Human Milk Feeding and Ultraprocessed Food Intake in Toddlerhood.

Objective: The objective of the study was to estimate associations between early-life human milk feeding and ultraprocessed food (UPF) intake at two timepoints during toddlerhood among children born at <35 weeks' gestation. Study Design: Children were enrolled in the Omega Tots trial (2012-2017, Ohio) at 10-17 months' corrected age after having discontinued human milk and formula feeding. Caregivers reported children's human milk feeding history at baseline and past month diet through a food frequency questionnaire at baseline and follow-up (180 days later). We used the NOVA classification system to estimate UPF intake. We estimated covariate-adjusted associations between human milk feeding (ever and duration) and UPF intake at baseline and follow-up using linear and logistic regression. Results: Nearly 89% (n = 295) of 333 toddlers had received human milk but only 4.2% (n = 14) were fed exclusively human milk to 6 months of age. UPFs represented 37.7 (standard deviation [SD] = 13.2)% and 43.4 (SD = 11.3)% of total calories at the two timepoints. Human milk feeding (exclusive or otherwise) was unassociated with UPF intake in toddlerhood (e.g., months of exclusive human milk feeding with the number of daily servings of UPFs at follow-up: ß=-0.09, 95% confidence interval [CI]: -0.26, 0.08). Conclusion: In this sample of toddlers born preterm, any exposure to as well as the duration of human milk feeding was unassociated with UPF intake during the second year of life. These results require replication in larger samples given the small number of children in some human milk feeding categories.

Associations of prenatal stress with 5-year-old children's executive function in a low socioeconomic status population.

Prenatal stress has a significant, but small, negative effect on children's executive function (EF) in middle and high socioeconomic status (SES) households. Importantly, rates and severity of prenatal stress are higher and protective factors are reduced in lower SES households, suggesting prenatal stress may be particularly detrimental for children's EF in this population. This study examined whether prenatal stress was linked to 5-year-old's EF in a predominantly low SES sample and child sex moderated this association, as males may be more vulnerable to adverse prenatal experiences. Participants were 132 mother-child dyads drawn from a prospective prenatal cohort. Mothers reported on their depression symptoms, trait anxiety, perceived stress, everyday discrimination, and sleep quality at enrollment and once each trimester, to form a composite prenatal stress measure. Children's EF was assessed at age 5 years using the parent-report Behavior Rating Inventory of Executive Function - Preschool (BRIEF-P) Global Executive Composite subscale and neuropsychological tasks completed by the children. Mixed models revealed higher prenatal stress was associated with lower BRIEF-P scores, indicating better EF, for females only. Higher prenatal stress was associated with lower performance on neuropsychological EF measures for both males and females. Results add to the limited evidence about prenatal stress effects on children's EF in low SES households.

The Tension Between AAP Safe Sleep Guidelines and Infant Sleep.

OBJECTIVES: To understand tension mothers experience when attempting to follow American Academy of Pediatrics safe sleep guidelines and enhancing infant and parental sleep. METHODS: Surveys and focus groups were conducted from November 2022 and March 2023 with United States-based English-speaking mothers of infants <6 months of age recruited via social media and who reported a nonrecommended sleep position and/or location ≥2 times the prior week. RESULTS: Twenty-five mothers participated in focus groups and surveys. A total of 80% reported holding or rocking their infant to sleep; 76% fed their infant to sleep. Almost all were aware of the ABCs (Alone, Back, Crib) of safe sleep and intended to follow them before delivery. Many felt that ABCs were unrealistic and placed their infants in nonrecommended locations or positions because they perceived them as more comfortable and helping their infant fall and stay asleep. Mothers were more likely to use nonrecommended practices when they were awake or sleeping nearby and believed they could closely monitor their infant. Some questioned whether ABCs were the only way to achieve safe sleep. Some prioritized other safety concerns (eg, fall prevention) over sudden infant death syndrome or sudden unexpected infant death prevention. Mothers expressed confidence about getting their baby to sleep in general but were less confident that they could do this while following guidelines. CONCLUSIONS: Despite awareness of the ABCs, mothers regularly engaged in nonrecommended practices with the goal of improving their own and their infant's sleep. Interventions focused on improving infant and parental sleep while maintaining sleep safety are needed.

Novel Implantation Technique for Thoracoabdominal Peripheral Nerve Stimulation via a Transversus Abdominal Plane Approach for Treatment of Chronic Abdominal Pain.

Background: Chronic abdominal pain (CAP) is a common and challenging to treat condition with a global prevalence of up to 25%. Despite extensive evaluation, approximately 40% of patients with CAP have an unknown diagnosis. Medications may be ineffective, and surgery is rarely indicated. Interventional treatment including sympathetic blocks, sympathetic neurolysis, and transversus abdominal plane (TAP) blocks may be an option, but their efficacy can wane over time. Neuromodulation has emerged as an option for these patients, as there is evidence of success with dorsal column spinal cord and dorsal root ganglion (DRG) stimulation. Peripheral nerve stimulation (PNS) may be an alternative option, particularly in higher risk patients or in patients for whom neuraxial access may be unsafe or too technically challenging. Thoracoabdominal nerve peripheral nerve stimulation via a TAP approach may be more specifically targeted in comparison to dorsal column or DRG stimulation. In this short report, we detail a technique that the authors have successfully used for thoracoabdominal nerve PNS via a TAP approach for management of CAP. Methods: This article describes a novel medial to lateral ultrasound guided thoracoabdominal nerve PNS via a TAP approach technique for lead placement and implantation. Results: A medial to lateral ultrasound guided TAP approach as described to successfully implant percutaneous thoracoabdominal nerve PNS leads for management of CAP. Conclusion: The thoracoabdominal nerve PNS via a TAP approach lead placement technique noted in this report has been used as a means for management of CAP utilizing peripheral neuromodulation. Here, we present a short report detailing a potential technique for PNS utilization for management of CAP. Further studies are needed to validate the safety and efficacy of this therapy modality, although the authors have found it to be a viable management option for patients with medically refractory neuropathic CAP.

Household chaos, child temperament, and structure-related feeding practices in toddlerhood: A moderation analysis.

Structure-related feeding practices may promote intuitive child eating behaviors and foster responsiveness to internal cues of hunger and satiety. Caregivers' ability to engage in structure-related feeding practices likely depends on a complex ecology of factors, including household- and child-characteristics. This study examined associations between household chaos and structure-related feeding practices, and the moderating effect of child temperament. Data were from 275 caregiver-toddler dyads from central Ohio. Child temperament was reported by caregivers when children were 18 months of age, whereas household chaos and structure-related feeding practices were reported by caregivers when children were 36 months of age. Multivariable linear regression models were constructed to assess the relationship between chaos and structure-related feeding practices. Interaction terms between household chaos and three dimensions of child temperament were tested to determine whether temperament moderated the relationship between chaos and structure-related feeding practices. Household chaos was not independently associated with structure-related feeding practices, but higher levels of child effortful control were associated with greater mealtime structure. There was a statistically significant interaction between household chaos and child temperamental surgency, such that greater levels of chaos were associated with less structured mealtimes, but only when children had low-surgency. Findings suggest household chaos and child temperament inform caregiver feeding practices, but the influence of chaos may depend on more proximal factors, like child temperament. Recommendations to improve caregiver-child feeding interactions should be sensitive to characteristics of the broader family home environment.

Equivalent Performance of Exam Items Associated with Case-Based Learning, Flipped Classroom, and Lecture in a Pre-clerkship Medical Curriculum.

The purpose of our study was to determine if knowledge acquisition, as measured by exam item performance, differed for active or passive learning activities in our medical curriculum. Additionally, we looked for differences in exam item performance in one second-year course that varies the method of an active learning activity, case-based collaborative learning (CBCL). Finally, we assessed whether item performance was impacted when small group activities were conducted online due to the COVID-19 pandemic. Exam item difficulty values were collected for several years of lectures, flipped classroom, and CBCL. Statistical analysis and modeling of data were performed to identify differences in difficulty of exam items that assess content delivered by different learning activities. Our analysis revealed no differences in difficulty of exam items that assess content delivered by different learning activities. Similarly, we determined that varying the execution of CBCL in one course did not impact exam item performance. Finally, moving CBCL small group sessions online did not impact exam item difficulty. However, we did detect a minor reduction in overall exam scores for the period of online instruction. Our results indicate that knowledge acquisition, as assessed by our multiple-choice summative exams, was equivalent regardless of learning activity modality. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01842-8.

Self-Compassion and Depressive Symptoms as Determinants of Sensitive Parenting: Associations with Sociodemographic Characteristics in a Sample of Mothers and Toddlers.

Parenting that is sensitive and responsive to children's needs has been shown to support children's optimal growth and development in many cultural contexts. Numerous studies suggest that self-compassion is positively related to sensitive parenting. Despite growing research interest linking self-compassion to responsive parenting, there are considerable gaps in the literature. The current study examined the associations between self-compassion, depressive symptoms, socioeconomic status, and sensitive parenting. Data was obtained from a cohort study of 300 families in central Ohio enrolled when children were a mean (SD) calendar age of 18.2 (0.7) months. Children of all gestational ages at birth are included, and 37% were born preterm (<37 weeks' gestation). Observational protocols were used to determine maternal sensitivity in a semi-structured play setting. Self-compassion was assessed with the Self-Compassion Scale when children were 24 months old. Self-compassion was not associated with sociodemographic characteristics including maternal education, household income, child sex and gestational age. In unadjusted regression models, depressive symptoms were related to sensitive parenting (B = -0.036, SE = 0.016, p = 0.03), but self-compassion was not a statistically significant predictor (p = 0.35) of sensitivity, and neither self-compassion nor depressive symptoms were statistically significant predictors of sensitive parenting after adjustment for covariates. Considerations for future studies are discussed.

Novel implantation technique for pudendal nerve peripheral nerve stimulation for treatment of chronic pelvic pain.

BACKGROUND: Chronic pelvic pain (CPP) is a pervasive, difficult to treat condition affecting up to 26% of the global female and 8.2% of the global male population. Considered a form of chronic regional pain syndrome (CRPS), it is medically complex and often refractory to multimodal management. Neuromodulation has become increasingly popular in treatment of chronic neuropathic pain conditions, including CPP and CRPS. Dorsal column spinal cord stimulation and dorsal root ganglion stimulation have had some success for managing CPP meanwhile peripheral nerve stimulators (PNS) have been suggested as another viable option. However, few studies in the literature have reported successful use of PNS in treatment of CPP. Here, we detail a possible technique for pudendal PNS lead placement for management of CPP. METHOD: This article describes a novel cephalad to caudad fluoroscopic guided technique for pudendal nerve PNS lead placement and implantation. RESULTS: A cephalad to caudal-medial fluoroscopic guided approach as described within to successfully implant a percutaneous pudendal nerve PNS for management of CPP. CONCLUSIONS: The pudendal nerve PNS lead placement technique noted within can be used to avoid many of the important neurovascular structures near the pelvic outlet. Further studies are needed to validate the safety and efficacy of this therapy modality but it may be a viable management option for patients with medically refractory CPP.

The timing and quality of sleep was associated with dietary quality and anthropometry in toddlers born preterm.

AIM: The aim of the study was to examine prospective associations of sleep characteristics (duration, timing, quality) with dietary and anthropometric measures among toddlers born preterm (<35 weeks). METHODS: Children participated in the Omega Tots trial at 10-17 months' corrected age (Ohio, USA; 26 April 2012 to 6 April 2017). Caregivers reported toddlers' sleep at baseline using the Brief Infant Sleep Questionnaire. After 180 days, caregivers reported toddlers' past month diet in a food frequency questionnaire, and anthropometry was measured using standardised protocols. The toddler diet quality index (TDQI: higher scores indicating better quality), and weight-for-length, triceps skinfold and subscapular skinfold z-scores were calculated. Linear and logistic regression assessed adjusted associations with dietary and anthropometric outcomes at 180-day follow-up (n = 284), and linear mixed models assessed changes in anthropometry. RESULTS: Daytime sleep was associated with lower TDQI (ßadj per hour = -1.62 (95% CI: -2.71, -0.52)) whereas night-time sleep was associated with higher TDQI (ßadj  = 1.01 (95% CI: 0.16, 1.85)). Night-time awakenings and caregiver-reported sleep problems were also associated with lower TDQI. Night awakening duration and sleep-onset latency were associated with higher triceps skinfold z-score. CONCLUSION: Daytime and night-time caregiver-reported sleep showed opposite associations with diet quality, suggesting that sleep timing may be important.

Essential anatomy for core clerkships: A clinical perspective.

Clerkships are defining experiences for medical students in which students integrate basic science knowledge with clinical information as they gain experience in diagnosing and treating patients in a variety of clinical settings. Among the basic sciences, there is broad agreement that anatomy is foundational for medical practice. Unfortunately, there are longstanding concerns that student knowledge of anatomy is below the expectations of clerkship directors and clinical faculty. Most allopathic medical schools require eight "core" clerkships: internal medicine (IM), pediatrics (PD), general surgery (GS), obstetrics and gynecology (OB), psychiatry (PS), family medicine (FM), neurology (NU), and emergency medicine (EM). A targeted needs assessment was conducted to determine the anatomy considered important for each core clerkship based on the perspective of clinicians teaching in those clerkships. A total of 525 clinical faculty were surveyed at 24 United States allopathic medical schools. Participants rated 97 anatomical structure groups across all body regions on a 1-4 Likert-type scale (1 = not important, 4 = essential). Non-parametric ANOVAs determined if differences existed between clerkships. Combining all responses, 91% of anatomical structure groups were classified as essential or more important. Clinicians in FM, EM, and GS rated anatomical structures in most body regions significantly higher than at least one other clerkship (p = 0.006). This study provides an evidence-base of anatomy content that should be considered important for each core clerkship and may assist in the development and/or revision of preclinical curricula to support the clinical training of medical students.

Sports Team Participation and Vaping Among High School Students: 2015-2019.

BACKGROUND AND OBJECTIVES: Electronic vapor products (EVPs) have gained popularity among adolescents despite the health risks. This study aimed to evaluate whether sports team participation, a well-established protective factor against cigarette use, is similarly associated with decreased EVP use. METHODS: This cross-sectional study analyzed the 2015-2019 Youth Risk Behavior Survey cohorts. Survey-weighted logistic regressions investigated associations between sports team participation and past 30-day exclusive cigarette use, exclusive EVP use, and dual cigarette/EVP use among US high school students, adjusting for sex, grade, and survey year. RESULTS: The analytic cohort included 16 790 sports team participants (1.7% exclusive cigarette users, 18.3% exclusive EVP users, 5.5% dual users) and 13 972 nonparticipants (3.1% exclusive cigarette users, 13.4% exclusive EVP users, 7.6% dual users). Sports team participation was associated with lower odds of cigarette use (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI], 0.48-0.71) and dual use (aOR, 0.74; 95% CI, 0.63-0.88) and higher odds of EVP use (aOR, 1.39; 95% CI, 1.25-1.54). Among exclusive cigarette users and exclusive EVP users, sports team participation was associated with lower odds of frequent (≥20 days in the past month) than intermittent (1-19 days in the past month) cigarette use (aOR, 0.30; 95% CI, 0.19-0.49) and EVP use (aOR, 0.74; 95% CI, 0.61-0.91), respectively. CONCLUSIONS: Our findings suggest that risk profiles for cigarette and EVP use differ with respect to sports team participation. Given the health risks associated with EVP use, aggressive efforts must be taken to educate student athletes about the health risks of EVP use.

Mental health and parenting demands among grandparent caregivers of young U.S. children.

Substance abuse epidemics and changes in incarceration and foster care policies have recently placed more young children in grandparent custody. Grandmothers bear much of this caregiving responsibility. Our objective was to compare grandparent caregivers of preschool-aged children (grandparent(s) only or in multigenerational households) to parent caregivers, by caregiver sex, in their mental health, available emotional support, and capacity to manage parenting demands. Using U.S. National Survey of Children's Health data (2016-2019), we used survey-weighted logistic regression models adjusted for socio-demographic confounders and conducted sub-group analyses by caregiver sex. Among 30,046 families with a child aged 1-5 years, 776 (4.1%) were grandparent-only, 817 (3.3%) multigenerational, 28,453 (92.7) parent-headed (weighted percentages). Most caregivers (78.7%) were in Excellent/Very Good mental health, but grandfathers in grandparent-only households were less so. Despite being more likely to parent alone, caregivers in grandparent-only households had about twice the odds of having a source of emotional support (adjusted prevalence odds ratio [aPOR] = 2.07; 95% confidence interval [CI] 1.12, 3.83). Grandmothers, in particular, had greater odds of handling day-to-day parenting demands (aPOR = 2.40, 95% CI 1.35, 4.27) and of reporting rarely/never feeling angry with the child in their care (aPOR = 2.77, 95% CI 1.53, 5.01), compared to mothers in parent households. Caregivers in multigenerational households displayed no differences as compared to parents except for grandfathers in multigenerational households who were more likely often bothered by the child. Despite increasing demands on grandparents, they generally reported faring as well as or better than parent caregivers, especially grandmothers. Their prior experience and social support may make them resilient.

Caregiver Concern About Child Overweight/Obesity in Grandparent Versus Parent-Headed Households in the United States.

OBJECTIVE: To examine the association of caregivers' concern about children's overweight and obesity status with family structure (grandparent versus parent-headed households). METHODS: Caregivers reported their relation to the child aged 10 to 17 years and the child's weight and height (National Survey of Children's Health 2016-20). Overweight/obesity was calculated using Centers for Disease Control and Prevention growth charts. We estimated associations (prevalence odds ratio) of residing in a grandparent-headed household with lack of weight concern (responding "Yes, it's too low" or "No, not concerned" to "Are you concerned about this child's weight?") among propensity score-matched children with overweight and obesity. Covariates included child's sex, race, ethnicity, age, family poverty ratio, primary household language, highest level of education among reported adults, caregiver mental and emotional health, usual source of care and survey year. RESULTS: The prevalence of child overweight/obesity was higher in grandparent-headed households. Among children with overweight/obesity, 64.65 (SE = 3.27)% of grandparents and 66.55 (SE = 0.81)% of parents did not express concern about the child's weight status. Among children with obesity, it was 52.42 (SE = 4.63)% and 49.04 (SE = 1.28)%, respectively. Family structure was not associated with caregiver lack of weight concern in propensity score-matched samples. CONCLUSIONS: Appropriate caregiver concern about child's weight status was low in both grandparent and parent-headed households in the United States.

Associations between maternal exposure to surgery or pregnancy exposure to fluorinated anesthetics and children's cognitive development and educational outcomes.

A transgenerational, epigenetic effect of anesthesia, particularly fluorinated agents, has been examined in rat models, but translation to humans is unclear. This study examined associations of maternal lifetime exposure to anesthesia and pregnancy exposure to fluorinated anesthetics with child cognitive and educational outcomes. Women in the US Collaborative Perinatal Project (1959-1963) reported lifetime history of surgeries, and the obstetric record captured pregnancy exposure to anesthetics. Children were followed to age 7 for global cognitive ability and educational outcomes (n=47,977). Logistic and linear regressions were adjusted for maternal and child birth years, race and ethnicity, smoking, education, parity, study site. Many outcomes were not associated with exposure to maternal surgery that occurred at various life stages. However, maternal surgery in early childhood was associated both with being in a special school or not in school (adj OR=1.42; 95% CI 1.02, 1.98) and with slightly better cognitive ability across childhood (e.g., WISC IQ (adj ß=0.59; CI 0.13, 1.04) (especially among boys)). Maternal surgery in puberty was associated with slightly lower IQ (adj ß = -0.42; CI -0.79, -0.05) and poorer spelling at age 7. Children's prenatal exposure to fluorinated anesthetics was associated with slightly better spelling ability (adj ß = 1.20; CI 0.02, 2.38) but lower performance IQ at age 7 (only among boys, adj ß = -1.97; CI -3.88, -0.06). This study shows inconsistent evidence of effects of maternal exposure to surgery or prenatal exposure to fluorinated agents on child developmental and educational outcomes Residual confounding by indication and socioeconomic status may explain observed associations.

Effects of Omega-3-6-9 fatty acid supplementation on behavior and sleep in preterm toddlers with autism symptomatology: Secondary analysis of a randomized clinical trial.

BACKGROUND: Children born extremely preterm disproportionately experience sequelae of preterm birth compared to those born at later gestational ages, including higher prevalence of autism spectrum disorder (ASD) and associated behaviors. AIM: Explore effects of combined dietary docosahexaenoic acid, eicosapentaenoic acid, gamma-linolenic acid, and oleic acid (omega 3-6-9) on caregiver-reported behavior and sleep in toddlers born at ≤29 weeks' gestation who were exhibiting symptoms commonly seen with ASD. STUDY DESIGN: 90-day randomized (1:1), double blinded, placebo-controlled trial. SUBJECTS: Thirty-one children aged 18-38 months received omega 3-6-9 (n = 15) or canola oil placebo (n = 16). OUTCOME MEASURES: Mixed effects regression analyses followed intent to treat and explored treatment effects on measures of caregiver-reported behavior (Child Behavior Checklist 1.5-5, Toddler Behavior Assessment Questionnaire - Short Form, Vineland Adaptive Behavior Scales, 2nd Edition) and sleep (Children's Sleep Habits Questionnaire, Brief Infant Sleep Questionnaire). RESULTS: Twenty-nine of 31 (94%; ntx = 13, nplacebo = 16) children randomized had data available for at least one outcome measure, 27 (87%; ntx = 12, nplacebo = 15) had complete outcome data. Children randomized to omega 3-6-9 experienced a medium magnitude benefit of supplementation on anxious and depressed behaviors (ΔDifference = -1.27, d = -0.58, p = 0.049) and internalizing behaviors (ΔDifference = -3.41, d = -0.68, p = 0.05); and a large magnitude benefit on interpersonal relationship adaptive behaviors (ΔDifference = 7.50, d = 0.83, p = 0.01), compared to placebo. No effects were observed on other aspects of behavior or sleep. CONCLUSIONS: Findings provide preliminary support for further exploration of omega 3-6-9 during toddlerhood to improve socioemotional outcomes among children born preterm, especially for those showing early symptoms commonly seen with ASD. Results need to be replicated in a larger sample. TRIAL REGISTRATION: Registered with ClinicalTrials.gov: NCT01683565.

Eating Competence Among Caregivers of Toddlers: Associations With Caregiver and Child Overweight/Obesity.

OBJECTIVE: To examine the association between caregiver eating competence and child overweight/obesity and caregiver obesity. DESIGN: Longitudinal cohort. SETTING: A large US children's hospital. PARTICIPANTS: Caregiver-child dyads (n = 288 with complete data at 2 time points) were sampled in 2017-2019 from those who received care at Nationwide Children's Hospital. MAIN OUTCOME MEASURE(S): Child overweight/obesity at 24 months of age (body mass index [BMI]) z-score >2 per World Health Organization standards and caregiver weight status (underweight/healthy [BMI < 25 kg/m2], overweight [BMI ≥ 25 and < 30 kg/m2], or obese [BMI ≥ 30 kg/m2]). ANALYSIS: Log-binomial models examined the relationship between caregiver eating competence (ecSatter Inventory) at 18 months and child overweight/obesity at 24 months of age. Proportional odds models investigated the relationship between caregivers' eating competence and weight status. RESULTS: Eating competent caregivers had more than twice the odds (odds ratio, 2.11; 95% confidence interval, 1.30-3.42) of having a lower BMI category and had lower average BMI than noneating competent caregivers. Child overweight/obesity at 24 months did not differ by caregiver eating competence. CONCLUSIONS AND IMPLICATIONS: Although child overweight/obesity did not vary by caregiver eating competence, caregiver eating competence was related to their weight status. Longer-term studies are needed to clarify the role of caregiver eating competence as children develop. Promoting caregivers' eating competence may translate into healthier behaviors and skills for caregivers and their children long term.

ezPreemie study protocol: a randomised controlled factorial trial testing web-based parent training and coaching with parents of children born very preterm.

INTRODUCTION: Children born very preterm (VPT; gestational age <32 weeks) are twice as likely to demonstrate behaviour problems such as aggression, non-compliance, temper tantrums and irritability compared with their term-born peers. While behavioural parent training (BPT), also referred to as behaviour therapy is a gold standard for prevention and treatment of childhood problem behaviours, there are limited accessible and effective BPT interventions for families with children born VPT. The purpose of this paper is to describe a multicentre, randomised controlled protocol for a factorial design trial evaluating the independent and combined effects of the ezParent BPT intervention plus brief, weekly coaching calls on parent and child outcomes for families with toddlers born VPT. METHODS AND ANALYSIS: The study employs a 2×2 factorial randomised design. Parents (n=220) of children aged 20-30 months corrected age who were born VPT (<32 weeks) will be recruited from two large metropolitan Neonatal Intensive Care Units follow-up clinics and randomised to one of four conditions: (1) ezParent (2) ezParent +coach, (3) Active control or (4) Active Control +coach. Data on parenting and child behaviour outcomes will be obtained from all participants at baseline and 3, 6 and 12 months postbaseline. All analyses will use an intention-to-treat approach, independent of their actual dose of each intervention. ETHICS AND DISSEMINATION: The study protocol has been approved by The Ohio State University Institutional Review Board (IRB) using a single IRB. Study results will be disseminated through presentations at regional and national conferences, publications in peer-reviewed journals, and sharing research reports with participating families and recruiting sites. TRIAL REGISTRATION NUMBER: NCT05217615.