Cognitive and motor improvement by tummy time practice in preemies from low-income settings: a randomized clinical trial.

Introduction: Early intervention and parental education for preemies are limited in some low-income countries. Thus, this study aimed to assess whether daily tummy time (TT) associated with usual care (UC) enhances motor and cognitive development in preemies from low-income countries. The main and secondary aim was to assess prone head elevation (PHE) and motor and cognitive functions, respectively. Methods: Thirty-one preemies with a mean gestational age at birth of 33.3 ± 1.6 weeks and weighing <2,500 g were included and 18 completed all assessments. Parents from the TT group were asked to perform TT with their preemies for at least 20 min during daily activities and playtime. Motor and cognitive functions were assessed by a blinded examiner using the motor and cognitive composite scores of Bayley-III after two and four months of corrected age. PHE was given by the angle from the tragus of the ear to the supporting surface of the infant; measurements were obtained using the Kinovea® software at baseline, after two, three, and four months of corrected age. Results: The Bayley-III motor composite score of the TT group was higher than the UC group after two and four months of corrected age. The PHE angle increased over time but did not differ between groups. Discussion: Nevertheless, TT expanded the perspective of preemies to explore their bodies and environment, favoring the stimuli for motor and cognitive patterns. The loss of participants (31%) was one of the limitations of the study, illustrating the challenge of providing continued early interventions to preemies from low-income countries. In this sense, TT practice is a home intervention that may improve motor and cognitive function of preemies immediately after hospital discharge.

Rural service coordination programming for women using substances and their families.

BACKGROUND: Women experiencing substance use during their pregnancies or after the birth of a child report being fearful of losing their children based on care, stigmatized when seeking assistance, and barriers to care such as having to provide the same information to different providers, and having to repeat their lived experiences with substance use in detail. Particularly these service barriers can be confusing, complicated, and difficult to follow, which could lead to non-compliance or not seeking services. OBJECTIVES: We evaluated components of a service coordination program for women experiencing substance use, their children, and larger families who help with caregiving. We examined stakeholder interest in the program, feasibility providing services over time, and initial program effectiveness. DESIGN: Participant enrollment and outcomes as well as service coordination activities provided over a 4-year period was gathered across three demonstration site locations (a birthing hospital, reunification program, and home visiting program). METHODS: Program information was gathered from needs assessment data, health survey data from enrolled caregivers and infants, training evaluations, and budget recordings of direct aid. In this mixed method design, we examined potential differences between baseline and the last assessment for women and children enrolled in the program. We also utilized univariate analyses of variance to examine the main effects of maternal and infant characteristics on final maternal and infant outcomes. RESULTS: Three sites enrolled 182 women and families for program services. Patient navigators provided direct aid, training, goal setting, and service coordination and planning. Families remained in the program, on average, 655 days and were satisfied with the services received. Respondents thought the program elements were easy to implement within the rural setting. The program effectively addressed basic needs, violence (p < 0.001; η2 = 0.34 (0.05-0.53)), infant development (p < 0.02; η2 = 0.51 (0.13-0.61)), and maternal depression (p < 0.05; η2 = 0.9 (0.00-0.22)). Select outcomes did differ by site. CONCLUSION: A service coordination model utilizing a patient navigator role to coordinate client services coupled with an approach that serves the infant and caregiver needs was feasible and desirable by all stakeholders within a rural setting. Service coordination effectively impacted select caregiver and infant outcomes.

Study using various reports from women who have, or still are, using substances, their family members, and providers about a service coordination structure designed to complement existing services for women and families in the rural setting.Why was the study done? Services for women who have, or still use, substances and their families are limited in rural settings. When they do exist, they are often disjointed, duplicative, and difficult to navigate. We hypothesized that a service coordination program with a key role available to help families navigate services would improve caregiver and family outcomes in many areas.What did the researchers do? The research team identified specific services offered in one program over the past five years. The program was given to women and families who had infants two years or younger and lived in rural communities. Caregivers and providers offered feedback about their experiences in the program. Caregiver and infant health were assessed and used to see if the program had a positive impact.What did researchers find? 182 families successfully enrolled in the program and stayed involved for an average of two years. Families and providers thought the program was easy to provide and navigate. They valued the role of the patient navigator and money offered to pay for essentials, if needed, was thought to be a key benefit, especially during COVID.What do the findings mean? Families may experience greater benefits from services if they have support for daily needs, when crises occur, someone to help navigate multiple services, and access to information when needed. These services are easy to provide and could be offered in rural communities.

Association of SARS-CoV-2 infection during late pregnancy with maternal and neonatal outcomes.

BACKGROUND: Limited data on the impact of the coronavirus disease 2019 (COVID-19) during pregnancy on newborn outcomes are available. This study aimed to characterize and compare the clinical outcomes of newborns from women with and without the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection during late pregnancy. METHOD: This was a retrospective cohort study of women who were either infected or not infected with the SARS-CoV-2 virus during late pregnancy. The neonatal complications associated with COVID-19-positive pregnant women were investigated and analyzed. RESULTS: Among 2063 pregnant women over 28 weeks of gestation, 1.2%, 3.3%, and 18.7% of patients with multiple pregnancies, abnormal fetal positions, and lack of maternal or neonatal follow-up data, respectively, were excluded. Patients who were COVID-19-negative (60.6%) and -positive (16.2%) remained for further analysis. SARS-CoV-2 infection was significantly associated with higher SARS-CoV-2 infection rates in newborns (0% vs. 1.49%, P < 0.01) and longer duration of hospital stay (6.39 ± 2.2 vs. 4.92 ± 1.6, P < 0.01). However, comparing neonatal complications, including Apgar score, preterm birth, low birth weight, cesarean section rate, newborn hearing, neonatal congenital heart defects, and height and weight compliance rate of 6-month-old children, between non-infected and infected participants did not reach statistical significance. CONCLUSION: SARS-CoV-2 infection in late pregnancy has no significant impact on neonatal outcomes. After six months of follow-up of the neonates, we observed that SARS-CoV-2 infection in the third trimester of pregnancy did not affect their growth and development. Hopefully, these findings will guide management strategies and clinical practice.

Diagnostic accuracy of Ages and Stages Questionnaire, Third Edition to identify abnormal or delayed gross motor development in high-risk infants.

AIM: To investigate the diagnostic accuracy of parent-completed Ages and Stages Questionnaire, Third Edition (ASQ-3) to identify abnormal or delayed gross motor development in infants born less than 1000 g or less than 28 weeks gestation. METHODS: Prospective cohort study of high-risk infants comparing ASQ-3 as the index test with concurrent score on Alberta Infant Motor Scale (AIMS) as the reference standard, at 4-, 8- and 12-month corrected (post-term) age. Reference standard positivity cut-offs were 'Abnormal motor development' (AIMS Clinical Range) and 'Motor delay' (AIMS score >1 SD below mean, not captured in Clinical Range). RESULTS: Participating infants (n = 191) had mean gestational age (95% confidence interval (CI)) 26.8 weeks (26.6-27.1) and mean birthweight (95% CI) 870 g (844-896). AIMS rated 51%, 31% and 23% of infants as having 'Abnormal motor development' and 12%, 28% and 13% with 'Motor delay', at 4, 8 and 12 months, respectively. Diagnostic accuracy of ASQ-3 to identify abnormal motor development was acceptable for older infants only if 'Monitor' cut-off was used: sensitivity (95% CI) 33% (23-44), 86% (73-95) and 80% (63-92) and specificity (95% CI) 84% (74-92), 76% (66-84), and 76% (67-83) at 4, 8 and 12 months, respectively. ASQ-3 sensitivity to identify motor delay was low. CONCLUSIONS: ASQ-3 has poor sensitivity to identify abnormal or delayed motor development at 4 months. Using the 'Monitor' cut-off improves the diagnostic accuracy of ASQ-3 for identification of older infants with abnormal motor development who are at high risk of motor disability. However, ASQ-3 has poor sensitivity to identify motor delay. Clinical motor assessment of high-risk infants is recommended, particularly in early infancy.

The influence of infant temperamental negative affect and maternal depression on infant and maternal social positive engagement during the Still-Face procedure.

Positive mother-infant interactions are important for infant development. Both mother and infant characteristics, such as maternal depression and infant temperamental negative affect are risk factors for adverse mother-infant bonding and infant outcomes. Although these predictors have been researched individually, limited studies have considered them in concert. This study aimed to examine the role of infant age (6-, 9- and 12-months), infant temperamental negative affect, and maternal depression on maternal and infant social positive engagement during the Still-Face procedure. Participants were 85 ethnically-varied mother-infant dyads (44 % girls). Mothers responded to questionnaires, prior to attending the laboratory for the Still-Face procedure (i.e., a task involving a social stressor). Results showed a significant moderating relationship between infant age, infant temperamental negative affect, and maternal depression on infant social positive engagement. For 12-month-old infants, higher infant temperamental negative affect was found to be compounded by greater maternal depression symptoms resulting in significantly lower social positive engagement following a social stressor. This relationship was not found for younger infants. No predictors were associated with maternal social positive engagement. Results from this study contribute to the literature on infant wellbeing. Results highlight the importance of interventions that aim to reduce maternal depression symptoms, especially, as maternal depression may disproportionately influence 12-month-old infants who have negative temperament.

Using the DRS-8 to measure unresolved/disorganized attachment: Associations with states of mind on the adult attachment interview, psychopathology, and offspring social-emotional development.

BACKGROUND: Unresolved/disorganized (U/d) attachment states of mind are associated with poor outcomes across numerous domains of functioning. However, the validity of existing self-report instruments measuring this construct remains questionable. OBJECTIVES: The aim of the current study was to validate the DRS-8, an alternative version of the Disorganized Response Scale (DRS), by assessing its construct validity, internal consistency, and criterion validity with the U/d attachment scales on the Adult Attachment Interview (AAI). PARTICIPANTS AND SETTING: Date were collected from 222 expectant parents (78 % women) at T1 and from 67 of them at 12 months postpartum (T2). METHODS: Participants completed the DRS-8 and questionnaires assessing childhood trauma, romantic attachment, and psychological symptoms during pregnancy (T1). Seventy-four of them participated in the AAI at T1. At T2, parents completed a questionnaire assessing their infants' social-emotional development. RESULTS: The DRS-8 has two highly correlated dimensions, i.e., lapses in the monitoring of reasoning (four items) and discourse (four items). A confirmatory factor analysis supported a bifactor structure of the instrument, showing good fit indices and internal consistency (ω = 0.87). The DRS-8 was significantly correlated with U/d states of mind on the AAI, r(72) = 0.28, p = .016, and demonstrated excellent construct validity. Significant indirect effects of the DRS-8 were found in the associations between childhood trauma and psychological symptoms, and between parental trauma and infant social-emotional development. CONCLUSIONS: The DRS-8 appears to be a promising self-report measure of U/d states of mind showing criterion validity with the AAI.

Trends in sex differences in neurodevelopmental outcomes among extremely preterm infants.

OBJECTIVE: To examine whether changes in survival without moderate or severe neurodevelopmental impairment (NDI) at 18-26 months' corrected age from 1999 to 2018 differed between male and female infants. DESIGN: This retrospective cohort study used data from the NICHD Neonatal Research Network hospitals. Robust Poisson regression models were used to estimate adjusted relative risks (aRRs) and 95% CIs for survival without moderate or severe NDI between males and females. Interactions between sex and time were assessed to evaluate temporal differences in the outcome by sex. Variables adjusted for included centre, maternal age, ethnicity/race, gestational age and small for gestational age. PATIENTS: Inborn infants with gestational age of 22-26 weeks at NICHD Neonatal Research Network hospitals from 1999 to 2018. MAIN OUTCOME MEASURE: Change over time in survival without moderate or severe NDI at 18-26 months' corrected age between male and female infants. RESULTS: Of 26 307 infants, 13 045 (49.6%) were male. Survival without moderate or severe NDI declined for both sexes over time, from 32.9% to 30.6% for males and from 47.4% to 40.0% for females, between 1999-2003 and 2014-2018. Males were less likely than females to survive without moderate or severe NDI (aRR=0.80; 95% CI 0.78 to 0.83). Changes in survival without moderate or severe NDI did not differ between males and females. CONCLUSION: There were no differential changes in survival without moderate or severe NDI between male and female infants.

Evaluation of the repeatability of kinesiological measurements of spontaneous infant movements using OSESEC computer analysis algorithms.

Purpose: There is a need to create objective and reproducible tool for assessing the quality of infant movements. It's substantially important to detect movement disorders in infants as early as possible. The study aimed to evaluate the reproducibility of kinesiological measurements of spontaneous movements performed by 51 infants (aged 6 to 15 weeks) recorded three times for two consecutive days using OSESEC computer analysis algorithms by determining numerical values of parameters, i.e., speed, acceleration, direction, and movement trajectory. Methods: The study group consisted of 51 infants. The diagnostic method of Prechtl was used for qualitative assessment. The quantitative assessment was based on the use of a OSESEC system. Numerical values for all movement parameters were determined, and the data obtained in the study were used for statistical analysis. Results: Analysis including movement parameter values on three consecutive recordings for the same infant revealed no statistically significant differences in location ( p = 0.073), range ( p = 0.557), shape ( p = 0.289), mean acceleration ( p = 0.124) and mean speed ( p = 0.767). This confirms the reproducibility of measurements of the proposed parameters of the objectification of spontaneous infant movements. Conclusions: The interpretability and accuracy of the presented parameters were proved. All parameters estimation is fully automated. Further research and testing requires a larger study group to create an objective diagnostic device for infants.

Cerebral injury and retinopathy as risk factors for blindness in extremely preterm infants.

OBJECTIVE: This study investigates whether and to what extent cerebral injury is associated with bilateral blindness in extremely preterm infants, which has been attributed mainly to retinopathy of prematurity (ROP). DESIGN: Multicentre analysis of children born from 1994 to 2021 at gestational age 22 0/7 to 28 6/7 weeks with follow-up at 18-26 months. Logistic regression examined the adjusted association of bilateral blindness with severe ROP and/or cerebral injury among extremely preterm infants. EXPOSURES: Severe ROP and cerebral injury, the latter defined as any of the following on cranial imaging: ventriculomegaly; blood/increased echogenicity in the parenchyma; cystic periventricular leukomalacia. MAIN OUTCOME MEASURES: Bilateral blindness, defined as a follow-up examination meeting criteria of 'blind-some functional vision' or 'blind-no useful vision' in both eyes. RESULTS: The 19 863 children included had a mean gestational age of 25.6±1.7 weeks, mean birth weight of 782±158 g and 213 (1%) had bilateral blindness. Multiplicative interaction between ROP and cerebral injury was statistically significant. For infants with only severe ROP (n=3130), odds of blindness were 8.14 times higher (95% CI 4.52 to 14.65), and for those with only cerebral injury (n=2836), odds were 8.38 times higher (95% CI 5.28 to 13.28), compared with the reference group without either condition. Risks were not synergistic for infants with both severe ROP and cerebral injury (n=1438, adjusted OR=28.7, 95% CI 16.0 to 51.7, p<0.0001). CONCLUSIONS: In a group of extremely preterm infants, severe ROP and cerebral injury were equally important risk factors for blindness. Besides ROP, clinicians should consider cerebral injury as a cause of blindness in children born extremely preterm. TRIAL REGISTRATION NUMBER: NCT00063063.

The Homeostasis-Enrichment-Plasticity (HEP®) Approach for Premature Infants with Developmental Risks: A Pre-Post Feasibility Study.

Background: The environmental enrichment (EE) framework has inspired several early intervention (EI) approaches. This study evaluated the feasibility, safety, caregiver acceptance, and satisfaction of implementing the HEP Approach intervention, a novel EI model based on the EE paradigm. Outcome measures for motor development, individual functional goals, sensory functions, caregiver-provided environmental affordances, and motivation for movement were examined. Methods: A pre-post-study design examined 18 premature infants (<33 weeks six days gestation) with a corrected age of 4-10 months. A 21-item Likert scale survey assessed the feasibility, safety, acceptability, and satisfaction of implementing the HEP Approach intervention. The Peabody Developmental Motor Scales-2, Test of Sensory Functions in Infants, Affordances in the Home Environment for Motor Development, and Infant Movement Motivation Questionnaire were used for outcomes. The goal attainment scale measured progress toward parent goals. The HEP Approach consisted of 12 one-hour sessions implemented over three months. Results: Most participating parents found the HEP Approach intervention feasible, safe, acceptable, and satisfactory. GAS scores demonstrated significant gains with a mean t-score of 67.75 (SD = 2.00). Results found significant improvement (p ≤ 0.05) in all outcome measures. Conclusions: Results suggest that the HEP Approach intervention is safe, feasible, and acceptable to implement. Outcome measures were meaningful and sensitive in identifying improved motor development, individualized parental goals, sensory functions, caregivers' use of environmental opportunities, and movement motivation in premature at-risk infants. Results suggest further studies on the HEP Approach are feasible, and highlight the potential of this intervention to inspire and guide future research in this field.

Parent-child interaction at age 5 months: genetic and environmental contributions and associations with later socio-communicative development.

BACKGROUND: Characteristics of parent-child interaction (PCI) early in life have been associated with later development in the child. Twin studies can help to disentangle child contributions to parent-child interaction, for example, by assessing the influence of the child's genetics on his/her social environment, which includes parental behaviour. METHODS: Infant twins from a community sample [354 monozygotic (MZ), 268 same-sex dizygotic (DZ)] were assessed in terms of PCI at age 5 months. We used the classical twin design to map the aetiology of several parent and child PCI scales and their covariation. We investigated the relations between PCI and later parent-rated child's social communication, language, and autistic traits at ages 2 and 3. RESULTS: Heritability was below 20% for all the included PCI traits. Unique (nonshared) environmental influences substantially overlapped across several PCI scales, suggesting that idiosyncrasies linked to each session shaped the scoring of several traits in a systematic way. Factor analysis revealed three uncorrelated latent factors, which were conceptualized as 'child negative affect', 'positive affective interaction', and 'parent's supportive strategies'. Parents who were rated highly on 'sensitive responsiveness' at 5 months tended to rate their offspring higher in terms of socio-communicative and language development and lower in terms of autistic traits in the second and third years of life. CONCLUSIONS: This study maps the phenotypic and aetiological structure of PCI in early infancy and supports the view that parents' sensitive responsiveness towards their infant is associated with later developmental gains in several domains. We did not find strong evidence of any so-called evocative genetic effects on parents' behaviour. We discuss the results considering the general challenge for lab-based observational PCI measures to capture the richness of parent-child interaction.

Minding the gap: a sex difference in young infants' mental rotation through thirty degrees of arc.

Mental rotation (MR) is an important feature of spatial cognition invoking mental imagery of an object's appearance when viewed from a new orientation. Prior studies have revealed evidence of MR in infants, including a sex difference similar to that detected in older populations. Some of these studies used visual habituation methods whereby infants were familiarized with an object rotating through a 240° angle, followed by test trials showing either the habituation object or a mirror image object rotating through the previously unseen 120° angle. Significantly longer looking at either of these objects was taken to reflect infants' ability to recognize the habituation object even when seen from a novel viewpoint, suggesting the capacity for MR. However, these infants' responses could, in theory, be explained with reference to perceptual discrimination rather than MR, because the views of the habituation and test objects were very similar in some video frames. In the current study, we observed a diverse population of 5-month-olds (24 females, 24 males) for evidence of MR through 30° of arc. In this more challenging test, our stimuli left a 30° gap angle between critical video frames representing the habituation and test objects. Consistent with earlier reports, we found that relative to female infants, male infants looked significantly longer at the mirror image test stimulus immediately following habituation. These results add to an emerging consensus that some young infants are capable of MR, and that male and female infants on average behave differently in this type of MR task.

Associating neuromotor outcomes at 12 months with wearable sensor measures collected during early infancy in rural Guatemala.

BACKGROUND: Sensitive measures to predict neuromotor outcomes from data collected early in infancy are lacking. Measures derived from the recordings of infant movement using wearable sensors may be a useful new technique. METHODS: We collected full-day leg movement of 41 infants in rural Guatemala across 3 visits between birth and 6 months of age using wearable sensors. Average leg movement rate and fuzzy entropy, a measure to describe the complexity of signals, of the leg movements' peak acceleration time series and the time series itself were derived. We tested the three measures for the predictability of infants' developmental outcome, Bayley Scales of Infant and Toddler Development III motor, language, or cognitive composite score assessed at 12 months of age. We performed quantile regressions with clustered standard errors, accounting for the multiple visits for each infant. RESULTS: Fuzzy entropy was associated with the motor composite score at the 0.5 quantiles; this association was not found for the other two measures. Also, no leg movement characteristic was associated with language or cognitive composite scores. CONCLUSION: We propose that the entropy of leg movement associated peak accelerations calculated from the wearable sensor data collected for a full-day can be considered as one predictor for infants' motor developmental outcome assessed with Bayley Scales of Infant and Toddler Development III at 12 months of age.

Lead contamination in human milk affects infants' language trajectory: results from a prospective cohort study.

Infants growing up in low- and middle-income countries are at increased risk of suffering adverse childhood experiences, including exposure to environmental pollution and lack of cognitive stimulation. In this study, we aimed to examine the levels of metals in the human milk of women living in São Paulo City, Brazil, and determine the effects on infants' neurodevelopment. For such, a total of 185 human milk samples were analyzed for arsenic (As), lead (Pb), mercury (Hg), and cadmium (Cd) using inductively coupled plasma mass spectrometry (ICP-MS). We applied the Bayley scales of infant and toddler development Third Edition (Bayley-III) to assess developmental milestones. In our analysis, we found a mean (standard deviation) concentration of As in human milk equal to 2.76 (4.09) µg L-1, followed by Pb 2.09 (5.36) and Hg 1.96 (6.68). Cd was not detected. We observed that infants exposed to Pb presented language trajectories lower than non-exposed infants (ß = -0.413; 95% CI -0.653, -0.173) after adjustment for infant age, maternal education, socioeconomic status, infant sex, and sample weights. Our results report As, Pb, and Hg contamination in human milk, and that infant exposure to Pb decreased infants' language development. These results evidence maternal-child environmental exposure and its detrimental impact on infants' health.

Capturing the complexity of child behavior and caregiver-child interactions in the HEALthy Brain and Child Development (HBCD) Study using a rigorous and equitable approach.

The HEALthy Brain and Child Development (HBCD) Study, a multi-site prospective longitudinal cohort study, will examine human brain, cognitive, behavioral, social, and emotional development beginning prenatally and planned through early childhood. This article outlines methodological considerations and the decision-making process for measurement selection for child behavior, parenting/caregiver-child interactions, and the family/home environment for HBCD. The decision-making process is detailed, including formation of a national workgroup (WG-BEH) that focused on developmentally appropriate measures that take a rigorous and equitable approach and aligned with HBCD objectives. Multi-level-observational and caregiver-report measures were deemed necessary for capturing the desired constructs across multiple contexts while balancing the nuance of observational data with pragmatic considerations. WG-BEH prioritized developmentally sensitive, validated assessments with psychometrics supporting use in diverse populations and focused on mechanistic linkages and prediction of desired constructs. Other considerations included participant burden and retention, staff training needs, and cultural sensitivity. Innovation was permitted when it was grounded in evidence and filled key gaps. Finally, this article describes the rationale for the selected constructs (e.g., temperament, social-emotional development, parenting behaviors, family organization) and corresponding measures chosen for HBCD visits from early infancy through 17 months of age.

Relationship between maternal postpartum depression, fatigue, sleep quality and infant growth: A cross-sectional study.

BACKGROUND: Current research separately analyzed the connection between postpartum depression, fatigue, sleep and infant development. However, depression, fatigue and sleep quality often coexisted as adverse symptoms in postpartum women and influenced infant development together. This study explored the maternal postpartum symptoms on infant growth. METHODS: Our study included 224 pairs of singleton full-term mothers and their infants who underwent routine pediatric outpatient clinics. Latent profile analysis was applied to identify the latent classes based on mothers' postpartum depression, fatigue and sleep profile characteristics. We evaluated the maternal adverse symptoms and infant development using multivariable logistic regressions. RESULTS: Totally, 224 pairs of eligible mothers (28.85 ± 4.43 years) and infants (30.93 ± 3.26 days) participated in this study. Latent profile analysis identified 3 latent groups: mild (58.04%), moderate (34.37%), and severe (7.59%) postpartum adverse symptoms. Postpartum adverse symptoms were associated with delayed development in the baby's motor level (χ2 = 6.572, p = .037) and weight-for-length (χ2 = 9.652, p = .008). After controlling for mother and infant related factors, postpartum adverse symptoms remained a risk factor for infant motor level (odds ratio [OR]: 4.35; 95% confidence interval [CI]: 1.25-15.08) and weight-for-length (OR: 5.53; 95% CI: 1.55-19.74). CONCLUSIONS: Maternal postpartum depression, fatigue and sleep quality are associated with infant development. Clinically, mothers with these symptoms should be intervened timely to avoid the aggravation of maternal symptoms, which affect baby's development.

Depth and Quality of Recommendations in Popular Sources About How to Play with Infants: Content Analysis.

AIM: Systematically evaluate the depth and quality of play recommendations provided in popular sources for parents of infants in the first year of life. METHODS: This represents the second stage of a larger analysis of educational content available to parents. Two coders (>90% agreement) extracted and coded play activities from popular websites, applications, and books screened from a systematic online search. Depth of instruction variables were extracted. Activity quality was rated based on opportunities for child-initiated movement, problem-solving with objects, and responsive communication. RESULTS: 4370 play activities from 214 sources were analyzed. Activities were likely to suggest specific ages for infants and that a caregiver be present. Less than half of the activities incorporated toys or provided guidance about how to position or physically support infants. Activity quality was low; most activities did not explicitly encourage parents to provide opportunities for child-initiated movement, problem-solving with objects, or quality communication. CONCLUSIONS: Parents may encounter a large number of play activities in popular sources, but the depth of instruction and quality of those activities could be improved. Provision of higher-quality education to parents may enhance parent-child play interactions to positively impact parent and child outcomes, especially for children at risk for delays.