Parent Dosing Tool Use, Beliefs, and Access: A Health Literacy Perspective.

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.

Links between Shared Reading and Play, Parent Psychosocial Functioning, and Child Behavior: Evidence from a Randomized Controlled Trial.

OBJECTIVE: To investigate pathways by which interventions that promote shared reading and play help prevent child behavior problems. We examined whether family processes associated with the family investment pathway (eg, parental cognitive stimulation) and the family stress pathway (eg, mothers' psychosocial functioning) mediated impacts of a pediatric-based preventive intervention on child behavior. STUDY DESIGN: The sample included 362 low-income mothers and their children who participated in a randomized controlled trial of the Video Interaction Project, a pediatrics-based preventive intervention that promotes parent-child interactions in the context of shared reading and play. Parent-child dyads were randomly assigned to group at birth. Three mediators-parental cognitive stimulation, maternal stress about the parent-child relationship, and maternal depressive symptoms-were assessed at child ages 6 and 36 months. The outcome, child externalizing behaviors, was assessed at 36 months. We used a series of path analytic models to examine how these family processes, separately or together, mediated the impacts of the Video Interaction Project on child behavioral outcomes. RESULTS: Intervention impacts on child behavior were mediated by enhancements in cognitive stimulation and by improvements in mothers' psychosocial functioning. A sequential mediation model showed that Video Interaction Project impacts on cognitive stimulation at 6 months were associated with later decreases in mothers' stress about the parent-child relationship and that this pathway mediated intervention impacts on child behavioral outcomes at 3 years of age (P = .023). CONCLUSIONS: Using an experimental design, this study identifies pathways by which parent-child interactions in shared reading and play can improve child behavioral outcomes. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00212576.

Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy.

OBJECTIVE: To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions. STUDY DESIGN: This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation. RESULTS: Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004). CONCLUSIONS: Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Enhancing Parent Talk, Reading, and Play in Primary Care: Sustained Impacts of the Video Interaction Project.

OBJECTIVE: To determine the early impacts of pediatric primary care parenting interventions on parent cognitive stimulation in low socioeconomic status families and whether these impacts are sustained up to 1.5 years after program completion. STUDY DESIGN: This randomized controlled trial included assignment to 1 of 2 interventions (Video Interaction Project [VIP] or Building Blocks) or to a control group. Mother-newborn dyads were enrolled postpartum in an urban public hospital. In VIP, dyads met with an interventionist on days of well-child visits; the interventionist facilitated interactions in play and shared reading through provision of learning materials and review of videotaped parent-child interactions. In Building Blocks, parents were mailed parenting pamphlets and learning materials. We compare the trajectories of cognitive stimulation for parents in VIP and control from 6 to 54 months. RESULTS: There were 546 families that contributed data. VIP was associated with enhanced reading, parent verbal responsivity, and overall stimulation at all assessment points, with analyses demonstrating a 0.38 standard deviation increase in cognitive stimulation overall. Trajectory models indicated long-term persistence of VIP impacts on reading, teaching, and verbal responsivity. CONCLUSIONS: VIP is associated with sustained enhancements in cognitive stimulation in the home 1.5 years after completion of the program and support expansion of pediatric interventions to enhance developmental trajectories of children of low socioeconomic status. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00212576.

Children under the age of two are more likely to watch inappropriate background media than older children.

AIM: To establish whether young children watched foreground electronic media or background media that was not aimed at them or was inappropriate for their age. METHODS: We performed a longitudinal analysis of mother-infant dyads participating in a larger parenting study. The primary dependent variable was maternal reports of watching habits from media diaries at 6, 14, 24 and 36 months. Independent variables were child age, programme content and whether the programme was turned on specifically for the child. RESULTS: We analysed 3570 programme exposures in 527 children, mostly from television. Children were significantly more likely to actually watch programmes if they were older, if the content was coded as 'educational young child' or if the parent tuned on the programme specifically so the child could watch it. Children under the age of two were more likely than older children to watch background media that featured age-inappropriate content or had not been turned on for them to watch [30% versus 16% of programmes; AOR = 2.19 (95%CI 1.82-2.65)]. CONCLUSION: Young children under the age of two frequently watch background media that has age-inappropriate content or has not been turned on for them to watch.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios.

BACKGROUND AND OBJECTIVES: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Achieving Child Health Equity: Policy Solutions.

Policy solutions to address child health equity, with evidence to support the policies, are presented. Policies address health care, direct financial support to families, nutrition, support for early childhood and brain development, ending family homelessness, making housing and neighborhoods environmentally safe, gun violence prevention, LGBTQ + health equity, and protecting immigrant children and families. Federal, state, and local policies are addressed. Recommendations of the National Academy of Science, Engineering, and Medicine and the American Academy of Pediatrics are highlighted when appropriate.

Validation of the StimQ2: A parent-report measure of cognitive stimulation in the home.

Considerable evidence demonstrates the importance of the cognitive home environment in supporting children's language, cognition, and school readiness more broadly. This is particularly important for children from low-income backgrounds, as cognitive stimulation is a key area of resilience that mediates the impact of poverty on child development. Researchers and clinicians have therefore highlighted the need to quantify cognitive stimulation; however existing methodological approaches frequently utilize home visits and/or labor-intensive observations and coding. Here, we examined the reliability and validity of the StimQ2, a parent-report measure of the cognitive home environment that can be delivered efficiently and at low cost. StimQ2 improves upon earlier versions of the instrument by removing outdated items, assessing additional domains of cognitive stimulation and providing new scoring systems. Findings suggest that the StimQ2 is a reliable and valid measure of the cognitive home environment for children from infancy through the preschool period.

Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review.

CONTEXT: Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE: To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES: PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION: Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION: Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS: Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS: No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS: Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.

Training physician investigators in medicine and public health research.

OBJECTIVES: We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health. METHODS: We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations. RESULTS: Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12). CONCLUSIONS: A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health.

Integrating Health Care Strategies to Prevent Poverty-Related Disparities in Development and Growth: Addressing Core Outcomes of 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.

Social Capital as a Positive Social Determinant of Health: A Narrative Review.

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.

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old.

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.

Screening for developmental delay in high-risk users of an urban pediatric emergency department.

OBJECTIVE: To determine whether screening children in an urban pediatric emergency department (PED) would lead to identification of previously undiagnosed developmental delay. METHODS: This was a cross-sectional study of families presenting to an urban public hospital PED with children 6 to 36 months and no history of developmental delay. Children were screened for possible developmental delay using the Ages and Stages Questionnaire; parents completed an instrument that assesses 5 domains: communication, gross motor, fine motor, problem solving, and personal-social. Sociodemographic data were also obtained. RESULTS: One hundred thirty-eight children were enrolled, all accompanied by their mothers. Mean age of the children was 18.9 months; 51.5% were female; 56.8% of the mothers were high-school graduates; 59.9% were immigrants; 75.4% were Latino. Twenty-one percent did not have a regular source of primary care; 26.8% (95% confidence interval, 20.1%-34.8%) screened positive in at least 1 domain, with a trend toward the highest percentage of positive screens on the communication domain (z = 1.89, P = 0.059). In a simultaneous multiple logistic regression model including all predictor variables, child age of 12 to 30 months was associated with increased adjusted odds of positive screen (adjusted odds ratio, 8.4; 95% confidence interval, 1.4-48.9). Having a primary caregiver born in the United States was statistically significant for screening positive in at least 1 Ages and Stages Questionnaire domain (P = 0.03). CONCLUSIONS: Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay, suggesting the utility of performing routine developmental screening in the PED. Pediatric emergency department use alone may be an indication for screening. Further study is needed for feasibility of screening for delay in the PED.

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

CONTEXT: In response to reports of unintentional drug overdoses among children given over-the-counter (OTC) liquid medications, in November 2009 the US Food and Drug Administration (FDA) released new voluntary industry guidelines that recommend greater consistency and clarity in OTC medication dosing directions and their accompanying measuring devices. OBJECTIVE: To determine the prevalence of inconsistent dosing directions and measuring devices among popular pediatric OTC medications at the time the FDA's guidance was released. DESIGN AND SETTING: Descriptive study of 200 top-selling pediatric oral liquid OTC medications during the 52 weeks ending October 30, 2009. Sample represents 99% of the US market of analgesic, cough/cold, allergy, and gastrointestinal OTC oral liquid products with dosing information for children younger than 12 years. MAIN OUTCOME MEASURES: Inclusion of measuring device, within-product inconsistency between dosing directions on the bottle's label and dose markings on enclosed measuring device, across-product use of nonstandard units and abbreviations, and presence of abbreviation definitions. RESULTS: Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation. CONCLUSION: At the time the FDA released its new guidance, top-selling pediatric OTC liquid medications contained highly variable and inconsistent dosing directions and measuring devices.

Do Verbal Interactions with Infants During Electronic Media Exposure Mitigate Adverse Impacts on their Language Development as Toddlers?

The goal of this study was to determine whether verbal interactions between mothers and their 6-month-old infants during media exposure ('media verbal interactions') might have direct positive impacts, or mitigate any potential adverse impacts of media exposure, on language development at 14 months. For 253 low-income mother-infant dyads participating in a longitudinal study, media exposure and media verbal interactions were assessed using 24-hour recall diaries. Additionally, general level of cognitive stimulation in the home [StimQ] was assessed at 6 months and language development [Preschool Language Scale-4] was assessed at 14 months. Results suggest that media verbal interactions play a role in the language development of infants from low-income, immigrant families. Evidence showed that media verbal interactions moderated adverse impacts of media exposure found on 14-month language development, with adverse associations found only in the absence the these interactions. Findings also suggest that media verbal interactions may have some direct positive impacts on language development, in that media verbal interactions during the co-viewing of media with educational content (but not other content) were predictive of 14-month language independently of overall level of cognitive stimulation in the home.

Health Literacy and Pediatric Health.

The chapters and reports in this book explore a wide variety of topics related to how health literacy can impact clinical practice and public health. While health literacy is relevant to healthcare issues across populations, it has unique implications in the field of pediatrics, where parents and other caregivers are responsible for managing their child's healthcare. Younger children have varying roles and involvement; over time, as children reach adolescence, they have an increasing understanding of and participation in their healthcare. This chapter will review the epidemiology of health literacy in parents, adolescents, and children, and how this compares to the general adult population. It will highlight unique considerations regarding health literacy and pediatric health. The chapter will then focus on the impact of health literacy and relevant health literacy-informed interventions on pediatric health. Finally, the chapter will discuss gaps in the literature and future directions.