CHAPTER 34

Literacy Promotion in Pediatric Practice

Wendy Miyares, RN, PNP

Early literacy promotion in the office setting is now recognized as an essential part of pediatric primary care. The American Academy of Pediatrics (AAP) and the Canadian Paediatric Society encourage health professionals to include literacy promotion in the routine clinical care of toddlers and young children. It is known from the ever-expanding evidence of early brain development that reading aloud, speaking to babies, singing, and sharing books can permanently change neuronal connections in the brain. These connections forged by reciprocal attention and spoken language are important for learning during the school years as well as for the emotional health of the child.

Literacy promotion can begin even before a baby learns to speak and long before a child is ready to learn to read. Eventual mastery of reading will depend on skills such as language ability, imagination, and familiarity with books and the reading process. Children develop many of these skills in the first few years after birth, even before they go to preschool. In fact, a child’s language ability by 3 years of age is strongly correlated with later academic performance. Parent-child interactions are crucial, and guidance for parents on literacy promotion activities at home should begin within the first year after birth.

Reading aloud to children on a regular basis is among the most effective means of promoting early literacy and language development. Language skills are the foundation for later reading ability and are largely dependent on the amount and quality of language exposure. The architecture of a developing brain is physically altered by experiences during infancy. At birth, a baby’s brain contains 100 billion neurons, which go on to form trillions more connections. Those connections that are stimulated by frequent use persist, and less-used synapses are eliminated as the brain matures. Reading aloud and book sharing may help ensure the preservation of brain connections associated with skills such as memory, creativity, comprehension, and language. Reading aloud is also a positive nurturing activity which in itself promotes other important neuronal connections and healthy development. The AAP recommends avoiding television or other electronic media for children younger than 2 years, because young children learn best by interacting with people.

Reading aloud exposes children to vocabulary they do not hear in daily conversations (eg, 3 bears, beanstalks). Reading aloud also stimulates the imagination (eg, cows jumping over the moon). In time, children learn that the abstract letters on the page represent words, and they become aware of different, smaller sounds that make up words. All these experiences result in reading readiness.

Consequences of Low Literacy

Low literacy has significant consequences as children age. Poor academic skills are consistently linked with higher dropout rates, entrance into the juvenile justice system, and unemployment. One-third of all juvenile offenders are reported to read below the fourth-grade level, and more than 80% of adult prison inmates are high school dropouts.

Literacy level and health outcomes are also intimately related. Health literacy is defined as the degree to which individuals can obtain, process, and understand the basic information they need to make appropriate health decisions. Multiple studies have demonstrated that a low literacy level negatively affects health and well-being. Compared with average or above-average health literacy, individuals with limited health literacy have a higher number of visits to emergency departments and hospitalizations, and increased morbidity.

Adolescents with low reading ability are more likely to smoke, use alcohol, carry a weapon, and be in a physical fight that results in the need for medical treatment. Conversely, higher levels of literacy are associated with positive health outcomes, such as appropriate use of inhaled asthma medication or choosing to breastfeed a baby.

Promoting literacy is good medicine not only for the individual but also for society. Aside from the societal effect of school failure, individuals with limited literacy incur medical expenses that are up to 4 times greater than patients with adequate literacy skills. Low literacy carries a high financial cost, with billions of dollars spent in the United States each year on preventable emergency department visits and hospital stays.

Literacy Promotion in the Medical Office

The AAP endorses the Reach Out and Read model of early literacy promotion, and this model is incorporated in the official AAP Bright Futures guidelines for pediatric health professionals.

The Reach Out and Read model has 3 main components:

1.Anticipatory guidance: During regular well-child visits, health professionals encourage parents to read aloud to their young children at home. The advice is age-appropriate, and concrete examples are provided or modeled by the physician (Table 34.1).

2.Books: A new developmentally and culturally appropriate book is given by the physician to patients and parents at each well-child visit so that parents have the tools to follow the physician’s advice.

3.Waiting rooms: Literacy-rich waiting rooms contribute to the literacy message. Gently used books for parents to read to their child while waiting and displays or information about local libraries are encouraged. Where appropriate and feasible, community volunteers read aloud in waiting rooms, modeling for parents the plea-sures and techniques of reading aloud to very young children.

Reach Out and Read had its origins in an urban clinic that served a high proportion of low-income families and has always had a special focus on children growing up in poverty. For complex reasons, poverty is a powerful predictor of children’s exposure to language. Children in low-income homes are 40% less likely to be read to on a daily basis than children in higher-income households. Pioneer researchers Hart and Risley estimate that by age 4 years, children living below the poverty line hear 30 million fewer words in total than those who grow up in higher-income households.

Adapted from Reach Out and Read. Milestones of early literacy development. www.reachoutandread.org/resources. Accessed February 19, 2020. Used with permission.

Providing advice to parents is easiest and most effective when a book is brought in at the beginning of a visit. That way, physicians can naturally weave in guidance that is appropriate to the age of the child (Box 34.1 and Table 34.1). Advice should be brief and to the point, supportive, and part of a general conversation about the child’s development and behavior.

Another advantage of presenting the book early in the visit is the amount of developmental and relationship information that can be observed by the health professional. The book is a tool that can speed informal developmental surveillance. If a 2-year-old exclaims, “Doggie says bow-wow!” there is no doubt she is putting 2 words together. If a 1-year-old uses an index finger to point and looks to see if his mother is watching, the physician can gain information about fine motor ability and the child’s social interaction in only a few moments.

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