ARTICLE Continuing Education

The Power of Language

Nutrition for Children’s
Brain Development,
Health, and Future
Academic Achievement
Lauren Head Zauche, MSn, BSN, RN,
Ashley E. Darcy Mahoney, PhD, NNP-BC, Taylor A. Thul, BSN, RN,
Michael S. Zauche, BS, Arianne B. Weldon, MPH, &
Jennifer L. Stapel-Wax, PsyD

ABSTRACT context of social interactions, is crucial for a child’s develop-

Language Nutrition, a term created to describe language expo- ment and is strongly associated with his/her future literacy, ac-
sure that is rich in quality and quantity and delivered in the ademic achievement, and health. However, significant
differences in children’s early language environments
Lauren Head Zauche, Doctoral student, PNP student, Emory
contribute to disparities in their educational and health trajec-
University Nell Hodgson Woodruff School of Nursing, Atlanta, GA.
tories. Interventions, including book distribution programs,
Ashley E. Darcy Mahoney, Director of Infant Research, George coaching parents to enrich their child’s language environment,
Washington University Autism and Neurodevelopmental and public awareness campaigns, have all been shown to
Disorders Institute, and Assistant Professor, George Washington positively influence a child’s access to language-rich interac-
University School of Nursing, Washington, DC.
tions. Incorporating Language Nutrition coaching and literacy
Taylor A. Thul, Doctoral student, FNP student, Emory University, promotion into pediatrics is a promising platform for building
Atlanta, GA. the capacity of parents to provide language exposure to their
Michael S. Zauche, Research Assistant, Emory University School children. By teaching parents both how and why to treat their
of Nursing, Atlanta, GA. child as a conversational partner and by modeling such inter-
actions, pediatric health care providers can help parents set
Arianne B. Weldon, Director, Get Georgia Reading Campaign,
Atlanta, GA.
their children on a pathway toward literacy, educational suc-
cess, and health. J Pediatr Health Care. (2017) 31, 493-503.
Jennifer L. Stapel-Wax, Associate Professor, Division of Autism
and Related Disorders, Department of Pediatrics, Emory
University School of Medicine; and Director of Infant and Toddler KEY WORDS
Research Operations, Marcus Autism Center, Atlanta, GA. Child development, Language Nutrition, language-rich inter-
Conflicts of interest: None to report. actions, literacy promotion

Correspondence: Lauren Head Zauche, MSn, BSN, RN, Emory OBJECTIVES

University Nell Hodgson Woodruff School of Nursing, 1520 Clifton 1. Describe the role of pediatric providers in literacy and
Rd NE Rm#130, Atlanta, GA 30322; e-mail: [email protected].
promotion of Language Nutrition.
0891-5245/$36.00 2. Understand the influence of Language Nutrition on a
Copyright Q 2017 by the National Association of Pediatric childs future education and health outcomes.
Nurse Practitioners. Published by Elsevier Inc. All rights 3. Develop skills to teach parents why and how to engage
reserved. in language-rich interactions and to provide Language
Nutrition to their children.
http://dx.doi.org/10.1016/j.pedhc.2017.01.007

www.jpedhc.org July/August 2017 493

 Early childhood is a critical period for developing lan- Greater reciprocity in speech, or conversational
guage skills, including learning to understand and speak turns, also promotes language outcomes and may
language (Shonkoff & Phillips, 2000). Language enables even be more influential than the quantity of words
a child to communicate and interact with others, which (Ambrose, VanDam, & Moeller, 2014; Kuhl, 2007;
encourages both social and cognitive development and Zimmerman et al., 2009). A conversational turn is
is a prerequisite of school readiness and literacy defined as back-and-forth communication, or
(Dickinson & Porche, 2011; Forget-Dubois et al., 2009; adult speech followed by a child’s vocalization within
Hart & Risley, 1995; Rowe, Raudenbush, & Goldin- 5 seconds or vice versa. Conversational turns invite chil-
Meadow, 2012; Weisleder & Fernald, 2013). Neural dren into the conversation regardless of whether they
networks for language acquisition are fully formed are able to communicate verbally or through nonverbal
before birth; babies are able to perceive and react to signals and provide children with the opportunity to
sound as early as at 24 weeks gestation and begin to build their communication skills in the context of an
learn language in utero by 35 weeks gestation, engaged social relationship (Kuhl, 2007; Zimmerman
suggesting that newborn infants’ brains are primed to et al., 2009). The importance of social engagement
learn language (Kisilevsky et al., 2009; Perani et al., through conversational turns is highlighted by studies
2011). In fact, growth in synapses responsible for showing that media exposure and overheard speech
language learning peaks at 6 months of age (Shonkoff not directed toward the child offer no support for a
& Phillips, 2000). This synaptic growth is influenced child’s early lexical development (Ambrose et al.,
by auditory stimuli in the child’s early language environ- 2014; Christakis et al., 2009; Mendelsohn et al., 2010;
ment (Hoff & Naigles, 2002; Shonkoff & Phillips, 2000). Weisleder & Fernald, 2013). This research suggests
Given this robust neuroplasticity, early childhood is a that the words a child hears need to be directed at the
time of both significant vulnerability and immense child for them to have developmental benefits. As a
opportunity for establishing the foundational neural result, language-rich interactions with an engaged care-
circuitry necessary for higher learning (Shonkoff & giver provide children with an environment that is
Phillips, 2000). conducive to language learning.
There are a number of programs across the United
LANGUAGE NUTRITION States that have begun to incorporate Language Nutri-
Early exposure to language-rich interactions between tion as a concept into pediatric health care. Language
adults and children forms the basis of Language Nutri- Nutrition coaching can be executed in different pro-
tion, a term created to describe the use of language suf- grams, by different pediatric providers, and in a variety
ficiently rich in engagement, quality, quantity, and of settings with the same goal of improving rich parent/
context that it nourishes the child neurologically, so- adult–child interaction.
cially, and linguistically (Head Zauche, Thul, Darcy
Mahoney, & Stapel-Wax, 2016; Weldon, 2014). Just as THIRTY MILLION–WORD GAP
a child needs an adequate amount of nutritious food Variations in the language environments of young chil-
for physical growth, so too does a child need dren have been well documented (Greenwood,
language for his or her brain development (Weldon, Thiemann-Bourque, Walker, Buzhardt, & Gilkerson,
2014). Evidence indicates that both the quantity and 2011; Hart & Risley, 1995; Hoff, 2003). Socioeconomic
quality of words spoken to a child in the first 3 years status has been shown to be a key determinant of the
of life predict a child’s language and emerging literacy language input parents provide for their children (Hart
skills more strongly than socioeconomic status, parent & Risley, 1995; Hoff, 2003, 2013; Rowe, 2008). Although
level of education, and race/ethnicity (Dickinson & all families communicate with their children, children
Porche, 2011; Hart & Risley, 1995; Hoff, 2003, 2013; who live in low-income families generally are more likely
Hurtado, Marchman, & Fernald, 2008; Huttenlocher, to hear shorter sentences and phrases and are less likely to
Waterfall, Vasilyeva, Vevea, & Hedges, 2010; Rowe, hear words of encouragement and prompts that
2012; Weisleder & Fernald, 2013). A higher number of encourage the child’s participation in the conversation
words spoken to a child contributes to increased (Fernald, Marchman, & Weisleder, 2013; Hart & Risley,
vocabulary development, enhanced language and 1995; Hoff, 2003). In addition to the quality of the
speech processing, and improved literacy outcomes language input, the quantity of words spoken to a child
(Hoff & Naigles, 2002; Hurtado et al., 2008; has substantial differences across socioeconomic groups
Huttenlocher, Haight, Bryk, Seltzer, & Lyons, 1991; (Fernald et al., 2013; Hart & Risley, 1995; Hoff, 2003). In
Weisleder & Fernald, 2013; Zimmerman et al., 2009). a renowned study by Hart and Risley, children growing
Remarkably, the quantity of words spoken to a child up in low-income families were found to hear 600 words
has been shown to mediate the relationship between per hour, whereas children growing up in middle- to
social risk factors, such as low socioeconomic status high-income families heard 2,000 words per hour (Hart
and low levels of parent education, and language & Risley, 1995). Over the course of the first 3 years of
outcomes (Burchinal, Vernon-Feagans, & Cox, 2008). life, this accumulates into a thirty million–word gap

494 Volume 31  Number 4 Journal of Pediatric Health Care

between children of low socioeconomic status and those This progressing gap in academic achievement be-
of higher socioeconomic status (Hart & Risley, 1995). In- tween children who can read and children who cannot
equalities in language and cognitive development by so- read at grade level by the end of third grade is high-
cioeconomic status are present as early as 9 months old, lighted through a disparity in educational attainment
and gaps in vocabulary skills rapidly widen throughout for these children. Children who meet the standards
early childhood (Fernald et al., 2013; Halle et al., 2009). for third grade literacy are 4 times more likely to reach
As a result, low-income children arrive in kindergarten high school graduation than those who are not as
with exposure to only about one third of the words heard literate (Fernandez, 2012; Fiester & Smith, 2010; The
by their more affluent peers. This disparity in language Campaign for Grade Level Reading, 2014).
exposure contributes to gaps in vocabulary, school read-
iness, and long-term academic achievement. It is impor- RELATIONSHIP BETWEEN EDUCATION AND
tant to note, however, that socioeconomic status does HEALTH
not by itself create these disparities, but rather differences Better education leads to healthier lives. Research
in average language exposure between socioeconomic points to significant associations between educational
groups. attainment and individual health outcomes (Fiester &
Smith, 2010; National Center for Health Statistics,
THIRD GRADE LITERACY 2012). High school graduates have a higher life
The word gap and disparities in early vocabulary have expectancy and are less likely to engage in risky
significant implications for a child’s future literacy and behaviors, have a chronic disease, receive welfare
educational trajectory. A child’s vocabulary at the age assistance, or be unemployed, victims of violence,
of 3 years has been found to be the single strongest pre- perpetrators of crimes, or incarcerated (Fiester &
dictor of a child’s ability to read proficiently by third Smith, 2010; Robert Wood Johnson Foundation, 2009;
grade (Dickinson & Porche, 2011; Hart & Risley, 1995; National Center for Health Statistics, 2012; Sum et al.,
The Campaign for Grade Level Reading, 2014). Third 2009). They also are more likely to engage in health-
grade marks a time when children are expected promoting activities such as exercise, follow screening
to shift from ‘‘learning guidelines, and be compliant with medication use
to read’’ to ‘‘reading to The word gap and (Fiester & Smith, 2010; Robert Wood Johnson
learn’’ (Fiester & Foundation, 2009; National Center for Health
Smith, 2010; The disparities in early Statistics, 2012; Sum et al., 2009). Promoting literacy
Campaign for Grade vocabulary have has been identified not only as an education priority
Level Reading, 2014). significant but also a public health imperative by government
Eighty-five percent or and public health officials at both the national and
more of the fourth implications for a state levels (Johnson & Shelton, 2014; Kanne, 2014;
grade curriculum in child’s future Office of the Governor, 2015; U.S. Department of
the United States is literacy and Education, 1999).
delivered through text-
books, smart boards, educational PURPOSE
computers, and work- trajectory. The importance of talking to babies, reading to young
sheets (Fielding, Kerr, children, and using everyday words as opportunities
& Rossier, 2007). As concepts in all subject areas start to enhance early lan-
to increase in complexity, their verbal descriptions guage learning has Although all
become more complex and are not comprehensible been gaining national families
to children who are not able to read proficiently prominence. Although
(Fielding et al., 2007; Fiester & Smith, 2010). As a all families
communicate and
result, children who are not able to read on grade communicate and interact with their
level by the end of third grade fall further behind in interact with their ba- babies, there is
school (U.S. Department of Education, 1999; Fiester & bies, there is substan-
Smith, 2010; The Campaign for Grade Level Reading, tial variation in
substantial
2014). In 2015, 64% of fourth graders in the United children’s early lan- variation in
States did not meet the standards for proficient grade- guage environments. children’s early
level reading (National Center for Education Statistics, Parent knowledge of
2015). This low literacy rate has enormous educational, child development
language
health, and economic implications, not only for the in- and the importance of environments.
dividual children but also for the nation (Fiester & language exposure
Smith, 2010; National Center for Health Statistics, greatly affects the quality of a child’s language environ-
2012; Robert Wood Johnson Foundation, 2009; Sum, ment and opportunities for learning (Rowe, 2008). Par-
Khatiwada, McLaughlin, & Palma, 2009). ents of infants and young children are uniquely poised

www.jpedhc.org July/August 2017 495

to be their child’s first and best teachers given the time Power of Interactions
they spend with their child and the influence of Social relationships drive the need for an understanding
parenting on a child’s health and development. There- of language and is an essential component of language
fore, parents are key targets for education and skill learning. Language is the basis by which individuals
building around language. are able to communicate with others and thus, language
The purpose of this article is to review key compo- learning does not occur passively. Extensive research
nents of language-rich interactions and examine exist- has shown the profound influence of social engagement
ing or previously developed interventions that focus for an infant’s language development, and theories of so-
on improving the language and literacy skills of 0- to cial learning have emphasized the importance of social
3-year-old children. This two-fold purpose will lead to interaction for language learning (Brofenbrenner,
a discussion of how pediatric health care providers 2005; Kuhl, 2007; Tomasello, 2003; Vygotsky, 1978).
can integrate Language Nutrition coaching into their Children who establish greater joint attention and
daily practice to help support families in optimizing follow the gaze of an adult develop a larger and more
their child’s future health and educational trajectory. complex vocabulary in the first year of life than
children who do not track eye movements (Brooks &
Meltzoff, 2008). It is possible that contingent and recip-
REVIEW OF THE LITERATURE rocal social behaviors, such as establishing joint atten-
PubMed and Web of Science were searched for peer- tion, provides additional information to infants that
reviewed studies published between 1990 and 2015 in help to scaffold their language development, including
the English language using the key terms parent or the provision of additional cues for communication in-
caregiver, infant or child, intervention, talk or read, tentions. Additionally, social interactions may help facil-
and language or literacy. Studies were selected if they itate language learning through increased attention to
discussed or evaluated parent-based interventions for the language being delivered; infant attention has been
improving the language or literacy of 0- to 3-year-chil- shown to be greater with a live person than a person
dren. A total of 57 articles met search criteria. via television or recordings (Kuhl, Tsao, & Liu, 2003).
There are no scientific data to suggest that television,
educational videos, or music recordings have the same
THE BASIS OF LANGUAGE NUTRITION positive, measurable impact on early childhood brain
Quantity of Words development as language from an interaction between
Many studies have documented the effects of the quan- an adult and child (Weisleder & Fernald, 2013). Infants
tity of child-directed speech on a child’s cognitive, lan- have been found to learn language from adults in the
guage, and academic outcomes (Head Zauche et al., context of an engaged adult–child interaction but not
2016; Hurtado, Marchman, & Fernald, 2008; Rowe, when the same information was delivered via a televi-
2008, 2012; Weisleder & Fernald, 2013; Zimmerman sion (Conboy, Brooks, Meltzoff, Kuhl, 2015). Although
et al., 2009). Research has shown that the quantity of certain educational toys, recordings, and videos may
speech directed at children even as young as provide learning enrichment for preschool-aged chil-
32 weeks’ corrected gestational age has resulted in dren, there are no data to support the claim that these
neurocognitive benefits (Caskey, Stephens, Tucker, & educational materials have beneficial effects on infants
Vohr, 2014). Greater quantity of speech directed at a and toddlers. In fact, evidence suggests the contrary, in
young child may result in improved language and aca- that media may actually adversely affect the language
demic outcomes by providing children with more op- development of infants and toddlers by limiting oppor-
portunities to interpret language and be exposed to a tunities for parental language input and child speech
greater variety of grammatical combinations and diver- (Christakis et al., 2009; Zimmerman et al., 2009).
sity of words and may help children develop skills Thus, the back-and-forth communication exchanges
necessary to learn language, such as word segmenta- between adult and baby is an essential component of
tion and language processing. language and brain development.
Words can be delivered in a variety of different ways
in multiple different contexts. Parents and caregivers PARENTESE
can narrate their daily activities, point out various ob- Parentese, or infant-directed speech, is a style of
jects in their environment, ask their baby questions communication that is used across various cultures
about how he/she is feeling, and share books, nursery and languages to talk with infants and young children
rhymes, and songs. All of these activities are ways in (Grieser & Kuhl, 1988). It uses actual words and senten-
which parents or caregivers increase the quantity of ces as opposed to ‘‘baby talk,’’ which simply mimics the
words in their child’s early language environment and sounds made by babies. It is characterized by varied
thus enrich their learning potential (Glascoe & Leew, intonation and prosody, elongated vowel and conso-
2010; Rodriguez et al., 2009; Topping, Dekhinet, & nant sounds, repetition, and exaggerated gestures and
Zeedyk, 2013). facial expressions (Griser & Kuhl, 1988).

496 Volume 31  Number 4 Journal of Pediatric Health Care

 Research has shown that parentese helps facilitate grams are appropriate for enhancing literacy and
language acquisition (Saint-Georges et al., 2013; Song, language development, because evidence suggests
Demuth, & Morgan, 2010). Slow speech and vowel that aspects of parent–child interactions associated
hyperarticulation may help a young child pick out with a child’s language development include (a)
words from sentences, and varying pitch at the ends amount of parent-child interaction, (b) amount and
of sentences may provide clues as to the boundaries quality of linguistic input, (c) responsiveness of child’s
of sentences and words (Saint-Georges et al., 2013; communication, and (d) the use of language-learning
Song et al., 2010). Parentese may facilitate quicker support strategies, such as book-reading (Hart &
word segmentation and thus contribute to faster Risley, 1995; Roberts & Kaiser, 2011; Rowe, 2012;
speech processing (Saint-Georges et al., 2013). In addi- Weisleder & Fernald, 2013; Zimmerman et al., 2009).
tion, parentese is associated with positive affect, praise, Most articles reported positive changes in parental
playing, teaching, and comforting a child, and thus may behaviors, including frequency of shared book-
influence language acquisition through a social mecha- reading and parent–child interactions, greater attention
nism (Saint-Georges et al., 2013). to child’s communication, and encouragement of the
child’s participation in conversations and book reading
Home Language (Glanemann, Reichmuth, Matulat, & Zehnhoff-
Home language refers to an individual’s first language, Dinnesen, 2013; Girolametto et al., 1994; Knoche,
or the language in which an individual is most fluent in. Sheridan, Edwards, & Osborn, 2010; Landry, Smith,
A growing number of children in the United States live Swank, & Guttentag, 2008; Roberts & Kaiser, 2012).
in homes where a language other than English is These changes were accompanied by improvements
spoken (National Center for Education Statistics, in children’s receptive or expressive language skills
2016). Language exposure is most beneficial in the lan- (Arnold, Lonigan, Whitehurst, & Epstein, 1994; Landry
guage the parent or caregiver is most comfortable et al., 2012; Mendelsohn et al., 2005; Sheridan,
speaking. Speaking in a nonfluent language generally Knoche, Kupzyk, Edwards, & Marvin, 2011; Tannock,
leads to simpler and grammatically incorrect phrases Girolametto, & Siegel, 1992; Whaley, Jiang, Gomez, &
and thus, the amount of language the child hears is Jenks, 2011). Furthermore, knowledge about child
significantly reduced (Paradis, Genesee, & Crago, development increased as a result of these
2011). Learning one language well lays a foundation interventions (Suskind et al., 2015). A few interventions
for learning another language (Espinosa, 2014). An that have a strong evidence base or are implemented
extensive body of research has highlighted the many through pediatric providers are highlighted in this
benefits of learning more than one language, including article as exemplars. A more complete list and descrip-
executive function and academic achievement, and no tion of these interventions can be found in the Table.
scientific evidence indicates that learning two lan- Factors that have contributed to the successful imple-
guages significantly delays a child’s acquisition of the mentation and dissemination of interventions include
second language (Bialystok, 2001; Espinosa, 2014; the simplicity of the messaging; well-defined and
Head, Baralt, & Darcy Mahoney, 2015). By reinforcing straightforward mission and tasks; the support of the
the primacy of the home language, children will be intervention within the pediatric profession; communi-
exposed to more complex ideas, abstract thoughts, cating about the intervention though published articles,
expanded vocabulary, which are all crucial for media, continuing education courses; and the genera-
children to development important cognitive and tion of data showing its effectiveness.
language skills necessary for educational success All of the interventions discussed here use the
(Paradis et al., 2011). concept of Language Nutrition. The goal for all of the
programs is to enrich the language interactions that
INTERVENTIONS young children have with their caregivers. All of the pro-
Efforts to promote early language exposure and grams reach their goals through Language Nutrition in
improve children’s language development have various settings and with different pediatric providers
focused on training parents to read, talk, and interact and educators reaching the families. Although there
more frequently with their child in a way that maxi- are multiple ways in which parent-based interventions
mizes the developmental benefits of these shared expe- can be designed and delivered to parents, incorporating
riences. Previously developed or existing interventions literacy and language promotion into pediatric primary
generally fell into at least one of five categories: (a) a health care represents a promising platform for the de-
book distribution program with anticipatory guidance livery of parent-based interventions for young children.
for shared-book reading, (b) teaching dialogic reading
techniques, (c) coaching parents to talk more with their Pequen ~ os y Valiosos (Young and Valuable)
child, (d) training parents to be responsive to their Peque~nos y Valiosos is a national public action
child’s focus of attention and communication initia- campaign that aims to help optimize learning in
tions, or (e) public awareness campaigns. Such pro- everyday moments for Hispanic children under the

www.jpedhc.org July/August 2017 497

 TABLE. Intervention descriptions
Intervention Description
Dialogic Reading Trains parents to use interactive reading techniques during book reading that follow the child’s
interest and invites the child to participate in story-telling by
 establishing joint attention (following child’s lead)
 facilitating conversational turns
 using strategies to expand child’s vocabulary
Enhanced Milieu Teaching Facilitates children’s language use in everyday contexts by following a teach–model–coach
review approach consisting of 28 1-hour sessions with the parent and child.
Getting Ready Early childhood professionals in the Head Start program promote parent–child interaction and
language-developing behavior during home visits by
 educating parents about childhood development
 recognizing parental strengths, modeling behaviors to parents, and providing feedback
Muenster Parent Program Delivers information to parents through lectures, video demonstration, and feedback from
trainers during six group sessions and two individual sessions, which build skills to
 follow the attentional focus of the child
 facilitate teaching of words through reacting to child’s communication
 enhance parental responsiveness to vocal and nonvocal communication from the child
~os y Valiosos
Pequen National public action campaign targeted for the Hispanic population that encourages talking,
reading, and singing to young children through radio and network programming and social
media
http://www.univisioncontigo.com/en/education/early-childhood/
Play and Learning Strategy Over a series of 10 visits, using video demonstrations and by videotaping the mother interacting
with her child and providing feedback, mothers are coached to
 increase responsive parenting behaviors
 establish joint attention with the child
 provide rich language input and opportunities for scaffolding language
https://www.childrenslearninginstitute.org/programs/play-and-learning-strategies-pals/
Providence Talks Initiative in Providence, RI that involves having families with children younger than 2 years conduct
home recordings using LENA technology and receive coaching and feedback on collected
data biweekly by a home visitor.
www.providencetalks.org
Reach Out and Read Incorporates literacy promotion into pediatric primary care well checks for children 6 through
60 months old by
 providing anticipatory guidance about shared reading
 distributing books
www.reachoutandread.org
Talk With Me Baby Statewide initiative in Georgia to integrate coaching about language-rich interactions as a core
competency of nurses and WIC nutritionists
www.talkwithmebaby.org
Thirty Million Words Initiative Delivers eight educational computer-based modules through 1-hour home visits with a trained
coach, strengthening the ability of parent language to build a child’s brain and narrow the
achievement gap. Parent–child interactions are recorded during home visits for feedback
purposes. Additionally, LENA technology is used by the coach to provide feedback, allowing
parents to set goals and recognize progress.
www.thirtymillionwords.org
Too Small to Fail: Talking is Teaching Public awareness campaign that
 delivers tips and videos to parents about building their child’s vocabulary through text mes-
sages on an app called ‘‘Text4baby’’
 delivers messages regarding language primacy through partnerships with Sesame Street
and Scholastic
http://talkingisteaching.org/
Video Interaction Project Incorporates one-on-one sessions with a child development specialist into low-income pediatric
primary care visits for children 2 weeks through 36 months in which
 parents are videotaped interacting with their child for 30 to 45 minutes
 specialist reviews videotape with parents and provides feedback and strategies for
enhancing interactions
www.videointeractionproject.org
Note. LENA, Language Environmental Analysis; WIC, Women, Infants, and Children.

age of 5 years by targeting parents/caregivers and panic population, and Too Small to Fail, a public aware-
broader Hispanic community (Univision ness and action initiative of the Clinton Foundation that
Communications, 2016). Through a partnership with mobilizes communities to improve the health and well-
Univision, the leading media company serving the His- being of young children, Peque~ nos y Valiosos delivers

498 Volume 31  Number 4 Journal of Pediatric Health Care

information to the Hispanic population across Univi- will, and skill of all parents and caregivers to become
sion platforms, radio and network programming, social conversational partners with their babies and children
media, and local community outreach to encourage (Talk With Me Baby, 2015). This cross-sector coalition
talking, reading, and singing to children (Univision is integrating coaching about language-rich interac-
Communications, 2016). tions as a core competency of two key large-scale work-
forces of trusted professionals that already serve most
Reach Out and Read parents and babies—nurses and Women, Infants, and
Reach Out and Read is a program that was started in Children clinic nutritionists, who see 99% and 50% of
1989 to address low literacy skills by incorporating liter- all new and expectant parents in Georgia, respectively.
acy promotion in pediatric primary care well-child visits TWMB has created a continuing education program to
for children 6 through 60 months old (Needlman, Fried, teach nurses how to coach parents on the provision
Morley, Taylor, & Zuckerman, 1991). Reach Out and of language-rich interactions and to encourage nurses
Read includes the following three components, which to model language-rich interactions in their own inter-
are each aimed at supporting and encouraging shared actions with infants and children (Talk With Me Baby,
reading between parents and young children: pediatric 2015). TWMB has also developed resources for parents
health care providers (a) provide anticipatory guidance to use to encourage conversations with their young
to parents about shared reading and (b) distribute a child, including a smartphone app called ‘‘Let’s Talk!’’
culturally and developmentally appropriate book to and videos showing how parents can incorporate talk-
the child at each well-child visit; (c) volunteers in wait- ing and interacting with their baby into their daily life.
ing rooms of primary care clinics model reading with TWMB has partnered with Scholastic to produce books
children and/or books are available for children to for children that emphasize the importance of
read in the waiting rooms (Needlman et al., 1991; language-rich interactions for a young child’s literacy
Zuckerman & Khandekar, 2010). and language development. Currently, evaluation
Reach Out and Read has developed into a nation- studies are being conducted to evaluate the efficacy
wide early literacy intervention. With endorsements of this initiative in both outpatient and inpatient
by the American Academy of Pediatrics, Reach Out settings.
and Read has been adopted by over 5,000 hospitals
and health clinics throughout the United States, reach- Thirty Million Words Initiative
ing 32% of children below the poverty level, and has The Thirty Million Words (TMW) Initiative is a program
been adapted in over a dozen countries (Zuckerman designed to strengthen the ability of parent language to
& Khandekar, 2010). The success of this intervention build a child’s brain and narrow the achievement gap.
is rooted in its simplicity and in support and dissemina- This initiative is delivered at the individual, community,
tion at a grass-roots level through physician champions and population level through individual coaching, so-
(Zuckerman, 2009). cial media, and a public awareness campaign in Chi-
Increased frequency of shared reading and improve- cago, Illinois.
ments in child language development have been docu- The TMW project involves eight educational,
mented by studies evaluating Reach Out and Read computer-based modules delivered by a trained coach
(Needlman, Toker, Dryer, Klass, & Mendelsohn, 2005; for 1 hour at weekly home visits (Suskind et al., 2016).
Zuckerman & Khandekar, 2010). The anticipatory guid- These educational modules emphasize using
ance component of Reach and Read was associated language-enhancing strategies with daily activities
with the greatest increase in shared reading, which and everyday contexts and provide information about
highlights the importance and influence of the educa- child language development (Suskind et al., 2016). A
tion provided by health care providers on parental simple message, called the ‘‘3 T’s’’, is emphasized to
behavior concerning literacy-promoting activities parents: ‘‘talk more, tune in, and take turns’’ (Suskind
(Sharif, Rieber, & Ozuah, 2002). et al., 2016). At the home visit, videos of the parent in-
Several other book distribution programs modeled teracting with the child are recorded to enable the
on Reach Out and Read have been developed and suc- coach to review the interaction with and provide feed-
cessfully implemented in health care settings, such as back to the parent (Suskind et al., 2016). In addition, the
the neonatal intensive care unit; at discharge from the coach uses Language Environmental Analysis digital
well-baby nursery; and in the Women, Infants, and Chil- language processors, which act as ‘‘word pedometers,’’
dren clinics (Lariviere & Rennick, 2011; Moore & Wade, in which the number of words, conversational turns,
2003; Veldhuijzen van Zanten, Coates, Hervas-Malo, & and child vocalizations in a child’s language environ-
McGrath, 2012; Whaley et al., 2011). ment are recorded (Gilkerson & Richards, 2009). Par-
ents receive feedback about each of the recordings by
Talk With Me Baby looking at reports generated by Language Environ-
Talk With Me Baby (TWMB) is a statewide initiative in mental Analysis, which offers a mechanism for parents
Georgia to dramatically transform the understanding, to set goals and recognize their progress and instills a

www.jpedhc.org July/August 2017 499

sense of competency in facilitating their child’s devel- Teaching ‘‘Why’’
opment (Suskind et al., 2016). As part of anticipatory guidance at well-child visits, pe-
A randomized controlled trial of TMW showed that diatric health care providers discuss development and
parental knowledge about language learning and pre- developmental expectations and assess whether the
dictors of school success dramatically improved after young child is meeting their developmental milestones.
the intervention and was sustained 4 months after the The American Academy of Pediatrics recommends that
study (Suskind et al., 2016). The intervention also re- providers ask about shared book reading and television
sulted in an increase in adult word count, conversational exposure, which could be a way to lead into discussing
turns, and child vocalizations (Suskind et al., 2016). Language Nutrition (Hagan, Shaw, & Duncan, 2008).
As mentioned, all parents and caregivers interact and
IMPLICATIONS FOR PRACTICE communicate with their infant or young child, but dis-
The American Academy of Pediatrics issued its first pol- parities exist in the amount and quality of these interac-
icy statement addressing early child literacy in 2014, tions. Merely asking parents or caregivers whether they
which established early literacy promotion, beginning read or talk with their baby and saying that it is impor-
in infancy, as an essential component of pediatric prac- tant that they do so will not convey the importance of
tice (High & Klass, 2014). This policy recommends that Language Nutrition for their baby’s future health and ac-
pediatric health providers receive training about liter- ademic success. Research has shown that when parents
acy promotion and that they provide anticipatory guid- understand the implications of their actions and under-
ance about early literacy promotion and how parents stand child development, their behavior changes
can provide opportunities for their child to learn (Suskind et al., 2016). Examples of messages to tell par-
(High & Klass, 2014). ents ‘‘why’’ can be found in Box 1.
The workforce of pediatric nurses and nurse practi-
tioners is well positioned to build the capacity of par- Teaching ‘‘How’’
ents to interact with their infants and young children In addition to understanding the importance of Lan-
in a way that promotes language learning, given guage Nutrition for a child’s health and educational tra-
many scheduled touchpoints: the frequency and near jectory, families need to be equipped with tools to
universality of these visits allow for an intervention, or implement practices into their daily lives. A powerful
educational and health messages, to be delivered and way to teach ‘‘how’’ is through modeling Language
reinforced on a regular basis by capitalizing on an Nutrition with infants and children. Greet the baby or
already existing infrastructure. Pediatric nurses and young child when entering the room and narrate the ex-
providers are uniquely qualified to deliver messages amination to the child. Direct questions and comments
regarding the importance of shared book reading, talk-
ing with a child, and engaging social parent–child inter-
actions given that part of pediatric well-child visits BOX 1. Teaching why
includes assessment of
developmental mile-  You have the ability to be your baby’s first and best
stones, as well as Pediatric health teacher simply by talking and interacting with him or her.
parent education and  Talking with your baby builds your baby’s brain.
care providers can  Even if your baby is not able to talk yet, your baby is
anticipatory guidance
on health and develop- incorporate actively learning the words you speak.
 Your baby is able to recognize your voice and is capable
ment. language of learning language even before birth.
Pediatric health care promotion  It is easier for your baby to learn at an early age because
providers can incorpo- the brain is growing more rapidly in the first 3 years of life
rate language promo- practices into
than at any other time.
tion practices into everyday tasks in  The more words you speak to your baby, the more
everyday tasks in early early childhood words he or she will know, which will help him or her
childhood checkups, do better in school.
sick visits, or hospital checkups, sick  Doing better in school leads to better health, a higher
stays. Coaching should visits, or hospital chance of graduating from high school/college, and a
include both the ‘‘why’’ lower chance of imprisonment.
stays.  Talking with your baby is a great way to build an
and the ‘‘how’’ to
emotional bond.
engage in language-
 By talking with your baby, you are teaching your baby
rich interactions and the demonstration of such an inter- how to engage socially with other people.
action. Strategies such as motivational interviewing and  The single strongest action you can take to increase
the teach-back method can help providers assess par- your child’s educational opportunities is to talk with
ents’ understanding and will to engage in language- your baby.
rich interactions with their child.

500 Volume 31  Number 4 Journal of Pediatric Health Care

to the infant—realizing that parents will supply the an- curricula, and early literacy milestone checklists and
swers. Directing the conversation to the baby provides videos for health care providers and/or parents. Web
families with an example to follow and reinforces the sites of the interventions are listed in the Table.
importance of Language Nutrition.
Pediatric health care providers should tell families to CONCLUSION
make the baby their conversational partner as often as The ability to provide Language Nutrition is crucial for
they can. As they go throughout their day, they can shaping the social, learning, and health outcomes of
narrate what they are doing and point out objects in young children (Head Zauche et al., 2016). All parents
the environment as a way to introduce new words. Fam- and caregivers are capable of being their baby’s first
ilies should pay attention to the baby or young child’s and best teacher; all parents know how to talk and
social and verbal communication, whether it be the can talk, either verbally or through sign language.
child looking at something, pointing to something, bab- Toys and books are not necessary for a family to be suc-
bling, or using actual words. Responding to the child’s cessful in influencing their child’s chances for academic
communication, even if it is nonverbal, and asking the success. Consistent with evidence, the single most
child questions facilitates reciprocity and, thus, lan- important action a parent can take to positively influ-
guage learning in a social context. Reading children’s ence their child’s future health and educational trajec-
story books and singing songs on a daily basis will tory is to talk with their children (Talk With Me Baby,
help establish daily practices of literacy promotion. 2015). By sharing these messages with families, pediat-
Additionally, families should be encouraged to speak ric health care providers can build the capacity of fam-
using parentese and the home language. Messages to ilies to talk with their children in a way that promotes
share with families about ‘‘how’’ can be found in Box 2. their linguistic, cognitive, and social development.
Many of the established interventions highlighted in Thus, pediatric providers have the potential to leverage
this article have Web sites that provide additional infor- dramatic results for children’s academic and health out-
mation and resources, including handouts, educational comes and be partners in the efforts to close the nation’s
educational achievement gap.

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