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BACKGROUND: Caregiver-child shared reading improves literacy skills, school readiness, familial relationships, and social-emotional development. This multiyear study seeks to evaluate the effect of exposure to Reach Out and Read (ROR) on caregiver reading frequency and behaviors. METHODS: Caregivers of children 6 months to 5 years in 427 primary care clinics in North and South Carolina were asked to complete the Reach Out and Read Parent Feedback Survey. Caregivers not previously exposed to ROR were categorized as "new," and those who had previously been exposed to ROR as "returning" to compare reading behaviors between groups. RESULTS: From 2014 to 2019, caregivers completed 100,656 surveys. Returning caregivers were more likely to report reading or looking at books every day (adjusted odds ratio [AOR] = 1.27; 95% confidence interval [95% CI], 1.22-1.33). Returning caregivers were more likely to perform behaviors like letting the child turn pages (AOR = 1.71; 95% CI, 1.62-1.79), making up stories about the pictures (AOR = 1.46; 95% CI, 1.39-1.53), asking what is happening in the pictures (AOR = 1.39; 95% CI, 1.32-1.47), helping identify things in the pictures (AOR = 1.57; 95% CI, 1.50-1.65), reading to the child 30 minutes every day (AOR = 1.39; 95% CI, 1.33-1.46), and taking the child to the library (AOR = 1.26; 95% CI, 1.20-1.34). CONCLUSIONS: This study shows a significant association between caregivers' exposure to ROR, high-frequency reading, and positive reading behaviors, and is consistent for all 6 years studied.retain-->.

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OBJECTIVE: We describe LP perceptions of pediatric and internal medicine/pediatrics residents and faculty and determine the relationship between LP training and perceptions of LP. Reach Out and Read (ROR) is a widely implemented evidence-based literacy promotion (LP) intervention. Recent data have shown that there is variability in both LP training for pediatric residents and implementation of ROR. However, little is known about the perceptions regarding LP and the relationship with training. METHODS: Faculty and residents at participating sites completed an anonymous online survey on LP perceptions and training. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression modeling. RESULTS: A total of 473 faculty and 1216 residents at 42 pediatric training programs participated. Faculty versus resident status was a significant predictor of almost all perception questions. Most faculty (65.3%) and residents (44.3%) completely agreed that it is the job of pediatricians to assess and encourage reading (P < .0001). Most faculty (69.6%) and residents (51.5%) completely agreed that LP is as important as advice about car seats, bike helmets, and "back-to-sleep" (P < .0001). More faculty (65.8%) than residents (46.6%) completely agreed with the statement "discussing sharing books with children at health supervision visits can be an effective early intervention strategy" (P < .0001). More faculty (34%) compared to residents (18.2%) completely agreed they felt confident modeling reading for parents during the visit (P < .0001). CONCLUSIONS: Faculty status predicted most favorable LP perceptions, while continuity clinic training and learning in-clinic from others predicted some favorable LP perceptions.

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BACKGROUND: Low health literacy affects one-third of adults in the United States and can have a negative effect on health behavior and outcomes. OBJECTIVE: The goal of this study was to examine attitudes and knowledge of health literacy among pediatric residents and faculty in pediatric resident continuity clinics across the country. METHODS: An online mixed-methods survey was distributed to pediatric faculty and residents through the Academic Pediatric Association's Continuity Research Network. The 20-question survey included questions about the participants' health literacy knowledge and health literacy practices in continuity clinics, such as use of universal health literacy precautions. Categorical answer choices were dichotomized into positive and negative groupings and resident and faculty responses were compared using the Chi-squared test (significance p < .05). Qualitative data were analyzed using emergent coding and grounded theory to determine themes. KEY RESULTS: Responses were received from 402 individuals at 24 pediatric residency programs. Most participants agreed or strongly agreed that they could correctly identify participants with low health literacy (76% residents vs. 53% faculty). Only 19% of residents and 26% of faculty were familiar with universal health literacy precautions. Many residents and faculty had received no training in health literacy (37% residents vs. 38% faculty). Barriers and challenges around health literacy included time, language, limited training or resources, low literacy, disease mismanagement, and fixed misconceptions. CONCLUSION: Despite ample evidence in the literature to the contrary, most respondents believed they could correctly identify individuals with low health literacy. Additionally, most participants had not heard of universal health literacy precautions and were unaware of their usage in their practice setting. This is not consistent with current expert recommendations. These findings are troubling as they are from academic residency programs, indicating an educational deficit. These findings point toward a next step in health literacy education for pediatric residents. [HLRP: Health Literacy Research and Practice. 2022;6(1):e51-e60.] Plain Language Summary: Pediatric residents and faculty in continuity clinics were surveyed about their opinions, health literacy knowledge, ability, and practices in continuity clinics. Despite evidence to the contrary, most respondents believed they could correctly identify individuals with low health literacy and had not heard of universal health literacy precautions. These findings highlight the need for more health literacy education for pediatric residents.

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Child care environments foster children's healthy eating habits by providing exposure to healthy foods and feeding practices. We assessed the healthfulness of nutrition environments, menu/meal quality, and the achievement of Child and Adult Care Food Program (CACFP) guidelines and best practices in Oklahoma CACFP-enrolled family child care homes (FCCHs) (n = 51). Two-day classroom observations were conducted. Healthfulness of classroom nutrition environments was assessed using the Environment and Policy Assessment and Observation (EPAO). Foods served to and consumed by children were quantified using the Dietary Observations in Child Care (DOCC) tool. Nutrient analysis was performed to determine total energy for foods listed on menus, served to, and consumed by children. Menu and meal food variety and CACFP Guideline Achievement Scores were determined. Average nutrition environment score was 11.7 ± 1.2 (61.5% of maximum possible score). Energy (kcals) from menus and consumed by children was insufficient to meet two-thirds of their daily reference intake. Children were exposed to 1.7 vegetables and 1.3 fruits per meal. CACFP Guideline Achievement Scores were 66.3% ± 7.8 for menus and 59.3% ± 7.6 for mealtimes. Similar to previous research, our findings indicate a need for improved FCCH nutrition practices. Tailored interventions for FCCHs are needed.

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BACKGROUND: The American Academy of Pediatrics regards literacy promotion as essential. Medical professionals are in a key position to promote children's early literacy, however this requires knowledge of existing literacy programmes. This study describes medical student training, awareness, experiences, and attitudes towards early literacy and the 'Reach Out and Read' (ROR) initiative. METHODS: An anonymous online survey was sent to all medical students at a medical school in the Midwest with two campuses. Data were analysed using descriptive statistics. RESULTS: We received data from 275 medical students. Almost half (46.5%) had completed their paediatric clerkship, 22.9% had observed ROR, and only 2.9% had received any training. Most (67%), wanted to learn more about early literacy, and 59% expressed a desire for more ROR training. Most respondents expressed preference for learning from residents and faculty in clinic followed by online training. 47% agreed that it was a role of medical students to assess and encourage reading. DISCUSSION: Medical students understand the importance of early literacy in primary care and emphasising this during clinical encounters. Most are eager to learn more about early literacy promotion and ROR. This interest decreases during third and fourth year so targeting the first 2 years of medical school is an important strategy. Providing formal literacy promotion training and education for medical students should be considered during this critical time in their education.

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BACKGROUND: Enhanced literacy and increased vocabulary related to Reach Out and Read (ROR) are well described. Less is known about clinicians' experience with the program. OBJECTIVE: Understand clinician experiences of implementing ROR. DESIGN/METHODS: This study was a collaboration between ROR and the Academic Pediatric Association's Continuity Research Network. Participants completed an anonymous online survey to evaluate Literacy Promotion activities and training, and were asked "What has been the most meaningful experience you have encountered with using ROR?" and "Is there anything else you would like to add?" Responses were evaluated by researchers and 4 themes were generated through discussion. All responses were divided and coded by researchers working in pairs and subsequently by all researchers until consensus was reached. Data were organized into themes. FINDINGS: Responses were provided by 592 (35%) participants. Qualitative analysis revealed benefits to participation in ROR within 4 themes: 1) Child/Family Impact (60%): "Seeing a child read for the first time" 2) Physician Impact (16%): "I... use the books... to connect with patients." 3) Impact on clinic practice (25%): "I... enjoy modeling for parents and use the books to assess... development" 4) Social Determinants of Health (2%): "The books... are an invaluable resource to our under-served population." CONCLUSION: Clinicians who implement ROR report positive impact on patients, families, and their own satisfaction and methods in practice. Clinicians value that the program addresses social determinants of health and facilitates developmental surveillance. Further study is needed to understand how clinician's perspectives affect and are affected by their experiences.

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Oklahoma established the first health services initiative (HSI) to expand Reach Out and Read (ROR), increase developmental screening and improve the quality of well-child visits (Early and Periodic Screening, Diagnostic and Treatment (EPSDT)). ROR uses a book in the exam room to assess development and parent-child interaction, however, little is known about the relationship between this training and using a formal developmental screening tool. The purpose of this study is to see if using federal funding would facilitate ROR expansion and if this expansion would improve developmental screening and EPSDT visits in Oklahoma. Medicaid billing data for state fiscal year (SFY) 2018 and 2019 were analyzed. Standard statistical methods were used to analyze the data descriptively to determine the proportion of developmental screenings performed and EPSDT visits. Comparisons were made between ROR and non-ROR sites. Nine new ROR sites were added with 26 new providers/staff and 130 providers/staff at existing sites trained in ROR from Novenber 2018 to June 2019. In SFY 2018, the developmental screening percentage at non-ROR sites was 33% vs 47% at ROR sites (p<0.0001), in SFY 2019 non-ROR sites were 36% vs 48% at ROR sites (p<0.0001). The EPSDT visit percentage in SFY 2018 was 50% at non-ROR sites vs 69% at ROR sites and in SFY 2019 was 51% at non-ROR sites vs 72% at ROR sites. HSIs are an effective way to fund ROR. Additional funding allowed for increased ROR sites and training. ROR sites are more likely to perform developmental screenings and EPSDT visits.

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BACKGROUND: Despite endorsement by the American Academy of Pediatrics, there are no national data on literacy promotion (LP) training and behaviors. OBJECTIVE: To describe LP training experiences and behaviors of pediatric and internal medicine/pediatrics residents and faculty nationally, and the association between LP training and behaviors. METHODS: The Academic Pediatric Association's Continuity Research Network and Reach Out and Read National Center sent an online survey to faculty and residents at participating Continuity Research Network clinics. Respondents were asked about LP training experiences and behaviors. Data were analyzed using descriptive statistics, chi-square tests, and logistic regression modeling. RESULTS: 473 faculty and 1216 residents at 42 institutions participated. More faculty than residents reported completing online Reach Out and Read training (63% vs 45%, P < .0001). More residents reported learning in clinic from others (92% vs 89%, P = .04). Training experiences did not differ otherwise. More faculty reported providing anticipatory guidance (87% vs 77%, P < .0001); modeling shared reading (69% vs 45%, P < .0001); and using books for developmental assessment (80% vs 62%, P < .0001). Both groups (97%) reported distributing books. The training modality most often endorsed as "very/extremely influential" was learning in clinic from others. Some LP behaviors were associated more strongly with online training while others were associated more strongly with in-person training. CONCLUSIONS: Online training and in-person training are both associated with high quality delivery of LP. Faculty members are more likely to have completed online training and to report engaging in the full range of recommended LP behaviors. These data have implications for LP training.

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IMPORTANCE: Oklahoma's infant mortality remains among the highest in the nation.1 Infant mortality rates are highest within the African American community.2 Physician and community partner efforts to decrease infant mortality are discussed to encourage more involvement in addressing infant mortality. The purpose of this article is to describe both provider and community-based efforts to combat infant mortality, particularly those focused on infant mortality disparities. OBSERVATIONS: The leading causes of infant deaths are prematurity, congenital malformations and/or chromosomal anomalies, and unclassified deaths such as Sudden Infant Death Syndrome or accidents. Prematurity accounts for the highest number of infant deaths. Efforts in Oklahoma focus on prematurity and SIDS prevention. Fetal Infant Mortality Review programs in Oklahoma and Tulsa Counties focus on local issues contributing to infant mortality and promote community engagement. In central Oklahoma, an Infant Mortality Alliance (IMA) was formed including over 180 stakeholders focusing on healthcare access, community and faith engagement, and health disparities. In the year following the IMA's initial work, the non-Hispanic African American infant mortality rate in Oklahoma County decreased by 18.8%.12. CONCLUSIONS AND RELEVANCE: Infant mortality is multifactorial and requires multiple strategies to combat. To address infant mortality and disparities, all aspects of the community must be involved. No individual alone can improve infant mortality. Physicians providing prenatal care make an impact by implementing recommended guidelines for progesterone therapy. Physicians seeing infants can encourage safe sleep practices among their families and local hospitals. While progress has been made addressing Oklahoma's infant mortality, much work remains.

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BACKGROUND: Reach Out and Read is an evidence based early literacy program used in primary care practices. In 2014, the program expanded to County Health Departments in Oklahoma. OBJECTIVE: To evaluate how implementation of the program in Health Departments affects access for at risk children. METHODS: Oklahoma program sites were classified as either Health Department or practice, geocoded, and mapped to census tract, census block group, and county subdivision maps. Sites were classified as rural or urban, and census data was used to classify sites as high or low poverty prevalence and education level. Sites were compared to determine their accessibility to at risk children as defined by living in rural areas, high poverty, and low educational level. RESULTS: There were 18 Health Department and 67 practice sites. Health Department sites were more likely to be in rural areas: 13 of 18 sites versus 16 of 67 practices (p<0.001). They were less likely to be in areas of high poverty: 10 of 18 versus 61 of 67 practices (p<0.001), and they were not more likely to be in areas of lower education, with 8 of 18 sites in low education areas versus 34 of 67 practices (p=0.8342). CONCLUSIONS: Implementation of Reach Out and Read in Health Departments in Oklahoma increased the number of rural program sites. Health Department locations were less likely to be in areas of poverty and lower education. Use of the program in Health Departments is an effective way to expand the program to serve rural children.

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Weight-based dosing for enoxaparin is recommended in the 2008 American College of Chest Physicians (ACCP) guidelines for venous thromboembolism (VTE) prophylaxis. Enoxaparin 0.5 mg/kg per dose administered subcutaneously every 12 hours is recommended for this indication in children. There is no established upper dosing limit of enoxaparin for prophylaxis in children, and the US Food and Drug Administration-approved enoxaparin dose for adults for VTE prophylaxis is 30 mg subcutaneously every 12 hours or 40 mg subcutaneously daily. Therefore, we assumed that the upper limit for children is 40 mg subcutaneously daily. We reviewed 3 cases of obese adolescent boys who required large doses of enoxaparin to achieve the ACCP-recommended anti-factor Xa range of 0.1 to 0.3 IU/mL for the prevention of VTE. All 3 patients required doses of enoxaparin that are higher than that recommended for adults for VTE prophylaxis: patient A (BMI: 105.9) required >0.28 mg/kg per dose, patient B (BMI: 95.7) required 0.15 mg/kg per dose, and patient C (BMI: 29.9) required 0.49 mg/kg per dose. The desired anti-factor Xa range was achieved when enoxaparin was administered every 12 hours in each patient with no reported episodes of VTE. One patient had minor bruising, but no other adverse events were noted. Because of the variability in dose requirements and unpredictability in patient responses demonstrated in our 3 adolescents, prospective studies are needed to provide definitive recommendations on dosing of enoxaparin for VTE prophylaxis in this subset of obese pediatric patients.

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