought to determine whether pediatric primary care interventions targeting positive parenting among low socioeconomic status mothers resulted in reduced referrals to the New York City Early Intervention Program (NYC-EIP). Participants in Building Blocks (BB) and the Video Interaction Project (VIP) were linked with the NYC-EIP administrative dataset to determine referrals. In all, 139 of 422 study participants (31.4%) meeting inclusion criteria were referred to the NYC-EIP. Although referrals did not differ overall by group (VIP 29.8%; BB 33.8%; control 35.3%), differences were found for mothers with education/literacy of seventh grade or higher (interaction p = .02). In that subgroup, VIP was associated with reduced referrals by age 3 years (22.4%; adjusted odds ratio 0.53; 95% confidence interval [0.29, 0.97]), compared with BB (35.0%) and controls (34.3%), with survival analysis showing reduced cumulative risk ( p = .04). We conclude that VIP resulted in reduced referrals for early intervention evaluation among children of mothers with seventh-grade education or higher.

* Abbreviation: ES — : effect size Parental responsivity, including back and forth interactions aligned with children’s social and verbal cues, improves children’s social-emotional, cognitive, and language development1,2 and is even associated with long-term indicators of health and well-being.3–5 Much work is underway to develop and test interventions designed to promote caregiver responsivity. In the current issue of Pediatrics , Sokolovic et al6 performed a meta-analysis of programs targeting parent responsivity to identify the impact of programs and the program characteristics associated with success. The analysis included 120 studies of randomized trials and found that, although these programs were diverse in how they operated, they were effective across a wide range of populations. The authors have made a major contribution to the literature in finding that such programs generally work and have effect sizes (ESs) at a level large enough to inform policies supporting implementation. These findings indicate a clinically meaningful impact that was observed across many family characteristics, platforms, and strategies especially relevant to pediatric practice, including for low-income families (ES 0.55), home visiting (ES 0.51), both group (ES 0.57) and individual (ES 0.60) format, use of didactics (ES 0.58) and video feedback (ES 0.61), and delivery by professionals, including … Address correspondence to Alan L. Mendelsohn, MD, NYU Grossman School of Medicine, 550 First Ave, New York, NY 10016. E-mail: alan.mendelsohn{at}nyulangone.org

BACKGROUND AND OBJECTIVES: Heterogeneity in risk among low-income families suggests the need for tiered interventions to prevent disparities in school readiness. Smart Beginnings (SB) integrates two interventions: Video Interaction Project (VIP) (birth to 3 years), delivered universally to low-income families in pediatric primary care, and Family Check-Up (6 months to 3 years), targeted home visiting for families with additional family risks. Our objective was to assess initial SB impacts on parent-child activities and interactions at 6 months, reflecting early VIP exposure. METHODS: Two-site randomized controlled trial in New York City (84% Latinx) and Pittsburgh (81% Black), with postpartum enrollment and random assignment to treatment (SB) or control. At 6 months, we assessed parent-child interactions through surveys (StimQ, Parenting Your Baby) and observation (video-recorded play, coded by using Parent-Child Interaction Rating Scales – Infant Adaptation). RESULTS: A total of 403 families were enrolled at child’s birth (201 treatment) with 362 (89.8%) assessed at 6 months. Treatment families had increased StimQ, including total score (Cohen’s d = 0.28; P < .001) and domains reflecting reading (d = 0.23; P = .02) and teaching (d = 0.25; P = .01), and Parent-Child Interaction Rating Scales – Infant Adaptation, including a cognitive stimulation factor (d = 0.40; P < .001) and domains reflecting support for cognitive development (d = 0.36; P < .001), and language quantity (0.40; P < .001) and quality (d = 0.37; P < .001). Thus, significant effects emerged across a broad sample by using varied methodologies. CONCLUSIONS: Findings replicate and extend previous VIP findings across samples and assessment methodologies. Examining subsequent assessments will determine impacts and feasibility of the full SB model, including potential additive impacts of Family Check-Up for families at elevated risk.

* Abbreviations: DPIL — : Dolly Parton’s Imagination Library ROR — : Reach Out and Read Poverty1 and systemic racism2 are critical causes of disparities in early child development and school readiness. Because these early disparities result in lifelong barriers to educational achievement, health, and economic security, there is consensus regarding the urgency of early preventive efforts. Pediatric primary care provides a unique opportunity for population-level engagement of the highest-risk families to support nurturing parent-child relationships critical to healthy child development.3,4 Parent-child book sharing supports early relational health,5 social emotional development,6,7 and early literacy,8 representing a modifiable target for intervention. Over 30 years, Reach Out and Read (ROR) has achieved the highest level of evidence and implementation, to our knowledge, of any early childhood developmental promotion program, with 6100 medical practices reaching 4.5 million children annually.9 In numerous studies, authors have documented large impacts on reading aloud and child language development from the infant-toddler periods through school entry10–12 at a fraction of the cost of intensive parenting interventions like home visiting. In the current issue, Szumlas et al13 added significantly to the evidence base for ROR and health care–based population-level prevention through an innovative study design. First, they combined ROR … Address correspondence to Jill M. Sells, MD, 7724 35th Ave NE, #15943, Seattle, WA 98115. E-mail: jsells{at}edc.org

Fathers' involvement in early childhood is important for children's physical, emotional, and cognitive development, particularly in low-income families. However, little is known about the longitudinal relations between early father involvement and children's later physiological responses to chronic stress and behaviors impacted by stress in the context of poverty. These issues are particularly important among Latinx immigrant families who face significant psychosocial and poverty-related risk. In the current study, we examined the relationship between father involvement in infancy and physiological chronic stress in the middle childhood period, as measured through hair cortisol concentration (HCC), and several behavioral measures (attention problems, working memory) in a Latinx immigrant sample with low income. Father involvement in infancy predicted children's later HCC, and working memory in second to third grade. Father involvement also moderated the effect of HCC on working memory, such that increased HCC predicted better working memory when fathers were not involved. These findings suggest that the fathers' involvement in infancy has lasting impacts on health and behavior and that associations between physiological and behavioral measures of stress may be moderated by differences in early father involvement.

Objectives Maternal stress has been associated with early child obesity through pathways related to decreased exclusive breastfeeding and increased nonresponsive maternal-infant feeding styles. We sought to gain an in-depth understanding of how maternal stress, sadness, and isolation are perceived to affect feeding, in order to inform modifiable targets of intervention. Methods We conducted semi-structured qualitative interviews with Hispanic mothers living in poverty with young infants between 3 and 7 months old (n = 32) from the intervention group of a randomized controlled trial of an early child obesity prevention intervention (Starting Early Program). Bilingual English-Spanish interviewers conducted the interviews, which were audio recorded, transcribed, and translated. Building on an existing theoretical framework developed by the National Scientific Council on the Developing Child, we used an iterative process of textual analysis to code the transcripts, until thematic saturation was reached. Results Three key themes were described: 1) maternal stress responses were varied and included positive (brief and mild), tolerable (sustained but limited long-term impacts), or toxic stress (sustained and severe); 2) buffers included support from family, infants, health care providers, social service programs, and community organizations; 3) perceived effects on infant feeding included decreased breastfeeding due to concerns about stress passing directly through breast milk and indirectly through physical closeness, and increased nonresponsive feeding styles. Conclusions Maternal stress, particularly toxic stress, was perceived to negatively affect infant feeding. Mothers reported disrupting healthy feeding to avoid infant exposure to stress. Interventions to enhance buffering may help to mitigate toxic stress and promote healthy feeding interactions.

[Figure: see text] OBJECTIVES: Poor early childhood development in low- and middle-income countries is a major public health problem. Efficacy trials have shown the potential of early childhood development interventions but scaling up is costly and challenging. Guidance on effective interventions’ delivery is needed. In an open-label cluster-randomized control trial, we compared the effectiveness of weekly home visits and weekly mother-child group sessions. Both included nutritional education, whose effectiveness was tested separately. METHODS: In Odisha, India, 192 villages were randomly assigned to control, nutritional education, nutritional education and home visiting, or nutritional education and group sessions. Mothers with children aged 7 to 16 months were enrolled (n = 1449). Trained local women ran the two-year interventions, which comprised demonstrations and interactions and targeted improved play and nutrition. Primary outcomes, measured at baseline, midline (12 months), and endline (24 months), were child cognition, language, motor development, growth and morbidity. RESULTS: Home visiting and group sessions had similar positive average (intention-to-treat) impacts on cognition (home visiting: 0.324 SD, 95% confidence interval [CI]: 0.152 to 0.496, P = .001; group sessions: 0.281 SD, 95% CI: 0.100 to 0.463, P = .007) and language (home visiting: 0.239 SD, 95% CI: 0.072 to 0.407, P = .009; group sessions: 0.302 SD, 95% CI: 0.136 to 0.468, P = .001). Most benefits occurred in the first year. Nutrition-education had no benefit. There were no consistent effects on any other primary outcomes. CONCLUSIONS: Group sessions cost $38 per child per year and were as effective on average as home visiting, which cost $135, implying an increase by a factor of 3.5 in the returns to investment with group sessions, offering a more scalable model. Impacts materialize in the first year, having important design implications.

OBJECTIVE: Children in low-income Hispanic families are at high risk of obesity and are more likely to live with grandparents than their non-Hispanic white counterparts. We aimed to determine if grandparent coresidence (prenatal through age two years) was associated with: 1) obesogenic feeding practices; and 2) child weight outcomes from birth to three years. METHODS: We analyzed data from 267 low-income, Hispanic mother-infant pairs in the control group of an obesity prevention trial in New York City. Linear and logistic regression tested differences in obesogenic feeding practices and weight outcomes at two and three years, dependent upon grandparent coresidence. Multilevel modeling tested associations between grandparent coresidence and WFAz over time. RESULTS: Persistent grandparent coresidence (versus none) was associated with putting cereal in the bottle (adjusted odds ratio [aOR] 3.46; 95% confidence interval [CI] 1.43, 8.40). Persistent grandparent coresidence (versus none) was associated with higher mean WFAz (2 years: B 0.83; 95% CI 0.41, 1.25; 3 years: B 0.79; 95% CI 0.32, 1.25) and higher odds of child overweight/obesity risk (two years: aOR 4.38; 95% CI 1.64, 11.69; three years: aOR 3.15; 95% CI 1.19, 8.36). In multilevel models, more occasions of grandparent coresidence were associated with higher WFAz. CONCLUSIONS: Grandparent coresidence may be associated with higher risk of child overweight/obesity in low-income, Hispanic families. Further research is needed to elucidate mechanisms of these associations and to inform obesity prevention strategies in the context of multigenerational families.

ObjectiveTo test breastfeeding duration and responsive parenting as independent predictors of infant weight change from birth to 12 months, and to test the moderating effect of a tiered parenting intervention on relations between breastfeeding and responsive parenting in relation to infant weight change.MethodsMother–infant dyads (N = 403) were participants in the ongoing Smart Beginnings (SB) randomized controlled trial testing the impact of the tiered SB parenting model that incorporates two evidence-based interventions: Video Interaction Project (VIP) and Family Check-Up (FCU). The sample was low income and predominantly Black and Latinx. Responsive parenting variables (maternal sensitivity and intrusiveness) came from coded observations of mother–infant interactions when infants were 6 months. Continuous weight-for-age (WFA) z-score change and infant rapid weight gain (RWG) from 0 to 12 months were both assessed.ResultsLonger breastfeeding duration was significantly associated with less WFA z-score change. The relationship between breastfeeding duration and WFA z-score change was significant only for infants in the intervention group. Intrusive parenting behaviors were also associated with greater WFA z-score change after accounting for breastfeeding duration.ConclusionsThis study is one of the first to test both breastfeeding and parenting in relation to infant weight gain in the first year. Findings may have implications for family-focused child obesity prevention programs.

OBJECTIVES: To determine impact of a primary care–based child obesity prevention intervention beginning during pregnancy on early childhood weight outcomes in low-income Hispanic families. METHODS: A randomized controlled trial comparing mother–infant pairs receiving either standard care or the Starting Early Program providing prenatal and postpartum nutrition counseling and nutrition parenting support groups targeting key obesity-related feeding practices in low-income groups. Primary outcomes were reduction in weight-for-age z-scores (WFAzs) from clinical anthropometric measures, obesity prevalence (weight for age ≥95th percentile), and excess weight gain (WFAz trajectory) from birth to age 3 years. Secondary outcomes included dose effects. RESULTS: Pregnant women (n = 566) were enrolled in the third trimester; 533 randomized to intervention (n = 266) or control (n = 267). Also, 358 children had their weight measured at age 2 years; 285 children had weight measured at age 3 years. Intervention infants had lower mean WFAz at 18 months (0.49 vs 0.73, P = .04) and 2 years (0.56 vs 0.81, P = .03) but not at 3 years (0.63 vs 0.59, P = .76). No group differences in obesity prevalence were found. When generalized estimating equations were used, significant average treatment effects were detected between 10-26 months (B = −0.19, P = .047), although not through age 3 years. In within group dose analyses at 3 years, obesity rates (26.4%, 22.5%, 8.0%, P = .02) decreased as attendance increased with low, medium, and high attendance. CONCLUSIONS: Mean WFAz and growth trajectories were lower for the intervention group through age 2 years, but there were no group differences at age 3. Further study is needed to enhance sustainability of effects beyond age 2.

This study examined the interrelated and longitudinal impacts of parent-child shared book reading, parenting stress, and early relational health, as measured by both parental warmth and parent sensitivity, from infancy to toddlerhood. To extend findings from previous studies of collateral effects that have been conducted in parenting interventions, we examined parenting behaviors in a broader context to determine whether shared book reading would confer collateral benefits to the parent and parent-child relationship beyond those expected (i.e., language and literacy). It was hypothesized that positive parent-child interactions, such as shared reading, would have positive impacts on parent outcomes such as parenting stress, parental warmth, and sensitivity. The sample consisted of 293 low-income mothers and their children who participated in a randomized controlled trial. Shared book reading, parenting stress, and parental warmth were assessed when children were 6 and 18 months old. We computed a series of cross-lagged structural equation models to examine longitudinal interrelations among these three factors. Results indicated that shared book reading at 6 months was associated with increases in observed and reported parental warmth and observed sensitivity and decreases in parenting stress at 18 months, controlling for baseline risk factors and treatment group status. These findings suggest that early parent-child book reading can have positive collateral impacts on parents' stress and the parent-child relationship over time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Attendance at well-child visits (WCVs) is a sine qua non of preventive care. We hypothesized that Reach Out and Read (ROR) would be associated with better WCV attendance. Parents of children 76 to 72 months at 8 clinics who did not yet have ROR reported how many WCVs their child had attended in the previous year; separate samples at the same clinics were interviewed 16 months after the ROR program was instituted. Comparing 267 parents before ROR and 254 after, the percentage who had attended the minimum number of WCVs required by the American Academy of Pediatrics periodicity schedule rose from 67.4% (180/267) to 78.3% (199/254; P < .01). This difference remained significant after controlling for multiple potential confounding factors (estimated odds ratio = 2.1, 95% confidence interval = 1.3-3.5). The largest differences were among Latino children and children of less-educated parents. Programs to enhance early literacy may increase attendance at WCVs among at-risk families.

Objective Prenatal maternal stresses have been associated with infant temperament patterns linked to later behavioral difficulties. Material hardships, defined as inability to meet basic needs, are important prenatal stressors. Our objective was to determine the associations between prenatal material hardships and infant temperament at 10 months. Methods This was a longitudinal study of mother-infant pairs in a randomized controlled trial of a primary care-based early obesity prevention program (Starting Early). Independent variables representing material hardship were: housing disrepair, food insecurity, difficulty paying bills, and neighborhood stress (neighborhood safety). Dependent variables representing infant temperament were assessed using questions from 3 subscales of the Infant Behavior Questionnaire: orienting/regulatory capacity, negative affect, and surgency/extraversion. We used linear regression to investigate associations between individual and cumulative hardships and each temperament domain, adjusting for confounders, and testing for depression as a moderator. Results Four hundred twelve mother-infant pairs completed 10-month assessments. Thirty-two percent reported food insecurity, 26% difficulty paying bills, 35% housing disrepair, and 9% neighborhood stress. In adjusted analyses, food insecurity was associated with lower orienting/regulatory capacity scores (β = −0.25; 95% confidence interval [CI], −0.47 to −0.04), as were neighborhood stress (β = −0.50; 95% CI, −0.83 to −0.16) and experiencing 3 to 4 hardships (compared with none; β = −0.54; 95% CI, −0.83 to −0.21). For neighborhood stress, the association was stronger among infants of mothers with prenatal depressive symptoms (interaction term P = .06). Conclusion Prenatal material hardships were associated with lower orienting/regulatory capacity. These findings support the need for further research exploring how temperament relates to child behavior, and for policies to reduce prenatal material hardships.

Text messages improve health outcomes for adults engaged in weight management. Little is known about whether text messaging parents of children enrolled in obesity treatment will improve child health.We conducted a 2-group randomized controlled study among 101 children aged 5-12 and their parent/guardian enrolling in tertiary-care obesity treatment. Participants were randomized to standard care or standard care plus daily motivational interviewing-based text messages. The primary outcome was change in child BMI at 3 months. Secondary outcomes included feasibility, health behaviors, attrition, motivation, and parent BMI.We enrolled 101 parent-child dyads and retained 81% to 3-month follow-up. Child participants had a mean age of 9.9 years, and baseline BMI of 30.5 kg/mParent-directed text messages did not significantly change child BMI. However, texting significantly reduced attrition for treatment visits. Nearly all parents in this racially diverse, low-income sample engaged in daily text messaging, making this a feasible approach.

Background: The burden of mental, neurological, and substance (MNS) disorders is greater in low- and middle-income countries (LMICs). The rapid growth of digital health (i.e., eHealth) approaches offer new solutions for transforming pediatric mental health services and have the potential to address multiple resource and system barriers. However, little work has been done in applying eHealth to promote young children's mental health in LMICs. It is also not clear how eHealth has been and might be applied to translating existing evidence-based practices/strategies (EBPs) to enable broader access to child mental health interventions and services. Methods: A scoping review was conducted to summarize current eHealth applications and evidence in child mental health. The review focuses on 1) providing an overview of existing eHealth applications, research methods, and effectiveness evidence in child mental health promotion (focused on children of 0-12 years of age) across diverse service contexts; and 2) drawing lessons learned from the existing research about eHealth design strategies and usability data in order to inform future eHealth design in LMICs. Results: Thirty-two (32) articles fitting our inclusion criteria were reviewed. The child mental health eHealth studies were grouped into three areas: i) eHealth interventions targeting families that promote child and family wellbeing; ii) eHealth for improving school mental health services (e.g., promote school staff's knowledge and management skills); and iii) eHealth for improving behavioral health care in the pediatric care system (e.g., promote use of integrated patient-portal and electronic decision support systems). Most eHealth studies have reported positive impacts. Although most pediatric eHealth studies were conducted in high-income countries, many eHealth design strategies can be adapted and modified to fit LMIC contexts. Most user-engagement strategies identified from high-income countries are also relevant for populations in LMICs. Conclusions: This review synthesizes patterns of eHealth use across a spectrum of individual/family and system level of eHealth interventions that can be applied to promote child mental health and strengthen mental health service systems. This review also summarizes critical lessons to guide future eHealth design and delivery models in LMICs. However, more research in testing combinations of eHealth strategies in LMICs is needed.

OBJECTIVE To examine the associations between breastfeeding intensity and underexplored features of maternal-child interaction quality over and above the influence of breastfeeding initiation. METHODS The current study leveraged an on-going, multisite randomized controlled trial of a tiered parenting program for 462 Medicaid-eligible mothers and their infants in the United States. We examined whether breastfeeding intensity and exclusivity was associated with observed maternal sensitivity, intrusiveness, and detachment, as well as self-reported maternal verbal responsiveness, 6 months infant age. Analyses controlled for breastfeeding initiation, demographics, and early parenting experiences. RESULTS Higher intensity breastfeeding at 6 months was significantly related to higher maternal sensitivity (β = 0.12, p = 0.004) and lower maternal intrusiveness (β = -0.10, p = 0.045). There was no significant association between breastfeeding intensity at 6 months and detachment (β = -0.02, no significant [ns]) or self-reported verbal responsiveness (β = 0.11, ns). Results were the same when intensity was measured as a dichotomous indicator for exclusive breastfeeding. Effect sizes were small-to-moderate, ranging from Cohen's d = 0.26 to 0.31. Associations did not vary by site, race/ethnicity, infant difficultness, or household poverty. CONCLUSION The finding that breastfeeding intensity was significantly and independently associated with maternal sensitivity and intrusiveness is novel in the literature on low-income families from the United States. These findings have implications for breastfeeding promotion strategies and indicate that future research should explore synergistic or spillover effects of interventions aimed at maternal-child interaction quality into the infant feeding domain, particularly in the primary care setting.

Play offers rich opportunities for toddlers to develop motor, social, cognitive, and language skills, particularly during interactions with adult caregivers who may scaffold toddlers to higher levels of play than toddlers achieve on their own. However, research on play has narrowly focused on children from White, middle-income backgrounds, leaving a dearth of knowledge about dyadic play in diverse cultural communities. We videorecorded 222 Mexican-American mothers playing with their 2-year-old toddlers with a standard set of toys. Play behaviors were coded as nonsymbolic or symbolic (play type) and as expressed through manual, verbal, or multiple channels (play modality). Play between toddlers and mothers was frequent, high in symbolic content, and toddler play closely corresponded with mother play in type and modality: Toddlers' nonsymbolic play related to mothers' nonsymbolic play; toddlers' symbolic play related to mothers' symbolic play; toddlers' manual play related to mothers' manual play; and toddlers' multimodal play related to mothers' multimodal play. Play in Mexican-American mothers and toddlers is frequent, multimodal, and symbolically rich, offering new directions for future research and practice.

Food insecurity is an important social determinant of health,1 a key indicator of limited resources and material hardship,2,3 and a source of significant stress as parents and other caregivers seek to provide healthy child nutrition.4 As such, food insecurity would be expected to adversely affect child growth5,6 and health and development more broadly.7,8 However, there has been limited study of associations between food insecurity and child outcomes during the critical period of early childhood.9–11 The authors of “Food Insecurity, Health and Development in Children Under Age Four Years” aim to address this gap by using a large sample of families at high risk for both food insecurity and child health disparities.12 Contrary to the authors’ hypotheses, limited relations between food insecurity and child obesity or other growth parameters were found in the study. The only significant associations were for children between 25 and 36 months old, for whom household food insecurity was associated with increased adjusted odds of obesity. In contrast, no significant associations were found after adjustment for … Address correspondence to Rachel S. Gross, MD, MS, Division of General Pediatrics, Department of Pediatrics, New York University School of Medicine, 462 First Ave, New York, NY 10016. E-mail: rachel.gross{at}nyulangone.org

Past research on predictors of participation in early childhood parenting programs suggest that families experiencing higher levels of sociodemographic adversity (e.g., younger maternal age, single parenthood, lower income or education) are less likely to participate in parenting programs. This is significant, as it may indicate that those most in need of additional support are the least likely to receive it. Data from a randomized control trial (RCT) of Smart Beginnings, an integrated, tiered model for school readiness, were used to explore predictors of attendance in Video Interaction Project (VIP) through 6 months. VIP is a primary preventive intervention delivered in tandem with pediatric well-child visits, aimed at reducing income-based disparities in early child development through promotion of responsive parent-child interactions. Using Poisson distribution models (N = 403; treatment arm, n = 201), we find that demographic, socioeconomic status (SES), and psychosocial variables are associated with program attendance but not always in the expected direction. While analyses show that first-time mothers have higher levels of program attendance as expected, we find that less-educated mothers and those with lower parenting self-efficacy have higher levels of attendance as well. The latter findings may imply that the VIP intervention is, by some indicators, effectively targeting families who are more challenging to engage and retain. Implications for pediatric-based interventions with population-level accessibility are discussed.

Objective Shared reading is believed to enhance parent-child relationships, but the extent to which it reduces harsh parenting is understudied. Associations between early shared reading and subsequent harsh parenting were investigated. Methods Data from a national urban birth cohort were used to estimate associations between mother-reported shared reading at ages 1 and 3 years and harsh parenting-based on a composite of psychological and physical aggression subscales of a validated self-report instrument-when the children were at ages 3 and 5 years. The authors used multivariable linear regression and generalized estimating equations to account for repeated observations. Given potential inverse associations between shared reading and child disruptive behaviors, which can trigger harsh parenting, the authors investigated the extent to which children's behavior at age 3 years mediated the association between shared reading at age 1 year and harsh parenting at age 5 years. Results This study included 2165 mother-child dyads. Thirty-four percent and 52% of mothers reported daily reading at ages 1 and 3 years. In adjusted models, shared reading at age 1 year was associated with less harsh parenting at age 3 years. Similarly, shared reading at age 3 years was associated with less harsh parenting at age 5 years. These associations remained significant in lagged repeated-measures models. Decreased disruptive behaviors partially mediated the association between shared reading at age 1 year and harsh parenting at age 5 years. Conclusion Shared reading predicted less harsh parenting in a national urban sample. These findings suggest that shared reading contributes to an important aspect of the parent-child relationship and that some of the association operates through enhanced child behaviors.

Objectives To assess parent decision-making regarding dosing tools, a known contributor to medication dosing errors, by evaluating parent dosing tool use, beliefs, and access, and the role of health literacy, with a focus on dosing cups, which are associated with an increased risk of multifold overdose. Study design Cross-sectional analysis of data collected for randomized controlled study in 3 urban pediatric clinics. English/Spanish-speaking parents (n = 493) of children ≤8 years of age enrolled. Outcomes: reported tool use, beliefs, and access. Predictor variable: health literacy (Newest Vital Sign; limited [0-3], adequate [4-6]). Multiple logistic regression analyses conducted. Results Over two-thirds of parents had limited health literacy. Oral syringes (62%) and dosing cups (22%) were most commonly used. Overall, 24% believed dosing cups were the best tool type for dosing accuracy; 99% reported having access to ≥1 dosing tools with standard measurement markings. Parents with limited health literacy had greater odds of dosing cup use (limited vs adequate: aOR = 2.4 [1.2-4.6]). Parents who believed that dosing cups are best for accuracy had greater odds of dosing cup use (aOR = 16.3 [9.0-29.3]); this belief mediated health literacy-effects on dosing cup use. Conclusions Factors associated with dosing tool choice, including parent health literacy and beliefs are important to consider in the design of interventions to reduce dosing errors; future larger-scale studies addressing this issue are needed.

Objective To determine whether prenatal social support was associated with infant adiposity in the first 18 months of life in a low-income, Hispanic sample, known to be at high risk of early child obesity. Study design We performed a longitudinal analysis of 262 low-income, Hispanic mother-infant pairs in the control group of the Starting Early child obesity prevention trial. Prenatal social support was measured using an item from the Maternal Social Support Index. We used multilevel modeling to predict weight-for-length z-score trajectories from birth to age 18 months and logistic regression to predict macrosomia and overweight status at ages 6, 12, and 18 months. Results High prenatal social support was independently associated with lower infant adiposity trajectories from birth to age 18 months (B = −0.40; 95% CI, −0.63 to −0.16), a lower odds of macrosomia (aOR = 0.35; 95% CI, 0.15-0.80), and a lower odds of overweight at ages 12 (aOR = 0.28; 95% CI, 0.10-0.74) and 18 months (aOR = 0.35; 95% CI, 0.14-0.89). Prenatal social support was not significantly associated with overweight status at age 6 months. Conclusions Prenatal social support may protect against excessive infant adiposity and overweight in low-income, Hispanic families. Further research is needed to elucidate mechanisms underlying these associations and to inform preventive strategies beginning in pregnancy.