Faculty Bibliography

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

OBJECTIVE: To determine the effects of pediatric primary care interventions on parent-child interactions in families with low socioeconomic status. DESIGN: In this randomized controlled trial, participants were randomized to 1 of 2 interventions (Video Interaction Project [VIP] or Building Blocks [BB]) or the control group. SETTING: Urban public hospital pediatric primary care clinic. PARTICIPANTS: Mother-newborn dyads enrolled post partum from November 1, 2005, through October 31, 2008. INTERVENTIONS: In the VIP group, mothers and newborns participated in 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading by reviewing videos made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. In the BB group, parenting materials, including age-specific newsletters suggesting interactive activities, learning materials, and parent-completed developmental questionnaires, were mailed to the mothers. MAIN OUTCOME MEASURES: Parent-child interactions were assessed at 6 months with the StimQ-Infant and a 24-hour shared reading recall diary. RESULTS: A total of 410 families were assessed. The VIP group had a higher increased StimQ score (mean difference, 3.6 points; 95% confidence interval, 1.5 to 5.6 points; Cohen d, 0.51; 0.22 to 0.81) and more reading activities compared to the control group. The BB group also had an increased overall StimQ score compared with the control group (Cohen d, 0.31; 95% confidence interval, 0.03 to 0.60). The greatest effects for the VIP group were found for mothers with a ninth-grade or higher reading level (Cohen d, 0.68; 95% confidence interval, 0.33 to 1.03). CONCLUSIONS: The VIP and BB groups each led to increased parent-child interactions. Pediatric primary care represents a significant opportunity for enhancing developmental trajectories in at-risk children. Trial Registration clinicaltrials.gov Identifier: NCT00212576

OBJECTIVES: To determine whether pediatric primary care-based programs to enhance parenting and early child development reduce media exposure and whether enhanced parenting mediates the effects. DESIGN: Randomized controlled trial. SETTING: Urban public hospital pediatric primary care clinic. PARTICIPANTS: A total of 410 mother-newborn dyads enrolled after childbirth. INTERVENTIONS: Patients were randomly assigned to 1 of 2 interventions, the Video Interaction Project (VIP) and Building Blocks (BB) interventions, or to a control group. The VIP intervention comprised 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading through review of videotapes made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. The BB intervention mailed parenting materials, including age-specific newsletters suggesting activities to facilitate interactions, learning materials, and parent-completed developmental questionnaires (Ages and Stages questionnaires). OUTCOME MEASURES: Electronic media exposure in the home using a 24-hour recall diary. RESULTS: The mean (SD) exposure at 6 months was 146.5 (125.0) min/d. Exposure to VIP was associated with reduced total duration of media exposure compared with the BB and control groups (mean [SD] min/d for VIP, 131.6 [118.7]; BB, 151.2 [116.7]; control, 155.4 [138.7]; P = .009). Enhanced parent-child interactions were found to partially mediate relations between VIP and media exposure for families with a ninth grade or higher literacy level (Sobel statistic = 2.49; P = .01). CONCLUSION: Pediatric primary care may represent an important venue for addressing the public health problem of media exposure in young children at a population level. Trial Registration clinicaltrials.gov Identifier: NCT00212576

OBJECTIVE: To determine whether duration and content of media exposure in 6-month-old infants are associated with development at age 14 months. DESIGN: Longitudinal analysis of 259 mother-infant dyads participating in a long-term study related to early child development, from November 23, 2005, through January 14, 2008. SETTING: An urban public hospital. PARTICIPANTS: Mothers with low socioeconomic status and their infants. Main Exposure Duration and content of media exposure at age 6 months. MAIN OUTCOME MEASURES: Cognitive and language development at age 14 months. RESULTS: Of 259 infants, 249 (96.1%) were exposed to media at age 6 months, with mean (SD) total exposure of 152.7 (124.5) min/d. In unadjusted and adjusted analyses, duration of media exposure at age 6 months was associated with lower cognitive development at age 14 months (unadjusted: r = -0.17, P < .01; adjusted: beta = -0.15, P = .02) and lower language development (r = -0.16, P < .01; beta = -0.16, P < .01). Of 3 types of content assessed, only 1 (older child/adult-oriented) was associated with lower cognitive and language development at age 14 months. No significant associations were seen with exposure to young child-oriented educational or noneducational content. CONCLUSIONS: This study is the first, to our knowledge, to have longitudinally assessed associations between media exposure in infancy and subsequent developmental outcomes in children from families with low socioeconomic status in the United States. Findings provide strong evidence in support of the American Academy of Pediatrics recommendations of no media exposure prior to age 2 years, although further research is needed

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

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

This study examined 3 questions: (1) What are sources from which low socioeconomic status (SES) mothers of newborns receive parenting information? (2) To what extent are sociodemographic characteristics associated with sources? (3) To what extent are sources associated with intentions regarding activities with infants? In this cross-sectional analysis, mothers were interviewed during the postpartum period about potential sources of information about parenting and asked if and when they planned to initiate shared reading and television exposure during infancy. Maternal high school graduation, US birth, non-Latina ethnicity, language English, higher SES, and firstborn child were each associated with one or more categories representing important sources of parenting information. In adjusted analyses, print, physicians and other health care professionals, and family/friends as important sources of information were each significantly associated with increased frequency of intention to begin shared reading in infancy; television as an important source was associated with intention to begin television in infancy

OBJECTIVES: To assess parents' liquid medication administration errors by dosing instrument type and to examine the degree to which parents' health literacy influences dosing accuracy. DESIGN: Experimental study. SETTING: Interviews conducted in a public hospital pediatric clinic in New York, New York, between October 28, 2008, and December 24, 2008. PARTICIPANTS: Three hundred two parents of children presenting for care were enrolled. MAIN OUTCOME MEASURES: Parents were observed for dosing accuracy (5-mL dose) using a set of standardized instruments (2 dosing cups [one with printed calibration markings, the other with etched markings], dropper, dosing spoon, and 2 oral syringes [one with and the other without a bottle adapter]). RESULTS: The percentages of parents dosing accurately (within 20% of the recommended dose) were 30.5% using the cup with printed markings and 50.2% using the cup with etched markings, while more than 85% dosed accurately with the remaining instruments. Large dosing errors (>40% deviation) were made by 25.8% of parents using the cup with printed markings and 23.3% of parents using the cup with etched markings. In adjusted analyses, cups were associated with increased odds of making a dosing error (>20% deviation) compared with the oral syringe (cup with printed markings: adjusted odds ratio [AOR] = 26.7; 95% confidence interval [CI], 16.8-42.4; cup with etched markings: AOR = 11.0; 95% CI, 7.2-16.8). Compared with the oral syringe, cups were also associated with increased odds of making large dosing errors (cup with printed markings: AOR = 7.3; 95% CI, 4.1-13.2; cup with etched markings: AOR = 6.3; 95% CI, 3.5-11.2). Limited health literacy was associated with making a dosing error (AOR = 1.7; 95% CI, 1.1-2.8). CONCLUSIONS: Dosing errors by parents were highly prevalent with cups compared with droppers, spoons, or syringes. Strategies to reduce errors should address both accurate use of dosing instruments and health literacy

OBJECTIVE: Controlling feeding styles in which parents regulate feeding without responding to child cues have been associated with poor self-regulation of feeding and increased weight, but have not been well studied in infancy. We sought to assess maternal perception of infant feeding cues and pressuring feeding styles in an urban Latina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population. METHODS: Secondary analysis of a larger study of Latina mothers participating in New York City WIC programs. We examined maternal perception of infant feeding cues and pressuring feeding style. Using logistic regression, we assessed: 1) characteristics associated with perceptions of cues and pressuring to feed, including sociodemographics, breastfeeding, and maternal body mass index; and 2) whether perceptions of cues were associated with pressuring feeding style. RESULTS: We surveyed 368 mothers (84% response rate). Most mothers perceived that babies sense their own satiety. However, 72% believed that infant crying must indicate hunger. Fifty-three percent believed that mothers should always make babies finish the bottle ("pressure to feed"). Pressuring feeding style was associated with foreign maternal country of birth (adjusted odds ratio [AOR] 3.05; 95% confidence interval [CI], 1.66-5.60) and less than a high school education (AOR 1.81; 95% CI, 1.12-2.91). Two perceptions of feeding cues were related to pressuring feeding style: belief that infant crying must indicate hunger (AOR 2.59; 95% CI, 1.52-4.42) and infant hand sucking implies hunger (AOR 1.83; 95% CI, 1.10-3.03). CONCLUSIONS: Maternal characteristics influence perception of infant hunger and satiety. Interpretation of feeding cues is associated with pressuring feeding style. Improving responsiveness to infant cues should be a component of early childhood obesity prevention.