The Prenatal Neighborhood Environment and Geographic Hotspots of Infants with At-risk Birthweights in New York City.

Infants born with low or high ("at-risk") birthweights are at greater risk of adverse health outcomes across the life course. Our objective was to examine whether geographic hotspots of low and high birthweight prevalence in New York City had different patterns of neighborhood risk factors. We performed census tract-level geospatial clustering analyses using (1) birthweight prevalence and maternal residential address from an all-payer claims database and (2) domains of neighborhood risk factors (socioeconomic and food environment) from national and local datasets. We then used logistic regression analysis to identify specific neighborhood risk factors associated with low and high birthweight hotspots. This study examined 2088 census tracts representing 419,025 infants. We found almost no overlap (1.5%) between low and high birthweight hotspots. The majority of low birthweight hotspots (87.2%) overlapped with a socioeconomic risk factor and 95.7% overlapped with a food environment risk factor. Half of high birthweight hotspots (50.0%) overlapped with a socioeconomic risk factor and 48.8% overlapped with a food environment risk factor. Low birthweight hotspots were associated with high prevalence of excessive housing cost, unemployment, and poor food environment. High birthweight hotspots were associated with high prevalence of uninsured persons and convenience stores. Programs and policies that aim to prevent disparities in infant birthweight should examine the broader context by which hotspots of at-risk birthweight overlap with neighborhood risk factors. Multi-level strategies that include the neighborhood context are needed to address prenatal pathways leading to low and high birthweight outcomes.

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.

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.

Duration of US Residence And Resource Needs In Immigrant Families With Young Children.

To mitigate the negative impact of resource needs on child health, practices serving low-income immigrant families have implemented screening programs to connect families to community resources. Little is known about how duration of US residence relates to patterns of resource needs and indicators of acculturation such as community resource knowledge/experience or self-efficacy. We conducted a cross-sectional analysis of a convenience sample of immigrant families with young children at an urban primary care clinic. These families were seen 5/2018-1/2020 for well child care, screening positive for ≥1 social need using a tool derived from Health Leads. Analysis of 114 families found that newly arrived families with a shorter duration of US residence (≤5 years) were more likely to report immediate material hardships like food insecurity and need for essential child supplies. Newly arrived families were also less likely to have access to technology resources such as a computer or smartphone. Long-term families with a longer duration of US residence (≥15 years) were more likely to report chronic needs like poor housing conditions, but also reported increased community resource knowledge/experience and increased self-efficacy. Primary care pediatric practices should assess immigration contextual factors to identify subgroups such as newly arrived families with young children to target resources (e.g., increase screening frequency) or enhance services (e.g., patient navigators) to relieve resource needs.

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.

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.

Material Hardships and Infant and Toddler Sleep Duration in Low-Income Hispanic Families.

OBJECTIVE: To assess relationships between material hardships, shortened sleep duration, and suboptimal sleep practices across infancy and toddlerhood in low-income Hispanic families. METHODS: We analyzed longitudinal data of 451 low-income Hispanic mother-child pairs from a child obesity prevention trial. During infancy and toddlerhood, we used adjusted linear regression to assess associations between material hardship (financial difficulty, food insecurity, housing disrepair, and multiple hardships), sleep duration (24-hour, night), and the number of suboptimal sleep practices (eg, later bedtime, co-sleeping). We used adjusted linear regression to assess the longitudinal association between the number of suboptimal sleep practices in infancy and toddlerhood, and tested whether specific or multiple hardships moderated this association. RESULTS: In infants, financial difficulty and multiple hardships were associated with decreased night sleep (B = -0.59 hours, 95% confidence interval [CI]: -1.04, -0.14; and B = -0.54 hours, 95% CI: -1.00, -0.08). Housing disrepair was associated with decreased 24-hour sleep (B = -0.64 hours, 95% CI: -1.29, -0.01). In toddlers, each additional suboptimal sleep practice was associated with a decrease in night sleep (B = -0.19 hours, 95% CI: -0.29, -0.09). Each additional suboptimal sleep practice in infancy was associated with a 0.30 increase in the number of suboptimal sleep practices in toddlerhood (P < .001), with greater increases for those with food insecurity or multiple hardships. CONCLUSION: Specific and multiple hardships shortened sleep duration during infancy, and moderated the increase of suboptimal sleep behaviors between infancy and toddlerhood. Future studies should consider these early critically sensitive periods for interventions to mitigate material hardships and establish healthy sleep practices.

Accuracy of Parent Perception of Comprehension of Discharge Instructions: Role of Plan Complexity and Health Literacy.

OBJECTIVE: Inpatient discharge education is often suboptimal. Measures of parents' perceived comprehension of discharge instructions are included in national metrics given linkage to morbidity; few studies compare parents' perceived and actual comprehension. We 1) compared parent perceived and actual comprehension of discharge instructions and 2) assessed associations between plan complexity and parent health literacy with overestimation of comprehension (perceive comprehension but lack actual comprehension). METHODS: Prospective cohort study of English/Spanish-speaking parents (n = 192) of inpatients ≤12 years old and discharged on ≥1 daily medication from an urban public hospital. We used McNemar's tests to compare parent perceived (agree/strongly agree on 5-point Likert scale) and actual comprehension (concordance of parent report with medical record) of instructions (domains: medications, appointments, return precautions, and restrictions). Generalized estimating equations were performed to assess associations between low parent health literacy (Newest Vital Sign score ≤3) and plan complexity with overestimation of comprehension. RESULTS: Medication side effects were the domain with lowest perceived comprehension (80%), while >95% of parents perceived comprehension for other domains. Actual comprehension varied by domain (41%-87%) and was lower than perceived comprehension. Most (84%) parents overestimated comprehension in ≥1 domain. Plan complexity (adjusted odds ratio 3.6; 95% confidence interval 2.9-4.7) and low health literacy (adjusted odds ratio 1.9; 1.3-2.6) were associated with overestimation of comprehension. CONCLUSIONS: Parental perceived comprehension of discharge instructions overestimated actual comprehension in most domains. Plan complexity and low health literacy were associated with overestimation of comprehension. Future interventions should incorporate assessment of actual comprehension and standardization of discharge instructions.

Association Between Outdoor Air Pollution Levels and Inpatient Outcomes in Pediatric Pneumonia Hospitalizations, 2007 to 2008.

OBJECTIVE: Pneumonia is a leading cause of pediatric admissions. Although air pollutants are associated with poor outcomes, few national studies have examined associations between pollutant levels and inpatient pediatric pneumonia outcomes. We examined the relationship between ozone (O3) and fine particulate matter with a diameter ≤2.5 µm (PM2.5) and outcomes related to disease severity. METHODS: In this cross-sectional study, we obtained discharge data from the 2007 to 2008 Nationwide Inpatient Sample and pollution data from the Air Quality System. Patients ≤18years with a principal diagnosis of pneumonia were included. Discharge data were linked to O3 and PM2.5 levels (predictors) from the patient's ZIP Code (not publicly available) from day of admission. Outcomes were mortality, intubation, length of stay (LOS), and total costs. We calculated weighted national estimates and performed multivariable analyses adjusting for sociodemographic and hospital factors. RESULTS: There were a total of 57,972 (278,871 weighted) subjects. Median PM2.5 level was 9.5 (interquartile range [IQR] 6.8-13.4) µg/m3. Median O3 level was 35.6 (IQR 28.2-45.2) parts per billion. Mortality was 0.1%; 0.75% of patients were intubated. Median LOS was 2 (IQR 2-4) days. Median costs were $3089 (IQR $2023-$5177). Greater levels of PM2.5 and O3 were associated with mortality, longer LOS, and greater costs. Greater O3 levels were associated with increased odds of intubation. CONCLUSIONS: Greater levels of O3 and PM2.5 were associated with more severe presentations of pneumonia. Future work should examine these relationships in more recent years and over a longer time period.

Medical training in school-based health centers: a collaboration among five medical schools.

School-based health centers (SBHCs) have tremendous untapped potential as models for learning about systems-based care of vulnerable children. SBHCs aim to provide comprehensive, community-based primary health care to primary and secondary schoolchildren who might not otherwise have ready access to that care. The staffing at SBHCs is multidisciplinary, including various combinations of nurse practitioners, physicians, dentists, nutritionists, and mental health providers. Although this unique environment provides obvious advantages to children and their families, medical students and residents receive little or no preparation for this type of practice. To address these deficiencies in medical education, five downstate New York state medical schools, funded by the New York State Department of Health, collaborated to define, develop, implement, and evaluate curricula that expose health professions students and residents to SBHCs. The schools identified core competencies and developed a comprehensive training model for the project, including clinical experiences, didactic sessions, and community service opportunities, and they developed goals, objectives, and learning materials for each competency for all types and levels of learners. Each school has implemented a wide range of learning activities based on the competencies. In this paper, the authors describe the development of the collaboration and illustrate the process undertaken to implement new curricula, including considerations made to address institutional needs, curricula development, and incorporation into existing curricula. In addition, they discuss the lessons learned from conducting this collaborative effort among medical schools, with the goal of providing guidance to establish effective cross-disciplinary curricula that address newly defined competencies.

Attitudes about shared reading among at-risk mothers of newborn babies.

OBJECTIVE: Attitudes about shared reading among at-risk mothers of newborn babies have not been the focus of previous study. Better understanding of factors associated with these attitudes would facilitate pediatricians' provision of anticipatory guidance. We sought to assess sociodemographic correlates of attitudes regarding and resources available for shared reading among multiethnic, low socioeconomic status (SES) mothers of newborns. METHODS: This was a cross-sectional analysis of consecutive mother-infant dyads enrolled during the postpartum period onto an urban public hospital. Dependent variables were attitudes and resources related to shared reading with infants. Independent variables were family sociodemographics, reading difficulties, and social risks. RESULTS: A total of 211 mother-newborn dyads were assessed; 23.7% reported not planning to look at books together until 12 months or later, 42.2% reported no baby books in the home, and 19.9% reported concerns about shared reading. In multiple logistic regression analyses, independent significant associations with not planning to share books together in infancy were lower maternal education, not speaking English, and firstborn. Independent significant associations of not having baby books were not speaking English, firstborn, and perceived difficulty reading in their native language. CONCLUSIONS: Many at-risk mothers of newborn babies do not report plans to read in infancy and do not have appropriate books in the home. Consideration should be given to universal provision of early anticipatory guidance addressing shared reading, either during the postpartum period or during initial well-child care visits.

Is exposure to media intended for preschool children associated with less parent-child shared reading aloud and teaching activities?

OBJECTIVE: To determine whether electronic media exposure is associated with decreased parental reading and teaching activities in the homes of preschool children. METHODS: A convenience sample presenting for well-child care to an urban hospital pediatric clinic was enrolled. Inclusion criteria were: child's age 3 to 5 years and not yet in kindergarten. Electronic media exposure (TV, movies/video, computer/video games) was assessed with a 24-hour recall diary and characterized on the basis of industry ratings. Reading aloud and teaching activities were assessed with the StimQ-Preschool READ and PIDA (Parental Involvement in Developmental Advance) subscales, respectively. RESULTS: A total of 77 families were assessed. Children were exposed to a mean (SD) of 200.8 (128.9) minutes per day of media, including 78.2 (63.7) minutes of educational young child-oriented, 62.0 (65.6) minutes of noneducational young child-oriented, 14.8 (41.4) minutes of school age/teen-oriented, and 29.2 (56.6) minutes of adult-oriented media, as well as to 16.6 (47.5) minutes of media of unknown type. A total of 79.2% watched 2 or more hours per day. Noneducational young child-oriented exposure was associated with fewer reading (semipartial correlation coefficient [SR] = -0.24, P = .02) and teaching (SR = -0.27, P = .01) activities; similar relationships were not found for other media categories. Children exposed to 2 or more hours of total electronic media per day had 1.6 (95% confidence interval, 0.4-2.9) fewer days per week of reading than children exposed to less than 2 hours (SR = -0.27, P = .01). CONCLUSIONS: This study found an association between increased exposure to noneducational young child-oriented media and decreased teaching and reading activities in the home. This association represents a mechanism by which media exposure could adversely affect development.

Use of videotaped interactions during pediatric well-child care: impact at 33 months on parenting and on child development.

OBJECTIVE: We performed a randomized, controlled trial to assess the impact of the Video Interaction Project (VIP), a program based in pediatric primary care in which videotaped interactions are used by child development specialists to promote early child development. METHOD: Ninety-nine Latino children (52 VIP, 47 controls) at risk of developmental delay based on poverty and low maternal education were assessed at age 33 months. VIP was associated with improved parenting practices including increased teaching behaviors. RESULTS: VIP was associated with lower levels of parenting stress. VIP children were more likely to have normal cognitive development and less likely to have developmental delays. CONCLUSION: This study provides evidence that a pediatric primary care-based intervention program can have an impact on the developmental trajectories of at-risk young preschool children.