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To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database.Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn.Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories.Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.

Purpose of review Mothers with substance use disorders are often referred for parenting support, though commonly available programs may miss the mark for families impacted by addiction. This may be related to a lack of attention to children's emotional needs, mothers' histories of adversity, and the neurobiological differences seen in mothers with addictions. We review the implications of addiction, adversity, and attachment for parenting interventions. We then describe Mothering from the Inside Out (MIO), an evidence-based parenting intervention designed specifically for mothers with addictions. Recent findings Evidence from clinical trials suggests that MIO improves outcomes for two generations: both mothers with addictions and their children. Recent trials demonstrate that MIO may be delivered effectively by community-based clinicians and may be beneficial for parents with other chronic stressors. Summary Addressing addiction, adversity, and attachment simultaneously may have a positive synergistic effect. Future research should study the implementation of MIO in real-world settings and examine the impact of MIO on maternal neurobiology.

CONTEXT Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes. OBJECTIVE To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data. DATA SOURCES Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020. STUDY SELECTION Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant’s first birthday. DATA EXTRACTION We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings. RESULTS Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes. CONCLUSIONS Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.

OBJECTIVE To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS). METHODS We conducted a retrospective cohort study of 256 infants born with NAS (2006-2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment. RESULTS Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09-4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37-5.31). CONCLUSION Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.

BACKGROUND: Increasing rates of maternal opioid use disorder has led to greater number of opioid exposed newborns (OENs). Maternal enrollment in medication for opioid use disorder (MOUD) program improves short term neonatal outcomes. This study aimed at assessing neurobehavioral outcomes for OENs. METHODS: Retrospective observational cohort study of OENs between Jul 2006 and Dec 2018. Two study groups were identified as initiation of medication for opioid use disorder (MOUD) prior to diagnoses of pregnancy or after. Primary outcome variables were enrollment in and duration of EI services. Secondary outcome variable was diagnoses of a behavioral and/or developmental disorder (BDD) during the study period. RESULTS: Of 242 infants, 113 were enrolled in EI and BDD diagnoses data was available for all infants [age range 6 to 12 years], 82% infants had exposure to maternal MOUD, while 18% were exposed to either maternal prescription non-MOUD opioids or illicit opioids. Maternal MOUD initiation prior to pregnancy was associated with improved short term outcomes for OENs. Almost a third of infants were diagnosed with a BDD with no differences between the two study groups. CONCLUSION: Early initiation of maternal MOUD improved short term outcomes and discharge disposition for OENs. Prolonged in-utero exposure to opioids presents a potential for negative impact on neurodevelopmental and behavioral outcomes. These risks must be considered to increase access and adherence to EI services, as well as to focus on non-opioid based maternal MOUD. Longitudinal studies assessing the safety of MOUD on short and long-term child health outcomes are needed.

Background Despite being highly motivated to recover, pregnant and postpartum women with opioid use disorders (OUD) are at high risk of relapse and death. While many services mitigate this risk, engagement in voluntary, outpatient services remains low. Our aim was to understand the experiences of and factors influencing outpatient service engagement during the perinatal period among women in recovery from OUD. Methods We conducted semi-structured interviews about perinatal experiences engaging with outpatient services, with 20 women in recovery aged 22–46 years who had children between 6 months and 10 years old. Interviews were audio-recorded, transcribed, coded, and analyzed using conventional content analysis. Results Women described a continuum of ‘collaborative engagement’ experiences, defined by the extent to which they perceived their providers or service organizations were invested in their journeys as a partners and advocates. The ability to achieve collaborative engagement depended upon two factors: (1) the woman's transformational development as a mother and woman in recovery, and (2) her perception of the providers’ ability to meet her multifaceted needs. Conclusions Women in recovery from OUD may experience deeper engagement in voluntary outpatient perinatal services when they perceive that their providers are invested and collaboratively engaging in their recovery and personal growth. Future research should test whether collaborative engagement improves service retention. Abbreviations: IPV: Intimate Partner Violence; OUD: opioid use disorder

In this commentary, we describe the triple threat that parents in recovery face during the COVID-19 pandemic due to the loss of social support. We explore how the absence of human connection during the pandemic can be detrimental to parents in recovery as well as the parent-child relationship. We conclude by proposing strategies to offer critical support for families as this period of social isolation extends and the effects become increasingly apparent.

BACKGROUND AND OBJECTIVES: Opioid-exposed infants frequently qualify for early intervention (EI). However, many eligible families choose not to enroll in this voluntary service. This study aims to understand the perceptions and experiences that may impact engagement with, and the potential benefits of, EI services among mothers in recovery from opioid use disorders (OUDs). METHODS: We conducted semistructured qualitative interviews (n = 22) and 1 focus group (n = 6) with mothers in recovery from OUDs in western Massachusetts. Transcripts were coded and analyzed by using a descriptive approach. RESULTS: The mean participant age was 32 years, and 13 had a high school degree or less. Five major themes emerged revealing mothers’ development through stages of engagement in EI services: (1) fear, guilt, and shame related to drug use (emotions acting as barriers to enrollment); (2) the question of whether it is “needed” (deciding whether there is value in EI for opioid-exposed infants); (3) starting with “judgment” (baseline level of perceived stigma that parents in recovery associate with EI); (4) breaking down the “wall” (how parents overcome the fear and perceived judgment to build partnerships with providers); and (5) “above and beyond” (need for a personal connection with mothers and concrete supports through EI in addition to the child-focused services provided). CONCLUSIONS: Barriers to engagement in EI among mothers in recovery from OUDs include a range of emotions, perceived stigma, and ambivalence. An effort to purposefully listen to and care for mothers through a strengths-based, bigenerational approach may help establish greater connections and foster stronger EI engagement among families affected by OUDs.

Recent improvements in child health have led to substantial decreases in child mortality globally.1 While progress is still needed, especially in regions afflicted by conflict and political instability,2 the next step is to promote young children’s development and early learning so they can remain healthy, take advantage of growing educational opportunities, and contribute to their communities’ economic growth. Every year, approximately 249 million children, mainly from low- and middle- income countries, fail to reach their developmental potential in the context of poverty and related health, nutrition, and social factors.3 Recessions and climate change additionally contribute to loss of developmental potential globally.4–7 While principles of early childhood development are universal, a global perspective must consider exposure to extreme poverty and high prevalence of infectious diseases, cultural context, and availability and type of resources. This chapter will describe biological and social factors that influence brain development and early learning and resilience, their cultural context, and examples of successful child development interventions globally. We also provide recommendations to rapidly accelerate the promotion of early childhood development globally with key strategies, including an emphasis on universal prevention programs rather than universal screening, multigenerational models that emphasize universal support for parents and targeted support for high-risk populations, integration of child development programs into child health and nutrition efforts, and use of technology.

OBJECTIVE As antiretroviral therapy (ART) expands for HIV-infected children, it is important to determine its impact on growth. We quantified growth and its determinants following ART in resource-limited (RLS) and developed settings. DESIGN Systematic review and meta-analysis. METHODS We searched publications reporting growth [weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) z scores] in HIV-infected children following ART through August 2014. Inclusion criteria were as follows: younger than 18 years; ART; at least 20 patients; growth at ART; and post-ART growth. Standardized and overall weighted mean differences were calculated using random-effects models. RESULTS A total of 67 articles were eligible (RLS = 54; developed settings = 13). Mean age was 5.8 years, and comparable between settings (P = 0.90). Baseline growth was substantially lower in RLS vs. developed settings (WAZ -2.1 vs. -0.5; HAZ -2.2 vs. -0.9; both P

* Abbreviation: EI — : early intervention In the current issue of Pediatrics, Magnusson et al1 describe findings from 22 semistructured interviews with low-income African American and Hispanic mothers. The mothers discuss health beliefs that facilitate or impede engagement with early intervention (EI) services for their children after a positive screen for developmental delay in the primary care setting. From these interviews, the authors identify 5 themes: (1) comparisons with other children influence perceptions of their own children’s development, (2) perceptions that children develop at their own pace can lead mothers to believe their children are developing normally, (3) social networks inform decisions to seek services, (4) competing stressors are often prioritized over services, and (5) conflicting information about EI referral processes can discourage engagement with services. These health beliefs clearly have important consequences for individual patients. What may be less clear is the role such health beliefs can (and should) play in informing research and clinical approaches to developmental screening within US pediatric primary care delivery systems. The principal implication of Magnusson et al’s1 study is that it offers a series of evidence-informed hypotheses for why families sort into those who engage with developmental services and those who … Address correspondence to Michael Silverstein, MD, MPH, Department of Pediatrics, Boston Medical Center, 1 Boston Medical Center Pl, Vose Hall 3rd Floor, Boston, MA 02118. E-mail: michael.silverstein{at}bmc.org

Objective: Disparities persist in breastfeeding exclusivity and duration despite increases in breastfeeding initiation. The objective of this study was to examine factors that influence maternal decision making surrounding infant feeding practices over time in a diverse inner-city population. Methods: We conducted a prospective qualitative study with 20 mothers recruited from 2 urban primary care clinics. Participants completed open-ended interviews and demographic questionnaires in English or Spanish administered at approximately 2 weeks and 6 months postpartum. Transcripts were analyzed using a combined technique of inductive (data-driven) and deductive (theory-driven, based on the Theory of Planned Behavior) thematic analysis using 3 independent coders and iterative discussion to reach consensus. Results: All women initiated breastfeeding, and 65% reported perceived insufficient milk (PIM). An association between PIM and behavioral control emerged as the overarching theme impacting early breastfeeding cessation and evolved over time. Early postpartum, PIM evoked maternal distress—strong emotional responses to infant crying and need to control infant behaviors. Later, mothers accepted a perceived lack of control over milk supply with minimal distress or as a natural process. Decisions to stop breastfeeding occurred through an iterative process, informed by trials of various strategies and observations of subsequent changes in infant behavior, strongly influenced by competing psychosocial demands. Conclusion: Infant feeding decisions evolve over time and are influenced by perceptions of control over infant behavior and milk supply. Tailored anticipatory guidance is needed to provide time-sensitive strategies to cope with challenging infant behaviors and promote maternal agency over breastfeeding in low-income populations.

The February 2010 earthquake and tsunamis destroyed 80% of the coastal town of Dichato, Chile, displacing over 400 families for nearly 4 years. The coalition Recupera Chile (RC) participated in the town’s integrated recovery process from January 2011 to the present with a focus on children’s mental health. The multidisciplinary RC coalition emphasized community-led post-disaster recovery, economic capacity rebuilding, and community health promotion (www.recuperachile.org). RC’s child health team fostered partnerships between the local elementary school, health clinic, Universidad de Concepcion, and Boston Children’s Hospital. The team responded to priorities identified by the town with a three-pronged approach of (1) case management, (2) resource development, and (3) monitoring and evaluation. This work resulted in the development of a model school-based program: La Escuela Basada en Realidad, which encompassed (1) health and mental health, (2) language and literacy, and (3) love of the sea. Post-disaster programs targeting mental health require a multi-year approach that extends beyond the completion of the physical reconstruction. Recovery is an organic process that cannot be prescripted and depends on solutions that emerge from the community. Finally, partnerships between schools and universities can foster resiliency and sustainability of programs for children and families. (Disaster Med Public Health Preparedness. 2017;11:633–636)

OBJECTIVES/SPECIFIC AIMS: This study aims to understand the factors influencing engagement with out-patient services from pregnancy to 1 year postpartum among women in recovery from opioid use disorders (OUD). METHODS/STUDY POPULATION: We conducted semi-structured qualitative interviews and a brief survey with 20 mothers in OUD recovery recruited from health care and community organizations in Western MA. Transcripts were coded by two independent coders and analyzed using a qualitative descriptive approach. RESULTS/ANTICIPATED RESULTS: The average duration of any addiction treatment among the 20 participants was 5.6 years with 80% receiving medication-assisted treatment during a pregnancy. Approximately two-thirds experienced relapse during pregnancy or the first year postpartum. We identified 3 themes elucidating women’s experiences around service engagement: “How I see myself” (personal development), “How services see me” (service delivery quality), and “Are you with me?” Personal development included response to past trauma, coping strategies and self-advocacy, and adjusting to parenthood. Service delivery quality was influenced by service design, efficacy of individual providers, and cultural norms (organizational and societal). In the final theme, intersection of individual and service-level factors influenced the degree and quality of the women’s experience engaging with services. DISCUSSION/SIGNIFICANCE OF IMPACT: Women describe successful engagement when they experience service providers as being emotionally supportive, delivering relevant services, and advocating on their behalf. To best support and engage families affected by OUD, relevant and timely services should be linked with compassionate delivery.

Randomized controlled trials, the gold standard, have been the backbone for 50 years of advancing medical knowledge to benefit patients.1 More recently, it has become the gold standard to test selected health policy, health systems, and even economic ideas. The article by Goff et al in this month’s Pediatrics is an example of an elegantly developed and implemented randomized controlled trial to evaluate the efficacy of patient navigators providing low-income prenatal patients with traditional quality measures of pediatric practices to see if it would inform their choice of pediatric care.2 The authors found that women in the intervention group were more likely to use this information presented by the navigator compared with a control group to make their decision to select a practice with higher clinical quality and patient experience scores. However, few women (5%) rated quality measures as among the most important factors in their selection. The authors conducted multiple additional analyses, including assessing potential effect modifiers with no important changes in findings. Given the labor-intensive approach of using patient navigators to get this marginal effect, it is unlikely to be implemented … Address correspondence to Barry Zuckerman, MD, East Concord St, Vose Building, Room 324L, Boston, MA 02118. E-mail: barry.zuckerman{at}bmc.org.

To: 1) examine sociodemographic factors associated with high parental self-efficacy and perceived control, and 2) determine how self-efficacy and control relate to the home learning environment (HLE), including whether they mediate the relationship between sociodemographic characteristics and HLE, among low-income parents of young children.Cross-sectional survey of English- and Spanish-speaking parents, 18 years of age and older, with children 15 to 36 months old, to assess parental self-efficacy, perceived control, HLE, and sociodemographic characteristics. Bivariate analysis identified sociodemographic predictors of high self-efficacy and control. Separate multivariate linear regression models were used to examine associations between self-efficacy, control, and the HLE. Formal path analysis was used to assess whether self-efficacy and control mediate the relationship between sociodemographic characteristics and HLE.Of 144 participants, 25% were white, 65% were immigrants, and 35% completed the survey in Spanish. US-born subjects, those who completed English surveys, or who had higher educational levels had significantly higher mean self-efficacy and perceived control scores (P .05). Higher self-efficacy and perceived control were associated with a positive change in HLE score in separate multivariate models (self-efficacy β = .7 [95% confidence interval (CI), 0.5-0.9]; control β = .5 [95% CI, 0.2-0.8]). Self-efficacy acted as a mediator such that low self-efficacy explained part of the association between parental depressive symptoms, immigrant status, and less optimal HLE (P = .04 and .001, respectively).High parental self-efficacy and perceived control positively influence HLEs of young children. Self-efficacy alone mediates the relationship between parental depressive symptoms, immigrant status, and less optimal early home learning.

Difficult infant temperament is associated with higher weight status in infancy. However, the association of infant temperament, including regulatory capacities, has not been well studied as a possible predictor of future weight status in early childhood. We examined prospective associations of infant regulatory difficulties with obesity in early childhood in a large, diverse cohort.We used data from 5750 children in the Early Childhood Longitudinal Study-Birth Cohort, excluding preterm infants and infants small or large for gestational age. Infant regulatory ability was measured at age 9 months by the Infant Toddler Symptom Checklist (ITSC). We created a multivariable logistic regression model comparing risk of obesity at preschool age in infants with ITSC scores ≥6 to infants with scores6. We further examined the association when stratified by a measure of maternal sensitivity.The cohort of children was 48% non-Hispanic white, and 51% were boys. Twenty-one percent of children with ITSC scores ≥6 were obese at preschool age. Infants with ITSC scores ≥6 had 32% increased odds of being obese at preschool age (adjusted odds ratio 1.32 [95% confidence interval 1.03, 1.70]). The strongest association existed among children described as demanding attention constantly. There was no difference in the association when comparing mothers with high or low maternal sensitivity.Infant regulatory difficulties are associated with a higher risk of obesity at preschool age. Helping parents manage and respond to difficult infant behaviors before preschool may serve as a focal point for future interventions.

CONTEXT: The pediatric primary care setting offers a platform to promote positive parenting behaviors and the optimal development of young children. Many new interventions have been developed and tested in this setting over the past 2 decades. OBJECTIVE: To summarize the recent published evidence regarding the impact of primary care–based interventions on parenting behaviors and child development outcomes; to provide recommendations for incorporation of effective interventions into pediatric clinics. DATA SOURCES: A literature search of PubMed and PsycINFO was conducted from January 1, 1999, to February 14, 2017. STUDY SELECTION: Publications in which primary care–based interventions and reported outcomes regarding the child’s development or parenting behaviors associated with the promotion of optimal child development are described. DATA EXTRACTION: Forty-eight studies in which 24 interventions were described were included. Levels of evidence and specific outcome measures are reported. RESULTS: Included interventions were categorized as general developmental support, general behavioral development, or topic-specific interventions. Two interventions resulted in reductions in developmental delay, 4 improved cognitive development scores, and 6 resulted in improved behavioral intensity or reduction in behavioral problems. Interventions used a variety of theory-based behavior change strategies such as modeling, group discussion, role play, homework assignment, coaching, and video-recorded interactions. Three interventions report the cost of the intervention. LIMITATIONS: Community or home-based interventions were excluded. CONCLUSIONS: Although several interventions resulted in improved child development outcomes for children aged 0 to 3 years, comparison across studies and interventions is limited by use of different outcome measures, time of evaluation, and variability of results.

In the past 15 years, North America made significant advances towards the Millennium Development Goal (MDG) targets despite a crippling and global financial crisis beginning in 2008. The three countries making up North America—Canada, the USA and Mexico—aspired to reach MDGs under strikingly different political and cultural contexts; yet within their own countries, they all face the common challenge of reducing the disparities that exist in education, employment and health across socioeconomic, racial and gender spectrums. Progress towards reduction of disparities in poverty and hunger is evident in North America. Mexico met its goal to cut in half the percentage of people living off