Faculty Bibliography

OBJECTIVES: : To explore the relationship between early cognitive stimulation in the home, 6-month infant communication, and 24-month toddler language in a low-socioeconomic status sample. METHODS: : Longitudinal analyses of mother-child dyads participating in larger study of early child development were performed. Dyads enrolled postpartum in an urban public hospital. Cognitive stimulation in the home at 6 months was assessed using StimQ-lnfant, including provision of toys, shared reading, teaching, and verbal responsivity. Early infant communication was assessed at 6 months including the following: (1) Emotion and eye gaze (Communication and Symbolic Behavior Scale DP-CSBS DP), (2) Communicative bids (CSBS DP), and (3) Expression of emotion (Short Temperament Scale for Infants). Toddler language was assessed at 24 months using the Preschool Language Scale-4, including the following: (1) expressive language and (2) auditory comprehension. RESULTS: : Three hundred twenty families were assessed. In structural equation models, cognitive stimulation in the home was strongly associated with early infant communication (beta = 0.63, p <.0001) and was predictive of 24-month language (beta = 0.20, p <.05). The effect of early cognitive stimulation on 24-month language was mediated through early impacts on infant communication (Indirect beta = 0.28, p =.001). Reading, teaching, availability of learning materials, and other reciprocal verbal interactions were all related directly to infant communication and indirectly to language outcomes. CONCLUSIONS: : The impact of early cognitive stimulation on toddler language is manifested through early associations with infant communication. Pediatric primary care providers should promote cognitive stimulation beginning in early infancy and support the expansion and dissemination of intervention programs such as Reach Out and Read and the Video Interaction Project.

OBJECTIVES: We explored the relationship between household food insecurity and maternal feeding styles, infant feeding practices, and perceptions and attitudes about infant weight in low-income mothers. METHODS: Mothers participating in the Special Supplemental Food Program for Women, Infants, and Children with infants aged between 2 weeks and 6 months were interviewed. By using regression analyses, the following relationships were examined between food insecurity and: (1) controlling feeding styles (restrictive and pressuring); (2) infant feeding practices, including breastfeeding, juice consumption, and adding cereal to the bottle; and (3) perceptions and attitudes about infant weight. Path analysis was used to determine if perceptions and attitudes about infant weight mediated the relationships between food insecurity and controlling feeding styles. RESULTS: The sample included 201 mother-infant pairs, with 35% reporting household food insecurity. Food-insecure mothers were more likely to exhibit restrictive (B [SE]: 0.18 [0.08]; 95% confidence interval [CI]: 0.02-0.34) and pressuring (B [SE]: 0.11 [0.06]; 95% CI: 0.001-0.22) feeding styles compared with food-secure mothers. No associations were found with feeding practices. Concern for their infant becoming overweight in the future was associated with food insecurity (adjusted odds ratio: 2.11 [95% CI: 1.02-4.38]). This concern mediated the relationship between food insecurity and both restrictive (P = .009) and pressuring (P = .01) feeding styles. CONCLUSIONS: Increased concern about future overweight and controlling feeding styles represent potential mechanisms by which food insecurity could be related to obesity. Obesity prevention should aim to decrease food insecurity and to reduce controlling feeding styles in families who remain food insecure.

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. (Am J Public Health. Published online ahead of print May 17, 2012: e1-e7. doi:10.2105/AJPH.2011.300486).

OBJECTIVE: Poor quality and variability of medication labeling have been cited as key contributors to medication misuse. We assessed the format and content of labels and materials packaged with common pediatric liquid nonprescription medications. METHODS: Descriptive study. A total of 200 top-selling pediatric oral liquid nonprescription medications (during the 52 weeks ending October 30, 2009) categorized as analgesic, cough/cold, allergy, and gastrointestinal products, with dosing information for children <12 years (representing 99% of U.S. market for these products) were reviewed. The principal display panel (PDP) and FDA Drug Facts panel (side panel) of each bottle, and associated box, if present, were independently examined by 2 abstractors. Outcome measures: content and format of active ingredient information and dosing instructions of the principal display panel and Drug Facts panel. RESULTS: Although almost all products listed active ingredients on the Drug Facts panel (side panel), nearly 1 in 5 (37 [18.5%]) did not list active ingredients on the PDP. When present, mean (SD) font size for PDP active ingredients was 10.7 (5.0), smaller than product brand name (32.1 [15.0]) and flavor (13.1 [4.8]); P < .001. Most products included directions in chart form (bottle: 167 [83.5%], box: 148 [96.1%], P < .001); mean (SD) font size: 5.5 (0.9; bottle), 6.5 (0.5; box), P < .001. Few products expressed dosing instructions in pictographic form: 4 (2.6%) boxes and 0 bottles. Nearly all products included the Food and Drug Administration-mandated sections. CONCLUSIONS: The format and content of labels for nonprescription pediatric liquid medications could be improved to facilitate parent understanding of key medication information, including active ingredient information and dosing instructions.

OBJECTIVE: Although low parent health literacy (HL) has been linked to poor child health outcomes, it is not known whether differences in perceptions related to access to care and provider-parent partnership in care are potential contributing factors. We sought to assess whether parent HL is associated with differences in perceived barriers to care and attitudes regarding participatory decision-making with the provider. METHODS: This was a cross-sectional analysis of data collected from parents presenting with their child to an urban public hospital pediatric clinic in New York City. Dependent variables were caregiver-reported barriers to care (ability to reach provider at night/on weekends, difficult travel to clinic) and attitudes towards participatory decision-making (feeling like a partner, relying on doctor's knowledge, leaving decisions up to the doctor, being given choices/asked opinion). The primary independent variable was caregiver HL (Short Test of Functional Health Literacy in Adults [S-TOHFLA]). RESULTS: A total of 823 parents were assessed; 1 in 4 (27.0%) categorized as having low HL. Parents with low HL were more likely to report barriers to care than those with adequate HL: trouble reaching provider nights/weekends, 64.9% vs. 49.6%, (p < 0.001, adjusted odds ratio [AOR] 1.7, 95% confidence interval [95% CI] 1.2-2.4); difficult travel, 15.3% vs. 8.0%, (p = 0.004, AOR 1.8, 95% CI 1.1-3.0). Low HL was also associated with not feeling like a partner (28.8% vs. 17.1%; AOR 2.0; 95% CI 1.4-3.0), preference for relying on the doctor's knowledge (68.9% vs. 52.2%; AOR 1.7; 95% CI 1.2-2.4), and preference for leaving decisions up to the doctor (57.7% vs. 33.3%; AOR 2.2; 95% CI 1.6-3.1). CONCLUSIONS: Addressing issues of parent HL may be helpful in ameliorating barriers to care and promoting provider-parent partnership in care.

OBJECTIVE: To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT Spanish). METHODS: Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8). RESULTS: Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), whereas only 0.6% had 9th grade or greater numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than one-half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than one-third (31.8%) were able to interpret a food label to determine whether it met WIC (Special supplemental nutrition program for Women, Infants, and Children) guidelines. Greater PHLAT-10 score was associated with greater years of education (r = 0.49), S-TOFHLA (r = 0.53), and WRAT-3 (r = 0.55) scores (P < .001). Internal reliability was good (Kuder-Richardson coefficient of reliability; KR-20 = 0.61). An 8-item scale was highly correlated with the full 10-item scale (r = 0.97, P < .001), with comparable internal reliability (KR-20 = 0.64). CONCLUSIONS: Many Spanish-speaking parents have difficulty performing health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

This study sought to determine the relationship between maternal controlling feeding styles and maternal perception of their infant's ability to regulate feeding and infant weight. A cross-sectional survey of 208 mothers with infants between 2 weeks and 6 months old was performed in a private pediatric office. The authors assessed the relationship between restrictive and pressuring feeding styles with (a) maternal perception of the infant's ability to regulate feeding and (b) infant weight (both actual and perceived). Restrictive feeding style was associated with the perception that infants could not recognize their own hunger or satiety and with concern that the infant would become overweight in the future. Pressuring feeding style was associated with the perception that the baby's appetite is less than other babies and with concern that the infant would become underweight in the future. Maternal perceptions of infant feeding and weight should be incorporated into early obesity prevention strategies.

Objective: Individuals with ADHD are often characterized as inconsistent across many contexts. ADHD is also associated with deficits in executive function. We examined the relationships between response time (RT) variability on five brief computer tasks to parents' ratings of ADHD-related features and executive function in a group of children with a broad range of ADHD symptoms from none to full diagnosis. Methods: We tested 98 children (mean age 9.9 +/- 1.4 years; 66 boys) from community clinics on short tasks of executive control (TEC) and the Eriksen Flanker task, while a parent completed the Conners' Parent Rating Scale and Behavior Rating Inventory of Executive Function. Results: Variability for two of the TEC tasks explained significant proportions of the variance of all five ADHD-related Conners' subscales and several executive function subscales. By contrast, variability on the flanker task or mean RTs for any task were not associated with any rating scale. Conclusion: The significant dimensional relationships observed between variability measures and parent ratings supported the utility of RT variability as an objective measure in ADHD and aspects of executive functioning that is superior to RT means or accuracy measures

OBJECTIVE: Medication dosing errors by parents are frequent. We sought to whether a pictographic dosing diagram could improve parent ability to dose infant acetaminophen, and to determine whether pictogram benefit varies by health literacy level. METHODS: We conducted an experimental study of parents presenting with their children to an urban public hospital pediatric clinic. Caregivers were randomized to dose infant acetaminophen with a standard dropper using text-only or text-plus-pictogram instructions (pictographic diagram of dose). The primary outcome variable was dosing accuracy (error defined as >20% deviation above/below dose; large overdosing error defined as >1.5 times recommended dose). Caregiver health literacy was assessed by means of the Newest Vital Sign measure. RESULTS: A total of 299 parents were assessed (144 text-only instructions; 155 text plus pictogram); 77.9% had limited health literacy (Newest Vital Sign score 0-3). Text-plus-pictogram recipients were less likely to make an error compared to text-only recipients (43.9% vs 59.0%, P = .01; absolute risk reduction, 15.2% [95% confidence interval, 3.8-26.0]; number needed to treat, 7 [4-26]). Of text-plus-pictogram recipients, 0.6% made a large overdosing error compared to 5.6% of text-only recipients (absolute risk reduction, 4.9% [0.9-10.0]; number needed to treat, 20 [10-108]). Pictogram benefit varied by health literacy, with a statistically significant difference in dosing error evident in the text-plus-pictogram group compared to the text-only group among parents with low health literacy (50.4% vs 66.4%; P = .02), but not for parents with adequate health literacy (P = .7). CONCLUSIONS: Inclusion of pictographic dosing diagrams as part of written medication instructions for infant acetaminophen may help parents provide doses of medication more accurately, especially those with low health literacy. High error rates, even among parents with adequate health literacy, suggest that additional study of strategies to optimize dosing is needed