Reach Out and Read: Books as a Pediatrician’s Secret Tool

When I decided to become a pediatrician, I did not think that books would be the most important part of my toolkit. I became a pediatrician with the goal of forming relationships with children and families that would allow them to thrive in society by safeguarding their physical health. I spent all of medical school learning about pathology, antibiotics and anatomy. Surely, this would prepare me for whatever I was going to find in exam rooms! But, when I got to residency, I found that the reality of seeing children for wellness exams was quite different. While some of what I encountered did relate directly to what I learned in medical school (i.e. how to treat an ear infections), most of what came up was more about what was going on in a child’s home, in their school, and within their family dynamic. The longer I have been in practice, the more I have come to realize that health begins at home and in the relationships that children have with the people who care for them.

The first thousand days of a child’s life have been identified as a critical period for brain development^1–3. Early literacy skills like phonological awareness, letter recognition and language^4–8 that are developed during this time strongly predict a child’s future success, including achievements in school⁹.Factors that are positively associated with early literacy skills include exposure to behaviors that promote language development such as talking, reading and singing beginning in the newborn period^10–12. Unfortunately, many parents are not reading with their newborns despite their intention to do so. Certain risk factors, including living in poverty, create barriers to the amount of time families spend reading at home. Children with low literacy skills in early childhood are more likely to perform poorly in school, and children who are not reading proficiently by third grade have a high school dropout rate three to four times higher than their peers. In low-income households, just over 20% of fourth graders are reading at grade level¹³. Beyond school success, low literacy in childhood may predict future low literacy in adulthood, which is linked to poor health outcomes. To increase early shared reading behaviors in families experiencing poverty, the American Academy of Pediatrics has recommended shared reading starting at birth and stated that provision of early literacy promotion and education is “an essential component of primary care pediatrics.”¹⁴

Currently, a wealth of evidence supports early childhood literacy promotion programs like Reach Out and Read in the outpatient clinic setting. Reach Out and Read (ROR) is an evidence-based early literacy promotion program that gives young children a foundation for success by incorporating books into pediatric care and encouraging families to read aloud together. The national Reach Out and Read program model was founded by two pediatric physicians and an early childhood educator in 1989 at Boston City Hospital in Boston, Massachusetts, based on the premise to “encourage parents to read regularly to their children and give them the tools (the books) to do so.” The Reach Out and Read intervention is based on the relationship of trust between medical provider and family. Research shows that parents listen and children learn as a result of literacy promotion by primary care providers, which offers a practical and evidence-based opportunity to support early brain development in primary care practices. The program is low cost and numerous studies showing that the program results in more frequent reading at home and higher receptive and expressive language scores compared to age-matched peers^9,15–18.

ROR has a three-part model to promote healthy brain development:

• The Conversation: During well-child visits, the doctor prescribes reading by modeling read aloud strategies while teaching and training the parent about how to share books and why it is important. Parents are engaged in the conversation as the provider offers anticipatory guidance and emphasizes how reading brings families together.
• The Book: Each child is given a new, culturally and developmentally-appropriate book to take home after each visit, building a collection of 10-15 new books in the home before the child goes to kindergarten.
• Literacy-Rich Environment and Resources: Clinic supports literacy-rich messaging and resources to families, supporting providers in community-health resources and parents in daily literacy activities with their children.

 

Currently, all children who receive care at any of the three locations of Duke Children’s Primary Care automatically receive a book at each well child visit from birth to age five. Our providers strive to begin each visit with the book, allowing for connection with the child and their family and an opportunity to observe children’s development through their interaction with the book. Here’s an example of what this looks like. As a pediatrician, I get so much value from using books during my visit both to assess development and to connect more deeply with patients and their families. My dream is to see this program implemented in all practices that serve children in North Carolina. This dream is closer to becoming a reality thanks to funding from a $3.1 million Health Services Initiative. You can hear more about this exciting news on Episode 13 of the ROR Podcast.

At the end of my clinic sessions, I know that I have been able to enhance the lives of children by empowering their parents and caregivers to share books at home to create moments of connection. The added benefit, of course, is that these small moments have a big impact for children’s language development and their future success in school. Ultimately, I believe the most important impact of this program is creating a foundation for a safe and secure attachment within families that promotes the health of family relationships.

 

It can be hard to know which books to select for your child and how to know what reading looks like for children of different ages. These are a few tips and recommendations. For more, check out the Reach Out and Read website.

6 to 12 months

Board books are perfect for babies to explore. They can begin to move the pages, chew on the edges, and pass the book from hand to hand. Faces will fascinate little ones at this age, and you can take the time to begin teaching them about their body parts. Do you see the baby’s nose? YOU have a nose!

Title: Baby Faces
Author: DK Publishing

Title: Global Babies
Author: The Global Fund for Children

 

12 to 18 months

Introducing animal sounds and names of familiar objects can be a lot of fun! Help your child to find and name things around them using the book as a guide to reinforce language development.

Title: Dear Zoo: A Lift-the-Flap Book
Author: Rod Campbell

Title: Where’s Spot?
Author: Eric Hill

 

18 to 24 months

Books with rhymes and word patterns help your baby learn how language works and how words and sounds fit together. It’s a bonus if they have songs to go with them that you and your family sing together.

Title: Brown Bear, Brown Bear, What Do You See?
Author: Bill Martin Jr

Title: My Heart Fills with Happiness
Author: Monique Gray Smith

 

​24 to 36 months

Books that continue to include rhymes and basic counting skills are perfect to introduce at this age. Also, books can be a great way to establish bedtime routines so it’s great to find some stories that talk about bedtime. Children are learning two to three new words per day at this stage and reading together helps this development.

Title: It’s Okay to Be Different
Author: Todd Parr

Title: Corduroy
Author: Don Freeman

 

3 years

Preschoolers are learning basic concepts like opposites and healthy habits at this age. Many children can also recite entire phrases from their favorite book and may notice when you miss a page. Use books to reinforce knowledge of colors or talk about things you do together during the day.

Title: Llama Llama Red Pajama
Author: Anna Dewdney

Title: Not Norman
Author: Kelly Bennett

 

4 years

By this age, children can follow books with stories and will often want to hear the same ones over and over again. Children can listen and pay attention for longer periods of time and can be expected to finish a whole book . . .or more than one! Engage your child by asking questions about the story like, “What do you think will happen next?” Or, you can begin to make up your own story with the pictures that you see.

Title: The Snowy Day
Author: Ezra Jack Keats

Title: The Story of Ferdinand
Author: Munro Leaf

 

5 years

Fairy tales, legends, and stories with twists and turns are fun for five year olds. Help your child point out specific letters and sound out some words together.

Title: Cloudy With a Chance of Meatballs
Author: Judi Barrett

Title: Ruby Finds a Worry
Author: Tom Percival

References

1. Shonkoff JP. Building a New Biodevelopmental Framework to Guide the Future of Early Childhood Policy. Child Dev. 2010;81(1):357-367.
2. Center on the Developing, Child at Harvard University. Five Numbers to Remember about Early Childhood Development. www.developingchild.harvard.edu
3. Roia A, Paviotti E, Ferluga V, et al. Promoting effective child development practices in the first year of life: does timing make a difference? BMC Pediatr. 2014;14:222-222. doi:10.1186/1471-2431-14-222
4. Barron RW. Proto-literacy, literacy and the acquisition of phonological awareness. Learn Individ Differ. 1991;3(3):243-255. doi:10.1016/1041-6080(91)90010-X
5. Kovelman I, Norton E, … JC-C, 2011undefined. Brain basis of phonological awareness for spoken language in children and its disruption in dyslexia. academic.oup.com. https://academic.oup.com/cercor/article-abstract/22/4/754/416751
6. Snowling M, Hulme C. The development of phonological skills. Philos Trans R Soc Lond B Biol Sci. 1994;346(1315):21-27. doi:10.1098/rstb.1994.0124
7. SB P, Y P, LM J. How Many Letters Should Preschoolers in Public Programs Know? The Diagnostic Efficiency of Various Preschool Letter-Naming Benchmarks for Predicting First-Grade Literacy Achievement. J Educ Psychol. 2012;104:954-958.
8. Foorman BR, Anthony J, Seals L, Mouzaki A. Language development and emergent literacy in preschool. Semin Pediatr Neurol. 2002;9(3):173-184. doi:10.1053/SPEN.2002.35497
9. Sharif I, Rieber S, Ozuah PO. Exposure to Reach Out and Read and vocabulary outcomes in inner city preschoolers. J Natl Med Assoc. 2002;94(3):171-177.
10. Letourneau N, Whitty P, Watson B, Phillips J, Joschko J, Gillis D. The influence of newborn early literacy intervention programs in three canadian provinces. Issues Compr Pediatr Nurs. 2015;38(4):245-265. doi:10.3109/01460862.2015.1065933
11. Sinclair EM, Mccleery EJ, Koepsell L, Zuckerman KE, Stevenson EB. Home Literacy Environment and Shared Reading in the Newborn Period. www.jdbp.org
12. Cates CB, Dreyer BP, Berkule SB, White LJ, Arevalo JA, Mendelsohn AL. Infant communication and subsequent language development in children from low-income families: the role of early cognitive stimulation. J Dev Behav Pediatr. 2012;33(7):577-585. doi:10.1097/DBP.0b013e318264c10f
13. Pathways to Grade-Level Reading | North Carolina Early Childhood Foundation. https://buildthefoundation.org/initiative/pathways-to-grade-level-reading/
14. High PC, Klass P, Donoghue E, et al. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):404-409.
15. Burton H, Navsaria D. Evaluating the Effect of Reach Out and Read on Clinic Values, Attitudes, and Knowledge. 2019;118(4):6.
16. Diener M. Kindergarten Readiness and Performance of Latino Children Participating in Reach out and Read. J Community Med Health Edu. 2012;2(3).
17. King TM, Muzaffar S, George M. The Role of Clinic Culture in Implementation of Primary Care Interventions: The Case of Reach Out and Read. Acad Pediatr. 2009;9(1):40-46. doi:10.1016/j.acap.2008.10.004
18. Mendelsohn AL, Mogilner LN, Dreyer BP, et al. The impact of a clinic-based literacy intervention on language development in inner-city preschool children. Pediatrics. 2001;107(1):130-134.