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Implementation of a pilot program of Reach Out and Read® in the neonatal intensive care unit: a quality improvement initiative

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Objective: Language exposure is important for neurodevelopment, but is sparse in the neonatal intensive care unit (NICU). Study design: We introduced Reach Out and Read (ROR) in the NICU as a quality improvement initiative to increase language exposure. Measures included availability of books, accessibility of parents, and enrollment of infants, percent infants read to by their parents, and data from parental surveys. Result: 98 infants were included (40 before, 58 after). We obtained books in the mother's language for 95% of infants, 82% eligible infants were enrolled, and 70% read to their infants (mean of 0.45 ± 0.35 times/day). Surveyed parents enjoyed reading, noted positive effect(s), and intended to read post-discharge. Conclusion: We launched a well-received pilot ROR program in the NICU and reached our goal of ≥50% infants being read to by their parents. Further study is needed to assess the impact of reading in the NICU on parents and infants.
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Journal of Perinatology (2018) 38:759766
https://doi.org/10.1038/s41372-018-0060-8
QUALITY IMPROVEMENT ARTICLE
Implementation of a pilot program of Reach Out and Read® in the
neonatal intensive care unit: a quality improvement initiative
Bernadette M. Levesque1,2 Anh Tran3Emily Levesque4Hira Shrestha4Ramona Silva5Marsha Adams5
Marilyn Valles5Judith Burke5Alison Corning-Clarke6Carole Ferguson6
Received: 11 August 2017 / Revised: 15 January 2018 / Accepted: 17 January 2018 / Published online: 12 February 2018
© Nature America, Inc., part of Springer Nature 2018
Abstract
Objective: Language exposure is important for neurodevelopment, but is sparse in the neonatal intensive care unit (NICU).
Study design: We introduced Reach Out and Read (ROR) in the NICU as a quality improvement initiative to increase
language exposure. Measures included availability of books, accessibility of parents, and enrollment of infants, percent
infants read to by their parents, and data from parental surveys.
Result: 98 infants were included (40 before, 58 after). We obtained books in the mothers language for 95% of infants, 82%
eligible infants were enrolled, and 70% read to their infants (mean of 0.45 ±0.35 times/day). Surveyed parents enjoyed
reading, noted positive effect(s), and intended to read post-discharge.
Conclusion: We launched a well-received pilot ROR program in the NICU and reached our goal of 50% infants being read
to by their parents. Further study is needed to assess the impact of reading in the NICU on parents and infants.
Introduction
Premature infants hear plenty of noise but little language in
the neonatal intensive care unit (NICU), and they are
deprived of the full extent of in-utero language exposure
due to their shortened gestation [1]. Language exposure,
such as talking, reading, or singing, is essential for normal
speech and language development [2,3]. Surviving pre-
mature infants often have delays in receptive and expressive
language processing, lower IQ scores, and lower Bayley
Mental Developmental Index scores [47]. The altered
sound and language exposure experienced by preterm
infants in the NICU may put them at increased risk for the
subsequent hearing, language, and cognitive disabilities that
are so common. This quality improvement (QI) initiative
was designed to increase language exposure for
preterm infants in our NICU out of concern that they may
not be exposed to enough language to foster optimal
development.
Greater language exposure in the NICU is associated
with better neurodevelopmental outcome at 1822 months
of age [8]. Both ambient language and audio-recordings of
maternal sounds have been shown to positively affect
neurodevelopment [8,9]. In contrast, infants cared for in
single family NICU rooms have lower Bayley III language
scores at 2 years of age compared to those cared for in the
NICUs open bay area, likely due to relative sensory
deprivation and less language exposure [10].
Low socioeconomic status (SES) infants experience
signicant disparities in language exposure during early
childhood and consequently have lower levels of vocabu-
lary growth, school readiness, and reading skills [11].
Shared book reading can help parents promote cognitive,
literacy, and reading achievement in their children [12], but
this activity is less common among non-Hispanic black,
*Bernadette M. Levesque
Bernadette.levesque@bmc.org
1Boston Medical Center, Division of Neonatology, Boston, MA,
USA
2Boston University School of Medicine, Boston, MA, USA
3Boston University School of Public Health, Boston, MA, USA
4Department of Pediatrics, Boston Medical Center, Boston, MA,
USA
5Department of Nursing, Boston Medical Center, Boston, MA,
USA
6Reach Out and Read of Massachusetts, Boston, MA, USA
Electronic supplementary material The online version of this article
(https://doi.org/10.1038/s41372-018-0060-8) contains supplementary
material, which is available to authorized users.
1234567890();,:
Hispanic, and less-educated mothers [13,14], and with non-
native English speakers [14]. Among preterm infants,
reading aloud by parents >2 times per week is associated
with higher cognitive development scores at 2 years of age,
even after adjusting for neonatal, maternal, and socio-
economic characteristics [13]. Parents who read to their
infant in the NICU are more likely to continue to read to
their infant after discharge, and they also experience less
stress [15], but this was not being done in our NICU prior to
this initiative. Introducing shared book reading to parents in
the NICU could impact a signicant, modiable factor
affecting neurodevelopmental outcome.
We identied our NICU population to be at particularly
high risk for inadequate language exposure. We serve a
diverse, low-income population for whom frequent visiting
can be a challenge. An open bayNICU, we were antici-
pating a move to private family rooms in January of 2017,
which could further reduce language exposure. With these
factors in mind, we opted to introduce Reach Out and Read
(ROR) in our NICU as a QI initiative.
ROR gives young children a foundation for success by
incorporating books into pediatric care and encouraging
families to read aloud together [16]. ROR was founded in
1989 by pediatricians at Boston Medical Center (then called
Boston City Hospital). Currently implemented in over 5800
primary care ofces, a new book and anticipatory guidance
are given at each well child visit from 6 months to 5 years of
age. The American Academy of Pediatrics supports literacy
promotion in primary care clinics beginning in infancy [17],
but ROR had not previously been implemented in the
NICU.
We report on our experience initiating ROR in the NICU,
a pediatric population not previously targeted until our
request, to increase language exposure for our preterm
infants. In July of 2015, we launched a QI intervention
aimed to increase the percentage of infants who are read to
by their parents in the NICU from zero to 50% by 31
December 2015. We chose several process measures to
assess the efciency of our program and explored potential
negative effects by way of a parent survey.
Fig. 1 Outline of aims, drivers, and change concepts, including process and balancing measures. NICU neonatal intensive care unit, ROR Reach
Out and Read
760 B. M. Levesque et al.
Patients and Methods
Context
The Boston Medical Center (BMC) NICU is a 21-bed unit
in an urban, non-prot, safety-net hospital in Boston, MA,
with ~2700 deliveries per year. BMC serves a diverse, low-
income population. At the time of this initiative, the NICU
was a 2 room, open baystyle unit.
Interventions and Measures
There are many socioeconomic and NICU-specic barriers
to parent reading in the NICU. These barriers and our pri-
mary and secondary drivers, aims, and potential change
concepts are summarized in our driver diagram (Fig. 1). Our
primary aim was to increase the percentage of infants who
are read to by their parents in the NICU from 0 to 50%.
Our process measures included: percent of infants for whom
we have books in mothers native language, average daily
visits by mother and/or father during hospitalization, and
percent of eligible infants who were enrolled in ROR. Our
balancing measures were parental feedback from an anon-
ymous survey and informal nursing feedback.
The Institute for Healthcare Improvement Model for
Improvement was used for this project [18]. The initial team
included one neonatologist, the NICU Nurse Manager, the
Boston-area ROR coordinator, and a data collector. We
added ve nurse champions midway through the project.
The neonatologists, NICU nurse manager, and ve nurse
champions completed the formal online ROR training that
focuses on children from 6 months to 5 years of age, and
this was the group tasked with enrolling families in ROR. In
preparation to launch our reading program, we created two
educational training PowerPoint presentations, one that was
created for the neonatologists and nurses who had already
completed the formal online ROR training. The second was
more comprehensive and was used as a Net Learning
presentation for the rest of the staff, whose role was to
encourage parents to read (and talk and sing) to their infants
when they visited. Books were initially obtained with a
preference for staff favorites.
All infants in the NICU at the time of the launch were
eligible to be enrolled in ROR, but only infants born
between 1 March 2015 and 31 December 2015 at
<37 weeks of gestation who remained in the NICU 7 days
were included in this data collection cohort.
At the time of enrollment, parents were provided with in-
person, one-on-oneanticipatory guidance regarding the
benets of reading to their infants, outlined in Table 1, and
were given two free books. A brief enrollment form was
completed that included notation of parentsprior experi-
ence with ROR, prior reading to their infant in the NICU,
degree of expressed interest, and the language(s) of the
books provided. At least one additional book was offered to
each patient weekly. At the time of enrollment, each family
was given a ROR calendar and a collection of stickers and
were asked to record when they read to their infants.
Calendars were collected each month and/or at discharge.
Parental presence in the NICU was tracked as routinely
recorded in the electronic medical record (EMR). The total
number of days where each parent was present in the NICU
was recorded for each infant and the percent of LOS days
where the mother, father, or both were present was calcu-
lated. Duration of visits are not recorded in the EMR, so
were not included.
Efforts were made to enhance the NICU environment in
support of reading. Childrens books were placed in the
Table 1 Information and Anticipatory Guidance for Parents
TALKING WITH PARENTS ABOUT BOOKS
Here are some suggestions for making literacy development part of
your standard anticipatory guidance.
In the NICU (Pilot Program)
Newborn babies love your voice: sing, talk, and read aloud as often
as possible.
Your baby already knows your voice, even at birth
Your baby needs to continue to hear words to help with brain and
language development
The NICU can be a noisy place, but sometimes it can be too quiet
Reading is a good way to increase the number of words your baby
hears
If you speak a language other than English, it is important for your
baby to hear your language
Reading to a premature baby is different from reading to an older
infant or child
Your baby wont know what you are saying, so you can read
anything that interests you
Your baby may respond to hearing your voice by relaxing, or making
little noises while you talk, or maybe just fall asleep!
You might not notice anything, but dont be discouraged, hearing
your voice is still helpful
A good time to sing, talk, and read is when your baby is awake but
quiet; it is OK to read while your baby sleeps too. Hold your baby if
you can, but if not, it is also good to read while your baby is in a crib
or through the portholes of the incubator
Sometimes your baby might not be in the mood for listening
If you notice your baby wont settle or cries or puts out his or her
hands like saying stop, then it may not be a good time. Try again
another time.
Implementation of a pilot program of Reach Out and Read® in761
waiting room for siblings, ROR posters were hung in pro-
minent NICU locations, and an ROR bulletin board was
created to post pictures and reading-related information.
Books were initially stored in the NICU with a small
selection presented to the parent(s) at enrollment. Subse-
quently, a book cart was obtained to bring a larger selection
to the bedside. At the time of discharge, parents took their
books home with them. During the last two months of the
intervention period, anonymous parental surveys were
conducted to elicit feedback on the program (survey
included in Supplementary Information). Nursing feedback
was elicited frequently during planning and implementa-
tion, but this was done informally.
Analysis
Comparisons of demographic characteristics and parental
presence were conducted using T-tests, with P<0.05 con-
sidered signicant. For parental presence in the NICU over
time, enrollment in ROR, and documentation of reading in
the NICU, analysis was conducted using run charts created
using QI-Charts Version 2.0.22 Add-in for Excel, using
rules for special causes to determine statistical signicance
[19].
Results
A total of 98 infants were included in the cohort, 40 were
discharged on or before 1 July 2015 when ROR was
launched, and 58 were discharged after. BMC serves a
diverse, low-income population; 70% were non-white, 96%
were insured by Medicaid, and only 53% were primarily
English speaking. There were no signicant differences in
demographic characteristics between the before and after
groups (Table 2).
We obtained books in English, Spanish, Portuguese,
French, Haitian Creole, and Vietnamese; some of the non-
English books were bilingual with English. Prior to launching
ROR in the NICU, we did not have any childrens books in
the NICU and parents did not bring in books. After launching
ROR, we had books in the mothers primary language for
95% of infants. During this time frame, we were unable to
provide books in the mothers primary language for ve
infants whose mothers spoke Albanian, Arabic, Bengali, or
Tigrinya. In these cases, we offered the family picture books
with very few English words. One mother was open about
being illiterate, and she chose similar such books.
One or both parents were present in the NICU a median of
75% of LOS days (rst quartile (Q1) 56.4%, third quartile
(Q3) 87.7%), or a median of 3 of every 4 days. Mothers were
present more frequently than fathers: mothersmedian 71.4%
(Q1 48.6%, Q3 85.5%) of LOS days compared to fathers
median 32.6% (Q1 13.6%, Q3 52.0%) of LOS days. There
were no trends in rates of parental presence over time during
our study period (data not shown). The median percentage of
infants enrolled in ROR per discharge month increased sig-
nicantly over time, from a median 0% before to 81.8% after
launching ROR (Fig. 2).
A total of 46 infants were enrolled in ROR. The median
day of life at entry was 15 (Q1 7, Q3 23.5) days, and the
median post-conceptual age was 34.8 (Q1 33.1, Q3 36.3)
weeks. Enrollment forms were completed for 43 of the 46
enrolled infants (94%) of infants. The enrolled infant was
rstborn in 44%. Seventy nine percent of the parents had no
prior experience with ROR; of the 21% who had prior
experience, all expressed favorable experiences. None of the
parents had read to their infants in the NICU prior to
enrollment, but all parents expressed interest in participating.
Not every family utilized the calendar to record reading
episodes; some used it sporadically. Calendars were
obtained from 34 of the 46 infants enrolled (74%); reading
episodes were recorded on 32 calendars, indicating that of
the 46 families enrolled in ROR, 70% of them used the
calendar to record that they had read to their infant at least
once. The percentage of families who read to their infants in
the NICU by month of discharge over time is presented in
Fig. 3. These data include all families: those who were not
enrolled in ROR, those who were enrolled but did not return
calendars, and those who were enrolled and returned
calendars. The median percentage of families who read to
their infants increased from 0% before to 59% after
launching ROR in the NICU. Of the 32 families who
returned calendars recording reading episodes, parents read
to their infants an average of 0.45 ±0.35 times per day from
enrollment to discharge (or roughly once every 23 days),
ranging from a minimum of 0.06 times per day (once every
910 days) to a maximum of 1.2 times per day.
We distributed 20 parental surveys (representing nearly
all parents of eligible infants during the last 2 months of the
intervention period), 15 were completed and returned: 87%
were completed by the mother, 87% remembered why they
had been encouraged to read, and 100% had read to their
infants while in the NICU. Of those who recalled why they
were encouraged to read, 73% said it was to help the babys
brain develop; other comments included: encourages great
mental health,helps communication,helps with voice
recognition, and makes baby feel safe to hear their parents
voice.All 15 said they enjoyed reading to their infant in the
NICU, and all said one of their favorite things about reading
was that they were helping their baby develop. The other
4 survey options of favorite things were chosen at least once
each (they liked the stories, felt more relaxed and happy
themselves, liked that it was something normal to do with
their baby, or baby seemed to like it). Thirteen of 15 (87%)
of respondents noted a least favoritething about reading: 6
762 B. M. Levesque et al.
(40%) did not like reading out loud in front of other people,
4 (27%) said they didnt like that they could not visit and
read more often, 3 (20%) didnt like that the baby did not
respond to the reading, and 2 (13%) said they wondered if it
could really help the baby. None reported that the books
were too difcult or complained about not having books in
their native language. Twelve out of 15 parents (80%) said
they noticed a change in their infants when they read to
them: 7 said they seemed more relaxed or fell asleep, 2
noted increased interaction, and 3 noted physiologic chan-
ges, including 2 with decreased oxygen requirement and 1
with decreased heart rate. Thirteen parents (87%) noted a
favorite book. Five of the 13 (38%) wrote that their favorite
book was written by Dr. Seuss. All 15 parents indicated that
they plan to continue to read to their infant after discharge.
The informal nursing feedback was similar. Most were in
favor of the program, and many advocated for their patients
to ensure they were enrolled, but one or two nurses won-
dered if it could make a difference for the baby.
Discussion
We introduced ROR in our NICU to increase language
exposure among our population of preterm, low-SES
infants. We obtained language-appropriate books for over
95% of our infants and found that parents were present
often enough to read to their infants with some frequency.
Enrollment in ROR was facilitated by the addition of bed-
side NICU nurses as ROR providers, allowing us to enroll a
median of >80% of eligible infants over time. When rst
approached, all parents were interested in participating in
Table 2 Demographic Characteristicsa
Variable Total population Discharged before ROR
in NICU
Discharged after ROR in
NICU
N=98 N=40 N=58
Gestational age (weeks),
mean ±SD
32.7 ±3.0 33.2 ±2.9 32.4 ±3.1
Birth weight (grams), mean
±SD
1867 ±684 1903 ±724 1841 ±660
Maternal age (years), mean
±SD
30.0 ±5.9 28.8 ±6.4 30.8 ±5.4
Maternal race (%)
White 30.6 37.5 25.9
Black 32.7 32.5 32.8
Hispanic 32.7 25.0 37.9
Asian 4.1 5.0 3.5
Maternal language (%)
English 53.1 60.0 48.3
Spanish 26.5 22.5 29.3
Haitian Creole or French 6.1 2.5 8.6
Portuguese or Portuguese
Creole
5.1 2.5 6.9
Vietnamese 4.1 5.0 3.5
African 1.0 0.0 1.7
Arabic 2.0 2.5 1.7
Other 2.0 5.0 0.0
Insurance
Private (%) 4.1 2.5 5.2
Medicaid (%) 95.9 97.5 94.8
LOS (days), mean ±SD
(Range)
36.9 ±30.1 (7133) 32.8 ±28.2 (8133) 39.7 ±31.3 (7133)
PCA at D/C (weeks), mean
±SD (Range)
37.9 ±2.1
(32.144.1)
37.8 ±2.0 (35.044.1) 38.0 ±2.1 (32.144.0)
D/C discharge, LOS length of stay, NICU neonatal intensive care unit, NS not signicant, P. Creole Portuguese Creole, PCA post-conceptual age,
ROR Reach Out and Read
aNone of these comparisons revealed statistically signicant differences
Implementation of a pilot program of Reach Out and Read® in763
ROR, and 70% of enrolled parents used the bedside
calendar to document reading to their infant, with a wide
range of reading frequency. We reached our goal of at least
50% of infants being read to by their parent(s) during their
NICU stay. Of our surveyed parents, most recalled why
they were encouraged to read, all had read their infants in
the NICU, and all had enjoyed it. They especially liked that
they were helping their baby to develop, though several
noted not liking to read in front of other people. Most had
noticed a positive effect on their infant, and all intended to
continue to read post-discharge.
We obtained books for this intervention from a variety of
sources: ROR provided approximately half free-of-charge;
we received 200 free books at a First Book event; we
purchased books online using BMC philanthropic resour-
ces; and staff members donated new books. Non-English
books in Spanish and French were readily available on low
cost sites, as were bilingual Spanish-English books, but
other languages were more difcult to nd. A greater
variety of non-English language childrens books were
found on conventional bookseller websites, but at greater
expense. Prior to this initiative, parents did not bring in
books to read to their babies, but following the launch,
several parents would bring books from home, including
childrens books, religious texts, and other reading material.
Mothers visited their infants more often than fathers. In
aggregate, parents visited often, but there was signicant
variability in frequency. While we have identied many
drivers for parental visitation, further investigation would be
necessary to fully understand the patterns and factors con-
tributing to visitation by our NICU parents.
Enrollment in ROR was greatly facilitated by the addition of
nurses to the ROR provider group. This is understandable, as
NICU nurses serve as the primary source of information for
parents and do the bulk of the parent teaching. Other staff
members that might be helpful in the future include pediatric
residents, child life staff, and volunteers. Enrollment during this
initial effort included completing an enrollment form, but we
have since simplied the process to a brief conversation touching
on the points outlined in Table1. We also give each family a
book mark that encourages reading along with a rst book that
provides information about reading and parenting called I Love
You Like Sunshineby Mariana Glusman and Marta Killner.
Our goal of having at least half of the infants read to at
least once during hospitalization was chosen due to the
variability in length of stay, timing of enrollment during
hospital stay, particularly with our initial launch, and degree
of infant illness while in the NICU. These factors would
have made the denominator for frequency so variable that
we decided that just reporting reading once would be our
goal. To compensate, we also presented data on frequency
from date of enrollment to discharge.
At the onset, we were not sure if this intervention would
be well-received, but we were pleased by the enthusiasm of
families and staff alike. While only a small portion of
parents were surveyed, our ndings mirror the positive
feedback we have received directly from parents, nurses,
and other staff members. Reading can have normalizing
effects for some parents, who often nd the NICU experi-
ence ranging from highly stressful to traumatic. We moved
to a new NICU in January 2016 that has 10 private rooms
and 12 semi-private rooms. We believe the added privacy
has alleviated some of the discomfort some parents
expressed about reading aloud in public.
We enrolled infants after they were stable enough to be
held, but several were enrolled earlier, either at the parents
request or staffs suggestion. Our method of tracking read-
ing using a calendar and stickers was admittedly limited.
Fig. 2 The percent of eligible infants enrolled in ROR are plotted for
10 sequential discharge months, from March to December 2015. The
median increased from zero prior to 81.8% after launching ROR in the
NICU. MDs medical doctors, NICU neonatal intensive care unit, RNs
registered nurses, ROR Reach Out and Read
764 B. M. Levesque et al.
Some families enthusiastically used the calendar, but others
did not. Some calendars were lost at the time of discharge.
We initially planned to wait until we could add a eld in our
EMR to document reading, but this would have delayed our
launch signicantly. While we reached our goal of 50% of
infants being read to by their parents in the NICU, we
believe this is an underestimation.
We did not inquire about parental literacy at the time of
enrollment; instead, we offered books that ranged greatly in
complexity. Most of our books were appropriate for 6-to 9-
year-old children, but we had a good selection of very
simple board books, compilations of nursery rhymes, and a
few short stories. Parents were free to choose the type of
book that they preferred; they often chose books that their
older children would also like. Some parents read other
material, including religious texts and novels, either in print
or electronic. After this project we elicited the help of an
English as a second language expert, and we have stocked
the waiting room with additional reading material that might
be of interest to our parents. Future efforts will be focused
on exploring literacy among our parent population, as this is
an important factor both in infant neurodevelopmental
outcome and in navigating the health care system.
One strength of this project was our close collaboration
with ROR. As the institution where ROR originated, we had
institutional support for ROR and the enthusiasm of the
staff, and we are now able to use our ndings to help spread
reading in the NICU through a wider launch of ROR in the
NICU. ROR is the oldest, largest, and most recognizable
reading program. While this is a small pilot project, ROR
has the organization, staff, and resources already in place
that could facilitate a state-wide and nation-wide launch.
They could also incorporate the NICU into their continuum
of care from infancy to age 5 years. For ROR, this project
was useful to test the feasibility of the program, assess
responsiveness, and help in selection of books for a wider
launch. Since this project, ROR in the NICU has been
launched in two other Massachusetts NICUs and there are
plans underway for further expansion.
Strengths of this project also include the multi-
disciplinary team approach, the inclusion of talking points
other centers could use to facilitate adoption of reading in
other centers, and the anonymous parental feedback. Our
small sample size was a limitation. Requiring a formal
enrollment prior to provision of books allowed us to gather
useful information, but may have also limited the numbers
enrolled for this pilot effort. Other limitations included the
inability to measure the length or quality of parental visits
and the lack of follow-up post-discharge.
In summary, we have launched a rst-ever program of
ROR in the NICU and have reached our primary goal of
50% of infants being read to by their parents while they
were in the NICU. Further research is required to determine
the short and long-term outcomes of supporting reading to
NICU patients, including the impact on family reading
behavior and neurodevelopmental outcome.
Acknowledgements
Funding This work was supported by grants from Reach Out and
Read of Massachusetts and the Cabot Family Charitable Trust, as well
as the Boston Medical Center Elaine Ullian Fund.
Compliance with ethical standards
Conict of Interest All authors are responsible for this reported
research. Dr. Levesque currently serves as a consultant to Reach Out
and Read of Massachusetts to provide training for other neonatal
intensive care units in Massachusetts who are interested in introducing
Reach Out and Read in their units. Alison Corning-Clarke and Carole
Ferguson are both employed by Reach Out and Read of Massachu-
setts. The remaining authors declare that they have no conict of
interest.
Fig. 3 The percent of eligible infants read to by their parent(s) in the
NICU per month are plotted for sequential discharge months
(MarchDecember 2015). The median increased from zero prior to
59.2% after launching ROR in the NICU. MDs medical doctors, NICU
neonatal intensive care unit, RNs registered nurses
Implementation of a pilot program of Reach Out and Read® in765
References
1. Caskey M, Stephens B, Tucker R, Vohr B. Importance of parent
talk on the development of preterm infant vocalizations. Pedia-
trics. 2011;128:9106.
2. Huttenlocher J. Language input and language growth. Prev Med.
1998;27:1959.
3. Mayberry RI, Lock E, Kazmi H. Linguistic ability and early
language exposure. Nature. 2002;417:38.
4. Briscoe J, Gathercole SE, Marlow N. Short-term memory and
language outcomes after extreme prematurity at birth. J Speech
Lang Hear Res. 1998;41:65466.
5. Bohm B, Katz-Salamon M, Institute K, Smedler AC, Lagercrantz
H, Forssberg H. Developmental risks and protective factors for
inuencing cognitive outcome at 5 1/2 years of age in very-low-
birthweight children. Dev Med Child Neurol. 2002;44:50816.
6. Vohr BR, Wright LL, Dusick AM, Mele L, Verter J, Steichen JJ,
et al. Neurodevelopmental and functional outcomes of extremely
low birth weight infants in the National Institute of Child Health
and Human Development Neonatal Research Network, 1993-4.
Pediatrics. 2000;105:121626.
7. Ortiz-Mantilla S, Choudhury N, Leevers H, Benasich AA.
Understanding language and cognitive decits in very low birth
weight children. Dev Psychobiol. 2008;50:10726.
8. Caskey M, Stephens B, Tucker R, Vohr B. Adult talk in the NICU
with preterm infants and developmental outcomes. Pediatrics.
2014;133:e578584.
9. Webb AR, Heller HT, Benson CB, Lahav A. Mothers voice and
heartbeat sounds elicit auditory plasticity in the human brain
before full gestation. Proc Natl Acad Sci USA. 2015;112:31527.
10. Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M,
Kidokoro H, et al. Alterations in brain structure and neurodeve-
lopmental outcome in preterm infants hospitalized in different
neonatal intensive care unit environments. J Pediatr.
2014;164:5260. e52
11. Hart B, Risley TR. Meaningful differences in the everyday
experience of young American children. Baltimore, MD: P.H.
Brookes; 1995.
12. Bus A, Van Ijzendoorn M, Pellegrini A. Joint book reading makes
for success in learning to read: a meta-analysis of intergenerational
transmission of literacy. Rev Educ Res. 1995;65:121.
13. Braid S, Bernstein J. Improved cognitive development in preterm
infants with shared book reading. Neonatal Netw. 2015;34:
1017.
14. Yarosz D, Barnett W. Who reads to young children? Identifying
predictors of family reading activities. Read Psychol.
2001;22:6781.
15. Lariviere J, Rennick JE. Parent picture-book reading to infants in
the neonatal intensive care unit as an intervention supporting
parent-infant interaction and later book reading. J Dev Behav
Pediatr. 2011;32:14652.
16. Zuckerman B, Khandekar A. Reach Out and Read: evidence based
approach to promoting early child development. Curr Opin
Pediatr. 2010;22:53944.
17. Council on Early C, High PC, Klass P. Literacy promotion: an
essential component of primary care pediatric practice. Pediatrics.
2014;134:4049.
18. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL,
Provost LP. The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance. 2nd ed. San Francisco,
CA: Jossey-Bass Publishers; 2009.
19. Perla RJ, Provost LP, Murray SK. The run chart: a simple ana-
lytical tool for learning from variation in healthcare processes.
BMJ Qual Saf. 2011;20:4651.
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... For example, efficient tools to screen early literacy skills and risk factors have been validated, [33][34][35] yet are not widely used in pediatric practice. Further, while evidence-based programs designed to enhance HLE are well-established in primary care (e.g., Reach Out and Read; ROR 36 ) and shared reading is increasingly advocated in Neonatal Intensive Care Units (NICUs), 37,38 no similar program exists during pediatric specialty or inpatient care. ...
... Reading programs in Newborn Intensive Care Units (NICUs) have recently shown promise in terms of reduced family stress, improved reading attitudes, and enhanced staff morale compared to usual practice. 37,38 However, no tested, reading-centric programs currently exist in pediatric inpatient care, reflecting opportunities for innovation and research. For example, tech-enabled approaches (e.g., mobile apps), which are widely used for pediatric health and disease management on inpatient and outpatient levels, 230 have shown promise to enhance literacy promotion during primary care. ...
Article
Full-text available
Literacy is a major social determinant of health, rooted in skills that develop during early childhood. Children arriving at kindergarten unprepared to learn to read are more likely to have low reading proficiency thereafter. General and health literacy are highly correlated, affecting understanding of health conditions, treatment adherence, and transition to self-care and adult healthcare services. The American Academy of Pediatrics (AAP) recommends literacy and school readiness promotion during well-visits and neurodevelopmental surveillance is emphasized across primary and subspecialty care. While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and chronic medical conditions are less appreciated and under-researched. This review applies an eco-bio-developmental framework to explore literacy across five complex chronic conditions affecting millions of children worldwide: asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease. In each, integration of an efficient reading brain network may be impacted by direct factors, such as ischemia, anesthesia, and/or medications, and also indirect factors, such as altered parent–child routines, hospital stays, and missed school. By integrating literacy into care management plans for affected children, pediatric primary care and specialty providers are poised to identify risks early, target guidance and interventions, and improve academic and health outcomes. Impact While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and/or chronic medical conditions such as asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease are substantial, less appreciated, and under-researched. General and health literacy are highly correlated, with implications for the understanding one’s health condition, treatment adherence, and transitioning to self-care, which is especially important for children with complex and/or chronic illness. Pediatric primary care and specialty providers are poised to integrate reading and literacy into care management plans for children with complex and/or chronic illness, including early screening, guidance, support, and interventions.
... There have been few studies on reading programs based in NICUs, and only one of these has examined reading aloud behaviors after discharge. 12,25,33 The preintervention NICU reading rate in our study was high (34%) compared with rates as low as 0% cited in a study based in Boston NICUs. 33 Similarly, the home reading rate in our preintervention group was also very high (67%) compared with a rate of 17% cited in a Canadian study involving NICU infants. ...
... 12,25,33 The preintervention NICU reading rate in our study was high (34%) compared with rates as low as 0% cited in a study based in Boston NICUs. 33 Similarly, the home reading rate in our preintervention group was also very high (67%) compared with a rate of 17% cited in a Canadian study involving NICU infants. 12 This high baseline rate was a likely contributor to the nonsignificant increase at home after the Bookworms intervention (to 73%). ...
Article
Objective To assess whether a citywide structured book-sharing program (NICU Bookworms) designed to promote reading to infants while admitted in the NICU would increase parental reading behaviors (≥3-4 days/week) in the NICU and after discharge home, including high-risk parents who do not themselves enjoy reading. Study design The NICU Bookworms program comprised staff training, parent education, and building a literacy-rich environment. In this quasi-experimental intervention study, parents of medically high-risk NICU graduates <6 months of age were administered a questionnaire at their first NICU follow-up clinic visit. The survey incorporated questions from the StimQ-I READ subscale to assess home reading environment and shared reading practices. Results A total of 317 infants were enrolled, 187 in an unexposed comparison group and 130 in the intervention group. Parents exposed to Bookworms were significantly more likely to read at least 3-4 days/week while in the NICU (34.5% vs 51.5%, P = .002; aOR=2.2 [95%CI: 1.2-4.0]), but reading at home did not differ (67.9% vs 73.1%,p=0.28; aOR=0.99 [0.5-1.8]). However, among parents who did not themselves enjoy reading, frequency was significantly higher both in the NICU (18.4% vs 46.1%, p=0.009, aOR=5.0 [1.2-21.5]) and at home (36.9% vs 70%,p=0.003, aOR=3.7 [1.1–12.9]). A qualitative thematic analysis found that Bookworms reduced parental stress, enhanced bonding, and supported positive parent-infant interactions. Conclusion A book-sharing intervention in the NICU increased parent-reported reading aloud during hospitalization and among parents disinclined to read for pleasure, both in the NICU and following discharge. This change may have been mediated by enhancement of parent-infant interactions.
... Positive benefits of book-reading interventions on linguistic skills were also observed in samples of preterm infants [69,70], although these studies assessed interventions implemented in the second year of infant life and did not consider the effects of early infant exposure to book-reading. A separate line of studies investigated the feasibility of book-reading intervention in the context of the NICU, finding that it is well-accepted by parents and not intrusive [56,71,72]; moreover, it was found to be associated with improvements in parental knowledge about when and how to read to their infant [73], and in their attitudes towards this reading practice [74]. Nevertheless, these studies did not assess possible effects on infant language skills. ...
Background: After preterm birth, infants are at high risk for delays in language development. A promising intervention to reduce this risk is represented by the exposure to parental voices through book-reading in Neonatal Intensive Care Units (NICU). This study investigated the possible advantages of book-reading to preterm neonates during their NICU stay on their subsequent language development. Methods: 100 families of preterm infants were recruited. The parents of 55 preterm infants (Reading Group) received a colored picture-book on NICU admission and were supported to read to their neonate as often as possible and to continue after hospital discharge. Forty-five infants (Control Group) were recruited before the beginning of the intervention. Infant language development was assessed with the Hearing and Language quotients of the Griffith Mental Development Scale at the corrected ages of 3, 6, 9, 12, 18 and 24 months. Results: Regardless of group membership, Hearing and Language mean quotients decreased between 9 and 18 months; nevertheless, this decrease was considerably reduced in the Reading group, compared to the Control Group. Conclusions: Reading in NICUs represents a suitable intervention that could positively influence language development and parent-infant relationships in preterm children. The study findings support its implementation as a preventive measure.
... Next, from a list of 68 potentially better practices [13], we can select a few to immediately implement in our units. I suggest three, which we are going to implement in our unit-improving our screening for social determinants of health, implicit bias training for staff, and a Reach out and Read program [14] in the neonatal intensive care unit. As a leader, I am committing to using my influence and available resources to making change happen in our unit. ...
Article
The phrase “I can’t breathe” has become a national slogan in recent months for those who are protesting against racial discrimination across the world. For clinicians caring for neonates, this phrase should serve as a reminder about the stark disparities in health outcomes and health services for black infants and their families that have persisted for decades in spite of a voluminous amount of literature describing these disparities and the factors contributing to them. It should galvanize us into action within the neonatal intensive care unit and beyond to ensure equal treatment for all patients and their families, and to take measures to compensate for the disparities.
... Other ways that families can impact the care when they are visiting include reading to their infants. Several studies have demonstrated improved parental bonding and decreased severity of postpartum depression after reading to their baby [44][45][46]. Parent talk has also been demonstrated to be the strongest predictor of preterm infant vocalizations at 32 and 36 weeks' gestation [47]. It was noted that infants were exposed to more conversational language when parents were present than when parents were absent [47]. ...
Article
Although the COVID-19 pandemic has largely not clinically affected infants in neonatal intensive care units around the globe, it has affected how care is provided. Most hospitals, including their NICUs, have significantly reduced parental and family visitation privileges. From an ethical perspective, this restriction of parental visitation in settings where infectious risk is difficult to understand. No matter what the right thing to do is, NICUs are currently having to support families of their patients via different mechanisms. In this perspective, we discuss ways NICUs can support parents and families when they are home and when they are in the NICU as well as provide infants the support needed when family members are not able to visit.
... 45. Establish a reach out and read program for patients and siblings [188][189][190][191][192][193] 46. Provide medical and developmental follow up [129][130][131][132][133][134][135][136] 47. ...
Article
Background: Preterm infants have known impairments in language development relative to infants born at full term, and the language-poor environment of the neonatal intensive care unit (NICU) is a contributing factor. Adapting outpatient literacy programs for the NICU is a potential evidence-based intervention to encourage adult speech exposure to infants through reading sessions during NICU hospitalization. Purpose: To evaluate implementation of a 10-day NICU Read-a-Thon and potential barriers and facilitators of a year-round program aimed at increasing reading sessions for NICU patients. Methods: We established an implementation team to execute a Read-a-Thon and evaluated its impact utilizing quantitative and qualitative approaches. Quantitative methodology was used to report number of donated books and infant reading sessions. Qualitative methodology inclusive of interviews, surveys, and source document reviews was used to evaluate the Read-a-Thon. Results: We received approximately 1300 donated books and logged 663 reading sessions over the 10-day Read-a-Thon. Qualitative evaluation of the Read-a-Thon identified 6 main themes: motivation, emotional response to the program, benefits and outcomes, barriers, facilitators, and future of literacy promotion in our NICU. Our evaluation informed specific aims for improvement (eg, maintaining book accessibility) for a quality improvement initiative to sustain a year-round reading program. Implications for practice and research: Neonatal units can leverage Read-a-Thons as small tests of change to evaluate barriers, facilitators, and change processes needed to implement reading programs. Process maps of book inventory and conducting a 5 W's, 2 H's (who, what, when, where, why, how, how much) assessment can aid in program planning.
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Objective Early meaningful auditory experiences in the neonatal intensive care unit (NICU) enhance language outcomes and promote cognitive and social–emotional development. Methods This is a descriptive report sharing our level III NICU experience of building a reading-aloud enrichment program with the goals of enhancing infant neurodevelopment and strengthening early parent–infant relationships. Results We propose a roadmap for program development, outline challenges and possible ways to mitigate them, and highlight opportunities for further research in this area. Key Points
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Inequities in neonatal care quality and outcomes persist. Current models of neonatal quality improvement (QI) typically involve implementation of standardized approaches to clinical care that seek to provide consistent care to all infants and their families, which may neglect to account for the unique needs of diverse patient populations. Current approaches often fail to track outcome and process measures by important social disparity metrics, such as race/ethnicity and primary language. Despite these shortcomings, use of a QI structure has tremendous potential to address disparities in neonatal care. Crucial components of a QI approach to achieve health equity include: (1) Identifying equity goals from the inception of a project; (2) Inclusion of diverse family members on multidisciplinary teams; (3) Tracking outcome and process measures according to disparity metrics; and (4) Conducting interventions that preferentially address barriers of high-risk social groups. Hospital-system commitment to diversity and inclusion in the healthcare work force, recognition of the impact of unconscious provider bias and advocacy in the greater public health setting are needed to address underlying social inequities that impact neonatal care quality.
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Reading regularly with young children stimulates optimal patterns of brain development and strengthens parent-child relationships at a critical time in child development, which, in turn, builds language, literacy, and social-emotional skills that last a lifetime. Pediatric providers have a unique opportunity to encourage parents to engage in this important and enjoyable activity with their children beginning in infancy. Research has revealed that parents listen and children learn as a result of literacy promotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary care practice. The American Academy of Pediatrics (AAP) recommends that pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry by (1) advising all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills; (2) counseling all parents about developmentally appropriate shared-reading activities that are enjoyable for children and their parents and offer language-rich exposure to books, pictures, and the written word; (3) providing developmentally appropriate books given at health supervision visits for all high-risk, low-income young children; (4) using a robust spectrum of options to support and promote these efforts; and (5) partnering with other child advocates to influence national messaging and policies that support and promote these key early shared-reading experiences. The AAP supports federal and state funding for children's books to be provided at pediatric health supervision visits to children at high risk living at or near the poverty threshold and the integration of literacy promotion, an essential component of pediatric primary care, into pediatric resident education. This policy statement is supported by the AAP technical report "School Readiness" and supports the AAP policy statement "Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health."
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Significance Newborns can hear their mother’s voice and heartbeat sounds before birth. However, it is unknown whether, how early, and to what extent the newborn's brain is shaped by exposure to such maternal sounds. This study provides evidence for experience-dependent plasticity in the auditory cortex in preterm newborns exposed to authentic recordings of maternal sounds before full-term brain maturation. We demonstrate that the auditory cortex is more adaptive to womb-like maternal sounds than to environmental noise. Results are supported by the biological fact that maternal sounds would otherwise be present in utero had the baby not been born prematurely. We theorize that exposure to maternal sounds may provide newborns with the auditory fitness necessary to shape the brain for hearing and language development.
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The goal of this study was to test the association of mean adult word counts at 32 and 36 weeks' postmenstrual age in the NICU with Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III), cognitive and language scores. It was hypothesized that preterm infants exposed to higher word counts would have higher cognitive and language scores at 7 and 18 months' corrected age. This prospective cohort study included 36 preterm infants with a birth weight ≤1250 g. Sixteen-hour recordings were made in the NICU by using a digital language processor at 32 and 36 weeks' postmenstrual age. Regression analyses were performed on adult word count per hour, with Bayley-III measures correcting for birth weight. Adult word counts in the NICU were positively correlated with 7- and 18-month Bayley-III scores. For the 32-week recording, in regression analyses adjusting for birth weight, adult word count per hour independently accounted for 12% of the variance in language composite scores (P = .04) and 20% of the variance in expressive communication scores at 18 months (P = .008). For the 36-week recording, adult word count per hour independently accounted for 26% of the variance in cognitive composite scores at 7 months (P = .0049). Increased amount of parent talk with preterm infants in the NICU was associated with higher 7- and 18-month corrected age Bayley-III language and cognitive scores. These findings offer an opportunity for language intervention starting in the NICU.
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The current review is a quantitative meta-analysis ofthe available empirical evidence related to parent-preschooler reading and several outcome mea- sures. In selecting the studies to be included in this meta-analysis, we focused on studies examining thefrequency ofbook reading to preschoolers. The results support the hypothesis that parent-preschooler reading is related to outcome measures such äs language growth, emergent literacy, and reading achievement. The overall effect size ofd = .59 indicates that book reading explains about 8% of the variance in the outcome measures. The results support the hypothesis that book reading, in particular, ajfects acqui- sition of the written language register. The effect of parent-presch ooler reading is not dependent on the socioeconomic Status of the families or on several methodological differences between the studies. However, the effect seems to become smaller äs soon äs children become conventional readers and are able to read on their own.
Article
The current review is a quantitative meta-analysis of the available empirical evidence related to parent-preschooler reading and several outcome measures. In selecting the studies to be included in this meta-analysis, we focused on studies examining the frequency of book reading to preschoolers. The results support the hypothesis that parent-preschooler reading is related to outcome measures such as language growth, emergent literacy, and reading achievement. The overall effect size of d = .59 indicates that book reading explains about 8% of the variance in the outcome measures. The results support the hypothesis that book reading, in particular, affects acquisition of the written language register. The effect of parent-preschooler reading is not dependent on the socioeconomic status of the families or on several methodological differences between the studies. However, the effect seems to become smaller as soon as children become conventional readers and are able to read on their own.
Purpose: To examine the effect of shared book reading on the cognitive development of children born preterm and to determine what factors influence shared book reading in this population. Design: Secondary analysis using the Early Childhood Longitudinal Study-Birth Cohort, a large, nationally representative survey of children born in the United States in 2001. Sample: One thousand four hundred singleton preterm infants (22–36 weeks gestation). Main Outcome Variable: Cognitive development measured using the Bayley Mental Scale score from the Bayley Scales of Infant Development Research Edition. Results: Adjusting for neonatal, maternal, and socioeconomic characteristics, reading aloud more than two times a week is associated with higher cognitive development scores in two-year-old children born preterm (p < .001). Race/ethnicity and maternal education affect how often parents read to their children. Shared book reading holds potential as an early developmental intervention for this population.
Article
Who reads to young children? Analyses of data from the National Household Education Survey of 1995 (NHES:95) are performed to investigate the influences on the frequency of parental reading to young children. The NHES:95 data set is based on a national survey of households utilizing random digit dialing methods and computer-assisted telephone interviewing (CATI) technology. Reports were obtained from the parents and guardians of a representative sample of 7,566 preschoolers and toddlers. Frequency of reading to children was found to vary by ethnicity, primary language spoken in the home, child's age, number of siblings, and mother's educational attainment. Income and number of parents in the home were not found to influence reading frequency when controlling for these other variables. Controlling for income, education, and family size and structure, there are differences among ethnic groups in reported frequency of families reading to children. The development of more culturally sensitive adult/ and or family literacy education may be called for, and parent education programs targeting those with the least education might be especially valuable. Further research aimed at understanding the associations between parental characteristics and reading to young children could contribute importantly to the development of improved literacy interventions for young children and their families.
Article
To determine the sound environment of preterm infants cared for in the NICU and to test the hypothesis that infants exposed to more adult language will make more vocalizations. This was a prospective cohort study of 36 infants who had a birth weight of ≤1250 g. Sixteen-hour recordings of the infant sound environment were made in the NICU from a digital language processor at 32 and 36 weeks' postmenstrual age. Adult word counts, infant vocalizations, and conversational turns were analyzed. Infant vocalizations are present as early as 32 weeks. Both adult word counts per hour and infant vocalizations per hour increase significantly between 32 and 36 weeks. Infant exposure to language as a percentage of time was small but increased significantly. When a parent was present, infants had significantly more conversational turns per hour than when a parent was not present at both 32 and 36 weeks (P < .0001). Preterm infants begin to make vocalizations at least 8 weeks before their projected due date and significantly increase their number of vocalizations over time. Although infant exposure to language increased over time, adult language accounted for only a small percentage of the sounds to which an infant is exposed in the NICU. Exposure to parental talk was a significantly stronger predictor of infant vocalizations at 32 weeks and conversational turns at 32 and 36 weeks than language from other adults. These findings highlight the powerful impact that parent talk has on the appearance and increment of vocalizations in preterm infants in the NICU.