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This commentary discusses how pediatricians can become involved in improving the mental health system for children and adolescents.

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.

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.

OBJECTIVES: To describe the characteristics of hospitalized children with severe acute respiratory syndrome coronavirus 2 in New York City metropolitan area. PATIENTS AND METHODS: This was a multicenter, retrospective cohort study at 4 hospitals comprising 82 hospitalized children (0–21 years) who tested positive for severe acute respiratory syndrome coronavirus 2 after symptoms and risk screening between March 1 and May 10, 2020. We subdivided patients on the basis of their admission to acute or critical care units and by age groups. Further subanalyses were performed between patients requiring respiratory support or no respiratory support. RESULTS: Twenty-three (28%) patients required critical care. Twenty-nine (35%) patients requiring respiratory support, with 9% needing mechanical ventilation, and 1 required extracorporeal support. All patients survived to discharge. Children with any comorbidity were more likely to require critical care (70% vs 37%, P = .008), with obesity as the most common risk factor for critical care (63% vs 28%, P = .02). Children with asthma were more likely to receive respiratory support (28% vs 8%, P = .02), with no difference in need for critical care (P = .26). Children admitted to critical care had higher rates of renal dysfunction at presentation (43% vs 10%, P = .002). CONCLUSIONS: Children with comorbidities (obesity and asthma in particular) were at increased risk for critical care admission and/or need for respiratory support. Children with renal dysfunction at presentation were more likely to require critical care.

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.

The United States has developed an effective safety net of programs starting during the Great Depression, picking up steam in the War on Poverty of the 1960s, and continuing to this day. These efforts have been impactful. Child poverty rates tracked by the supplemental poverty measure have dropped by nearly 50% since the 1960s. Causal studies show that many of these programs improve child outcomes by alleviating income poverty. Some of the evidence shows that such impacts last into adulthood. Nevertheless, addressing child poverty is unfinished business for the United States. Children are still the poorest age group in our society. More robust versions of present safety net programs, as well as the possible introduction of child benefits/child allowances, which many other high-resource countries already provide to families, will need to be considered if we are going to make further progress in substantially reducing child poverty.

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.

Health literacy plays a role in the events leading up to children's hospitalizations, during hospital admission, and after discharge. Hospitals and providers should use a universal precautions approach and routinely incorporate health-literacy-informed strategies in communicating with all patients and families to ensure that they can understand health information, follow medical instructions, participate actively in their own/their child's care, and successfully navigate the health care system. Interventions that incorporate health-literacy-informed strategies and that target patients/families and health care systems should be implemented to improve patient outcomes and patient-centered and family-centered care.

This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents’ values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Importance Children of parents expressing limited comfort with English (LCE) or limited English proficiency may be at increased risk of adverse events (harms due to medical care). No prior studies have examined, in a multicenter fashion, the association between language comfort or language proficiency and systematically, actively collected adverse events that include family safety reporting. Objective To examine the association between parent LCE and adverse events in a cohort of hospitalized children. Design, setting, and participants This multicenter prospective cohort study was conducted from December 2014 to January 2017, concurrent with data collection from the Patient and Family Centered I-PASS Study, a clinician-family communication and patient safety intervention study. The study included 1666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspecialty patients 17 years and younger in the pediatric units of 7 North American hospitals. Data were analyzed from January 2018 to May 2020. Exposures Language-comfort data were collected through parent self-reporting. LCE was defined as reporting any language besides English as the language in which parents were most comfortable speaking to physicians or nurses. Main outcomes and measures The primary outcome was adverse events; the secondary outcome was preventable adverse events. Adverse events were collected using a systematic 2-step methodology. First, clinician abstractors reviewed patient medical records, solicited clinician reports, hospital incident reports, and family safety interviews. Then, review and consensus classification were completed by physician pairs. To examine the association of LCE with adverse events, a multivariable logistic regression was conducted with random intercepts to adjust for clustering by site. Results Of 1666 parents providing language-comfort data, 1341 (80.5%) were female, and the mean (SD) age of parents was 35.4 (10.0) years. A total of 147 parents (8.8%) expressed LCE, most of whom (105 [71.4%]) preferred Spanish. Children of parents who expressed LCE had higher odds of having 1 or more adverse events compared with children whose parents expressed comfort with English (26 of 147 [17.7%] vs 146 of 1519 [9.6%]; adjusted odds ratio, 2.1; 95% CI, 1.2-3.7), after adjustment for parent race and education, complex chronic conditions, length of stay, site, and the intervention period. Similarly, children whose parents expressed LCE were more likely to experience 1 or more preventable adverse events (adjusted odds ratio, 2.3; 95% CI, 1.2-4.2). Conclusions and relevance Hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.

BACKGROUND AND OBJECTIVES: Infection with a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic. There are limited data describing the impact of SARS-CoV-2 infection on pregnant mothers and their newborns. The objective of this study is to describe characteristics and outcomes of maternal-newborn dyads with confirmed maternal SARS-CoV-2. METHODS: This was a multicenter, observational, descriptive cohort study with data collection from charts of maternal-newborn dyads who delivered at 4 major New York City metropolitan area hospitals between March 1 and May 10, 2020, with maternal SARS-CoV-2 infection. RESULTS: There were a total of 149 mothers with SARS-CoV-2 infection and 149 newborns analyzed (3 sets of twins; 3 stillbirths). Forty percent of these mothers were asymptomatic. Approximately 15% of symptomatic mothers required some form of respiratory support, and 8% required intubation. Eighteen newborns (12%) were admitted to the ICU. Fifteen (10%) were born preterm, and 5 (3%) required mechanical ventilation. Symptomatic mothers had more premature deliveries (16% vs 3%, P = .02), and their newborns were more likely to require intensive care (19% vs 2%, P = .001) than asymptomatic mothers. One newborn tested positive for SARS-CoV-2, which was considered a case of horizontal postnatal transmission. CONCLUSIONS: Although there was no distinct evidence of vertical transmission from mothers with SARS-CoV-2 to their newborns, we did observe perinatal morbidities among both mothers and newborns. Symptomatic mothers were more likely to experience premature delivery and their newborns to require intensive care.

* Abbreviations: COVID-19 — : coronavirus disease 2019 PART — : Pediatricians Against Racism and Trauma We have seen the horrifying cell phone and surveillance video footage of the murder of George Floyd replay again and again in the last few weeks. The aftermath begs the question why this particular murder of a Black man by a police officer has sparked the international response so few have received.1 Scores of other Black men, women, and children have been killed by police since the 2014 murder of Eric Garner in New York City, in which he suffered an illegal chokehold and uttered the devastating refrain “I can’t breathe,” and countless others have been murdered over generations. These cases represent just the tip of the iceberg because these murders happened to be recorded on bystander cell phone video or police webcam capture. Moreover, it is the tip of another iceberg because these cases represent modern-day lynchings. The lynching of Black people in the United States was routine before the “civil rights era,” when there were major legal advances to change the treatment of Black Americans in this country. However, it was not until February 2020 that federal legislation, the Emmett Till Antilynching Act, was passed by the House of Representatives but is still … Address correspondence to Benard P. Dreyer, MD, FAAP, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, New York University Grossman School of Medicine and Department of Pediatrics, Bellevue Hospital Center, 550 First Ave, New York, NY 10016. E-mail: benard.dreyer{at}nyulangone.org

BACKGROUND: Multiple factors constrain the trajectories of child cognitive development, but the drivers that differentiate the trajectories are unknown. We examine how multiple early life experiences differentiate patterns of cognitive development over the first 5 years of life in low-and middle-income settings. METHODS: Cognitive development of 835 children from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) multisite observational cohort study was assessed at 6, 15, 24 (Bayley Scales of Infant and Toddler Development), and 60 months (Wechsler Preschool and Primary Scale of Intelligence). Markers of socioeconomic status, infection, illness, dietary intake and status, anthropometry, and maternal factors were also assessed. Trajectories of development were determined by latent class-mixed models, and factors associated with class membership were examined by discriminant analysis. RESULTS: Five trajectory groups of cognitive development are described. The variables that best discriminated between trajectories included presence of stimulating and learning resources in the home, emotional or verbal responsivity of caregiver and the safety of the home environment (especially at 24 and 60 months), proportion of days (0–24 months) for which the child had diarrhea, acute lower respiratory infection, fever or vomiting, maternal reasoning ability, mean nutrient densities of zinc and phytate, and total energy from complementary foods (9–24 months). CONCLUSIONS: A supporting and nurturing environment was the variable most strongly differentiating the most and least preferable trajectories of cognitive development. In addition, a higher quality diet promoted cognitive development while prolonged illness was indicative of less favorable patterns of development.

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.

Social determinants of health influence child health behavior, development, and outcomes. This paper frames social capital, or the benefits that a child receives from social relationships, as a positive social determinant of health that helps children exposed to adversity achieve healthy outcomes across the life course. Children are uniquely dependent on their relationships with surrounding adults for material and nonmaterial resources. We identify and define three relevant aspects of social capital: 1) social support, which is embedded in a 2) social network, which is a structure through which 3) social cohesion can be observed. Social support is direct assistance available through social relationships and can be received indirectly through a caregiver or directly by a child. A child's social network describes the people in a child's life and the relationships between them. Social cohesion represents the strength of a group to which a child belongs (eg, family, community). Pediatric primary care practices play an important role in fostering social relationships between families, the health care system, and the community. Further research is needed to develop definitional and measurement rigor for social capital, to evaluate interventions (eg, peer health educators) that may improve health outcomes through social capital, and to broaden our understanding of how social relationships influence health outcomes.

Objective To examine pediatricians' attitudes toward public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP). Methods Data from the AAP Periodic Survey in October 2014 to March 2015 were used. Respondents ranked 1) attitudes toward government programs, and 2) attitudes toward AAP policies on: income support, housing, education, job training, food, and health care. Results were analyzed according to age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship. Results Response rate was 47% (n = 650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), and food and shelter (90.0%). Most also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There was variation among the level of support on the basis of practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of children as well as citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those younger than 40 and 50 to 59 years of age were more supportive of government guaranteeing enough to eat and a place to sleep for children. More than 55% supported the AAP advocating for income support, housing, education, and access to health care. Conclusions Pediatricians strongly support government policies that affect child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates, and policy-makers focused on children and families.

Key Points Question Is living in a neighborhood with high police presence associated with increased risk of preterm birth? Findings In this cross-sectional study of 1059 Minneapolis residents who gave birth to a live singleton in 2016, the odds of preterm birth for pregnant people living in a neighborhood with high police presence was significantly higher compared with the odds of their racial counterparts in a low-presence neighborhood (90% increase for White individuals, 100% increase for US-born Black individuals, and 10% for Black individuals born outside of the US). The higher the proportion of Black residents in the neighborhood, the greater the number of police incident reports. Meaning These findings suggest that greater police presence in Black vs White neighborhoods may contribute to the persistent Black-White preterm birth disparity in Minneapolis., This cross-sectional study examines the association between community-level police contact and the risk of preterm birth among White pregnant people, US-born Black pregnant people, and Black pregnant people who were born outside the US., Importance Police contact may have negative psychological effects on pregnant people, and psychological stress has been linked to preterm birth (ie, birth at

We proposed and tested a theoretical framework for how use of Teach-back could influence communication during the pediatric clinical encounter.Audio-taped pediatric primary care encounters with 44 children with asthma were coded using the Roter Interaction Analysis System to measure patient-centered communication and affective engagement of the parent. A newly created Teach-back Loop Score measured the extent to which Teach-back occurred during the clinical encounter; parental health literacy was measured by Newest Vital Sign. Logistic regression was used to test the relationship between Teach-back and features of communication. Focus groups held separately with clinicians and parents elicited perceptions of Teach-back usefulness.Teach-back was used in 39% of encounters. Visits with Teach-back had more patient centered communication (p=0.01). Adjusting for parent health literacy, parent age, and child age, Teach-back increased the odds of both patient centered communication [proportional AOR (95% CI)=4.97 (4.47-5.53)]and negative affect [AOR (95% CI)=5.39 (1.68-17.31)]. Focus group themes common to clinicians and parents included: Teach-back is effective, could cause discomfort, should be used with children, and nurses should use it.Teach-back was associated with more patient-centered communication and increased affective engagement of parents.Standardizing Teach-back use may strengthen patient-centered communication.

Sustained Animus toward Latino Immigrants U.S. policies are inflicting ongoing harm on migrant children, enacting an animus against immigrants that is baked into our history. U.S. physicians can ad...

In 2017, 18% of children in the United States were living below the federal poverty level.1 Studies have documented the myriad negative impacts poverty has on child outcomes, with many lasting into adulthood. Because of its impact on early brain development, poverty in early childhood is particularly toxic, leading to lack of school readiness, poor educational outcomes, poor health, and intergenerational poverty.2 A number of questions have been raised about these impacts. Is it income poverty itself or associated covariates, such as low parental education, poor prenatal care, and parental mental health and substance use, that cause these outcomes? How important is growing up in a poor neighborhood versus growing up in a poor family? How early and how long does the child have to experience poverty for the negative effects to be seen? In this month’s issue of Pediatrics , Roos et al3 from the University of Manitoba have taken advantage of the linkable de-identified data available in Canada to answer some of these important questions. This includes census data and … Address correspondence to Benard P. Dreyer, MD, Department of Pediatrics, New York University School of Medicine, 462 1st Ave, NBV 8E-11, New York, NY 10016. E-mail: bpd1{at}nyulangone.org

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.

Child sleep problems are prevalent and have been linked to poor behavior, worse school performance, and obesity. Low health literacy (HL) is associated with suboptimal parenting practices and worse health outcomes, but the relationship between parent HL and child sleep-related issues is not known. We examined the association between parent HL and child sleep-related issues.This was a cross-sectional analysis of data from caregivers enrolled in a cluster randomized trial of a primary care-based child obesity prevention program in 4 pediatric clinics. Parent HL was assessed using the Short Test of Functional Health Literacy in Adults. At the 9-month well-child visit, sleep-related factors were assessed: presence of TV in room where child sleeps, regular naptimes and bedtimes (≥5 days/wk), low daytime and nighttime sleep duration (1 SD below mean on the basis of national data). Multiple logistic regression analyses were performed.We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2%$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes norbedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).Low parent HL is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

In all parts of the world, an important discussion has begun in response to the discord and turbulence of the 2016 US Presidential campaign and some postelection actions.1 The tensions and stressors that have generated a global wave of worry and uncertainty have created a need to ensure tolerance and understanding in our generation, in our children, and in future generations. We hope that an awareness of the need for enhanced tolerance and understanding of other people and other people’s beliefs can help unite us and begin a journey of healing. We address this commentary to the entire child and adolescent health community. As pediatricians, we wish to discuss steps we can all take to be more welcoming, tolerant, and understanding of those who may see things differently from us. This includes fellow pediatricians and other pediatric health professionals whose opinions may not be the same as their colleagues but who share a common commitment to ensuring a bright future for all children and adolescents. We believe tolerance and understanding are intertwined in the path toward human progress. In all health care settings and in all policy discussions, both tolerance and understanding are essential. We define tolerance as the acceptance of another person, another viewpoint, or another behavior that is different from our own. Tolerance expands our ability to be open to new ideas, to people who have different viewpoints, or to people who are different from ourselves. Tolerance for those who are different from us or disagree with us allows us to recognize … Address correspondence to Peter G. Szilagyi, MD, MPH, FAAP, Department of Pediatrics, UCLA, 10833 LeConte, MC 175217, 12-358 MDCC, Los Angeles, CA 90095. E-mail: pszilagyi{at}mednet.ucla.edu

Objective To measure the frequency US pediatricians report screening and referring for social needs and identify pediatrician and practice-level predictors for screening and referral. Methods Data were from the American Academy of Pediatrics Periodic Survey for October 2014 to March 2015 with a response rate of 46.6% (732/1570). Respondents reported on: 1) routine screening of low-income families for social needs, 2) attitudes toward screening, and 3) referral of low-income families for community resources. Results were analyzed by pediatrician and practice characteristics. Results Although most pediatricians (61.6%) thought that screening is important, fewer (39.9%) reported that screening is feasible or felt prepared addressing families' social needs (20.2%). The topics that pediatricians reported routinely asking low-income families about at visits (defined as ≥50% visits) were need for childcare (41.5%) and transportation barriers (28.4%). Pediatricians were less likely to report asking about housing (18.7%), food (18.6%), and utilities/heating (14.0%) insecurity. In multivariable analyses, pediatricians were more likely to report both that they screen and refer when they reported having more patients in financial hardship and having someone in the practice with the responsibility to connect low-income families to community services. Pediatricians who endorsed the importance of screening and who reported being prepared were also more likely to screen/refer. Conclusions A minority of pediatricians report routinely screening for social needs. Pediatricians were more likely to report that they screen and refer if they had positive attitudes toward the importance of screening, felt prepared, and had support staff to assist families in need.

OBJECTIVE: To assess the extent to which associations between shared reading at age 1 and child vocabulary at age 3 differ based on the presence of sensitizing alleles in the dopaminergic and serotonergic neurotransmitter systems. STUDY DESIGN: We conducted a secondary analysis of data from a national urban birth cohort using mother reports in conjunction with child assessments and salivary genetic data. Child vocabulary was assessed using the Peabody Picture Vocabulary Test (PPVT). The primary exposure was mother-reported shared reading. We used data on gene variants that may affect the function of the dopaminergic and serotonergic systems. We examined associations between shared reading and PPVT score using multiple linear regression. We then included interaction terms between shared reading and the presence of sensitizing alleles for each polymorphism to assess potential moderator effects adjusting for multiple comparisons. RESULTS: Of the 1772 children included (56% black, 52% male), 31% of their mothers reported reading with their child daily. Daily shared reading was strongly associated with child PPVT scores in unadjusted (B=7.9; 95% confidence interval (CI): 4.3–11.4) and adjusted models (B=5.3; 95% CI: 2.0–8.6). The association differed based on the presence of sensitizing alleles in the dopamine receptor 2 and serotonin transporter genes. CONCLUSIONS: Among urban children, shared reading at age 1 was associated with greater vocabulary at age 3. Although children with sensitizing alleles on the dopamine receptor 2 and serotonin transporter genes were at greater risk when not read to, they fared as well as children without these alleles when shared reading occurred.

Objective To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. Design Prospective, multicenter before and after intervention study. Setting Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. Participants All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. Intervention Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds (“family centered rounds”), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. Main outcome measures Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. Results The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, “excellent”) ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. Conclusions Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. Trial registration ClinicalTrials.gov NCT02320175 .

* Abbreviations: AAP — : American Academy of Pediatrics ECFMG — : Educational Commission for Foreign Medical Graduates IMG — : international medical graduate The American Medical Association Physician Masterfile reveals 26 000 physicians who attended medical school outside the United States and Canada and who are not currently in residency, declaring pediatrics as their specialty. According to the Educational Commission for Foreign Medical Graduates (ECFMG), in 2015, 3 countries (India, Canada, and Pakistan) contributed the highest numbers of non–US-born international medical graduates (IMGs) receiving ECFMG certification. However, there were also a sizable number of certificate holders from Latin America, the Middle East, and Africa (Nigeria).1 Non–US-born pediatricians inherently offer a broad cultural, linguistic, and ethnic diversity; as such, they may contribute to the goal in our pediatric specialty to improve workforce diversity and culturally effective health care.2,3 IMGs (including US-born IMGs) comprise >26% of the entire physician workforce in the United States. Forty-one percent of practicing IMGs are in primary care disciplines as defined by the Association of American Medical Colleges.4 They play a vital role in the care of vulnerable populations in both rural and urban underserved areas.2,5 Non–US-born IMGs also constitute a disproportionate number of subspecialists … Address correspondence to Rana Chakraborty, MD, MSc, FRCPCH, FAAP, FPIDS, PhD, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. E-mail: chakraborty.rana{at}mayo.edu

* Abbreviations: AAP — : American Academy of Pediatrics ACE — : adverse childhood experience NYC — : New York City Family homelessness in the United States became an egregious problem in the 1980s and was the reason that I, as a young pediatrician, discovered the importance of advocacy. In my hometown, New York City (NYC), because of increasing income inequality, neighborhood gentrification, and poor housing policies nationally and locally (all leading to dramatically decreased availability of affordable housing for low-income families), there was a growing number of children living in so-called “welfare hotels.” This number increased from 5000 each night in 1983 to 12 000 each night in 1988.1 Because many of these families were sheltered in hotels in midtown Manhattan, my program at Bellevue Hospital Center provided many of these children with health care within our hospital as well as in a clinic that we ran in one of the biggest hotels. I became active in my American Academy of Pediatrics (AAP) chapter and started the Committee on Homeless Families in New York Chapter 3. My colleagues and I learned how to collaborate with community-based advocacy organizations to fight for better treatment of homeless families in the shelter system as well as for better housing policies, at least in NYC. The result of those efforts by many advocates was that by 1990–1991, the number of children without a home being sheltered each night was back down to ∼5000.1 The nightmarish conditions of the lawless hotels were gone, and instead, safer and better-resourced, city-run shelters housed these families. Today, however, there are more homeless families in NYC than ever, with 22 000 children in 15 000 families being housed … Address correspondence to Benard P. Dreyer, MD, Department of Pediatrics, New York University School of Medicine, 462 First Ave, NBV 8E-11, New York, NY 10016. E-mail: bpd1{at}nyulangone.org

What's New The NIH-funded SAFE Rx for Kids study has identified best practices for the labeling/dosing of pediatric liquid medications. Findings support use of pictographic instructions and optimized provision of dosing tools, along with careful selection of the unit of measurement used.

Poor children are at greater risk for worse health, less productivity, and harms to well-being that extend into adulthood and subsequent generations. Timing and duration of poverty matter and influence life course outcomes, especially for education, health, and lifetime productivity. This article focuses on interventions by policy advocacy and the pediatric health system, and protection of the health and well-being of families in economic hardship from disadvantages and trauma wrought by poverty. A framework is presented for child poverty prevention and its consequences for lifelong health and success on a national scale.

Parental engagement is critical to children’s educational achievement. Before and during elementary school, it is crucial for parents to be involved in their children’s education in order to foster development and achievement. Hispanic parents’ immigrant status, coupled with a lack of English proficiency, means that they often find themselves of low socioeconomic status (SES). Being low SES also means that parents possess fewer resources for engaging with their children. The current study seeks to understand low-income, primarily Hispanic mothers’ perceptions of their roles in their first grade children’s education. Mothers were interviewed regarding parenting confidence related to teaching their children, and responses were analyzed using qualitative research methods. Mothers in this study associated their roles in their children’s education with two primary areas: helping their children to learn, and raising their children to be well-behaved and respectful. The main barrier to parental confidence in these roles appeared to be mothers’ lack of English proficiency. This is consistent with previous research demonstrating that Hispanic parents maintain the perception of a lack of proficiency in English as a significant barrier to parental involvement in their children’s education in the United States. Future interventions with teachers and parents may benefit from these findings in consideration of the optimal ways to involve parent related to their perceived personal strengths regarding parental engagement.

OBJECTIVES: To determine impacts on social-emotional development at school entry of a pediatric primary care intervention (Video Interaction Project [VIP]) promoting positive parenting through reading aloud and play, delivered in 2 phases: infant through toddler (VIP birth to 3 years [VIP 0–3]) and preschool-age (VIP 3 to 5 years [VIP 3–5]). METHODS: Factorial randomized controlled trial with postpartum enrollment and random assignment to VIP 0-3, control 0 to 3 years, and a third group without school entry follow-up (Building Blocks) and 3-year second random assignment of VIP 0-3 and control 0 to 3 years to VIP 3-5 or control 3 to 5 years. In the VIP, a bilingual facilitator video recorded the parent and child reading and/or playing using provided learning materials and reviewed videos to reinforce positive interactions. Social-emotional development at 4.5 years was assessed by parent-report Behavior Assessment System for Children, Second Edition (Social Skills, Attention Problems, Hyperactivity, Aggression, Externalizing Problems). RESULTS: VIP 0-3 and VIP 3-5 were independently associated with improved 4.5-year Behavior Assessment System for Children, Second Edition T-scores, with effect sizes (Cohen’s d) ∼−0.25 to −0.30. Receipt of combined VIP 0-3 and VIP 3-5 was associated with d = −0.63 reduction in Hyperactivity (P = .001). VIP 0-3 resulted in reduced “Clinically Significant” Hyperactivity (relative risk reduction for overall sample: 69.2%; P = .03; relative risk reduction for increased psychosocial risk: 100%; P = .006). Multilevel models revealed significant VIP 0-3 linear effects and age × VIP 3-5 interactions. CONCLUSIONS: Phase VIP 0-3 resulted in sustained impacts on behavior problems 1.5 years after program completion. VIP 3-5 had additional, independent impacts. With our findings, we support the use of pediatric primary care to promote reading aloud and play from birth to 5 years, and the potential for such programs to enhance social-emotional development.

BACKGROUND AND OBJECTIVES: Poorly designed labels and dosing tools contribute to dosing errors. We examined the degree to which errors could be reduced with pictographic diagrams, milliliter-only units, and provision of tools more closely matched to prescribed volumes. METHODS: This study involved a randomized controlled experiment in 3 pediatric clinics. English- and Spanish-speaking parents (n = 491) of children ≤8 years old were randomly assigned to 1 of 4 groups and given labels and dosing tools that varied in label instruction format (text and pictogram, or text only) and units (milliliter-only ["mL"] or milliliter/teaspoon ["mL/tsp"]). Each parent measured 9 doses of liquid medication (3 amounts [2, 7.5, and 10 mL] and 3 tools [1 cup, 2 syringes (5- and 10-mL capacities)]) in random order. The primary outcome was dosing error (>20% deviation), and large error (>2× dose). RESULTS: We found that 83.5% of parents made ≥1 dosing error (overdosing was present in 12.1% of errors) and 29.3% of parents made ≥1 large error (>2× dose). The greatest impact on errors resulted from the provision of tools more closely matched to prescribed dose volumes. For the 2-mL dose, the fewest errors were seen with the 5-mL syringe (5- vs 10-mL syringe: adjusted odds ratio [aOR] = 0.3 [95% confidence interval: 0.2–0.4]; cup versus 10-mL syringe: aOR = 7.5 [5.7–10.0]). For the 7.5-mL dose, the fewest errors were with the 10-mL syringe, which did not necessitate measurement of multiple instrument-fulls (5- vs 10-mL syringe: aOR = 4.0 [3.0–5.4]; cup versus 10-mL syringe: aOR = 2.1 [1.5–2.9]). Milliliter/teaspoon was associated with more errors than milliliter-only (aOR = 1.3 [1.05–1.6]). Parents who received text only (versus text and pictogram) instructions or milliliter/teaspoon (versus milliliter-only) labels and tools made more large errors (aOR = 1.9 [1.1–3.3], aOR = 2.5 [1.4–4.6], respectively). CONCLUSIONS: Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.

CONTEXT:Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents’ ability to manage discharge instructions has not been examined before in a systematic review.OBJECTIVE:To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.DATA SOURCES:We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).STUDY SELECTION:We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.DATA EXTRACTION:Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.RESULTS:Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).LIMITATIONS:The studies were primarily observational in nature.CONCLUSIONS:Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

Background and Objectives A recent American Academy of Pediatrics policy statement recommends milliliter-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to milliliters only, and the role of health literacy and prior milliliter-dosing experience. Methods Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE Rx for Kids study). English- and Spanish-speaking parents (n = 493) of children aged ≤8 years were randomized to 1 of 4 study arms and given labels and dosing tools which varied in label instruction format (text plus pictogram, text only) and units (milliliter only ["mL"], milliliter/teaspoon ["mL"/"tsp"]). Outcomes included teaspoon preference in dosing instructions and perceived difficulty with milliliter-only dosing. The predictor variable was health literacy (Newest Vital Sign; low [0–1], marginal [2–3], adequate [4–6]). The mediating variable was prior milliliter-dosing experience. Results Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use milliliters, perceived milliliter-only dosing to be easy, and had prior milliliter-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived milliliter-only dosing will be difficult, and 17.7% had no prior milliliter-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs adequate: adjusted odds ratio [AOR] = 2.9 [95% confidence interval [CI] 1.3–6.2]), and greater odds of perceiving difficulty with milliliter-only dosing (low vs adequate: AOR = 13.9 [95% CI 4.8–40.6], marginal vs adequate: AOR = 7.1 [95% CI 2.5–20.4]). Lack of experience with milliliter dosing partially mediated the impact of health literacy. Conclusions Most parents were comfortable with milliliter-only dosing. Parents with low health literacy were more likely to perceive milliliter-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. RESULTS: Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2–4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03–3.5) dose; associations greater for parents with low health literacy and non–English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon–associated measurement errors. CONCLUSIONS: Findings support a milliliter-only standard to reduce medication errors.