The vast majority of infants and a plurality of toddlers in Massachusetts live in child care deserts, new state data show. Despite the recent increases in early education system capacity, sizeable gaps remain between available seats and the overall number of children, and program capacity falls short for tens of thousands of young children in each early education age group across the state.

Around 59,000 (70 percent) of infants, around 43,000 (43 percent) of toddlers, and around 10,000 (5 percent) of preschoolers in Massachusetts live in an access desert. The state defines this as areas where for every three children there is only one child care slot, though there are regions particularly in central Massachusetts where the ratio is greater than ten children to one slot.

Enrollment differences between regions, student age groups, and income levels paint a picture of a system struggling to meet potential demand and that is most available to those at the highest income brackets.

鈥淲e know the need is considerable, so we know that growth is good, but it doesn’t tell us whether or not that growth is particularly responsive to where child and family need is perhaps strongest and greatest,鈥� Tom Weber, executive director of the Massachusetts Business Coalition for Early Childhood Education, said at a recent听听focused on improving early education data practices. 鈥淥r is it in fact responsive to other environmental factors, like the rules and policies that we put in place or where we have decided presently to concentrate our public funding?鈥�

The data were presented at the second meeting of the Data Advisory Commission on Early Education and Care, an entity created in the state budget signed in July 2024 to better understand the gaps in the child care landscape. Comprised of state, education, and business leaders, the commission鈥檚 goal is to improve the quality of data collection on child care needs, figure out how best to use it, and make sure the public has access to it.

Coming out of the peak of the Covid pandemic, which shuttered centers and placed much of the child care burden on parents juggling remote or essential in-person work, enrollment and capacity have been on the rise, researchers with the Department of Early Education and Care noted.

Over the last two years, the early education and care system has added about 17,000 new seats, bringing the total capacity of licensed center-based care, licensed family child care, and state-funded programs to 259,744. Care options for infants and toddlers have the fewest overall seats compared to other age groups, but their capacity has risen the most 鈥� 5 percent over the last year compared with 3 percent growth for preschoolers and 1 percent growth for school-age children.

While all regions of the state have seen increased capacity since 2023, the rate of growth slowed in central and southeast Massachusetts over the past year 鈥� regions already struggling with accessible child care. Enrollment in formal care for newborns to 5-year-olds peaks at 56 percent in the Boston area and northeast Massachusetts, with the least (48 and 47 percent) in central and southeast Massachusetts, respectively.

In families earning less than half of the average median income, 51 percent of children are enrolled in formal care. That drops to between 37 and 35 percent for families making half to 100 percent of the standard income, and spikes to 66 percent at the highest wage brackets of more than 150 percent of the standard income.

鈥淲e see the highest enrollment rates or those who have higher financial resources,鈥� said Michelle Saulnier, a data analyst at the early education department. 鈥淭his is an opportunity for us to maybe conclude that those who are in the higher income bracket may be a closer measure to parent preference and demand for enrollment in formal care,鈥� she said.

Essentially, the families with the most resources are enrolling about two-thirds of their children in formal care, which can give education researchers clues about how many children may need spots to meet true demand.

Research published last year from Professor Jeffrey Liebman at the Harvard Kennedy School that 80 percent of families surveyed who were not currently using formal care would use it if they could afford it. Plus, 70 percent of those currently using it would use more hours if it were more affordable.

Ashley White, research director for the early education department, noted that the state collects information on child age, care type, and region for those using child care financial assistance programs. But there are still holes in data on family income, race and ethnicity, country of origin, disability status, and household language. Improvements to systematically collecting that information would bolster the data sets, White said.

The department does not currently collect data on early intervention for developmental delays, though partner groups and sister agencies focused on these interventions have some relevant data听that the early education department can aggregate.

There are similar data gaps for families on wait lists for licensed programs, making it hard to gauge the demand for the different types of child care and where it would make sense to add seats. 听Across the state, data on children and families is generally limited to those accessing care funded through the grant program that supports child care providers, so White said there is a need to 鈥渢hink creatively鈥� about how best to gather information on education and care needs outside of the C3 program.

The state is also the family portal and case management system for child care financial assistance programs, which at the moment involves a number of different tools and applications. Some parts involve more of an open notes field, which makes it hard to capture and sort information systemically. A better digital intake process would let them collect more 鈥済ranular鈥� data, unify the experience for families, streamline care management, and improve operational efficiency.

鈥淚 think one of the wonderful things about the family portal is that it’s going to allow us to collect more information earlier in the process and have to do less verification and going back to families and asking for them to update information,鈥� White said. 鈥淪o we’ll know more initially than we ever have before.鈥�

This first appeared on and is republished here under a .

In mid-April, nurses in Wichita, Kansas, ratified their first-ever union contracts with two Ascension health system hospitals. The victory followed a similar win in March in Austin, Texas, when nurses at Ascension Seton Medical Center voted to ratify their first union contract with Ascension. Neither success came easily or quickly, say members of (NNU), the country鈥檚 largest union and professional association of registered nurses.

鈥淚 don鈥檛 think [Ascension] calculated on our determination and resolve to get the results we wanted, and our patients needed,鈥� says Marvin Ruckle, NNU member and a veteran nurse who has worked at Ascension St. Joseph in Wichita since 1989, with 24 of those years in the Neonatal Intensive Care Unit. 鈥淥ur community has been so supportive, coming out to our strikes, bringing us food and water. Workers from all the other unions around the Wichita area 鈥� steel workers, UPS, Spirit (airplane factory) 鈥� joined us. Most of these people have either been a patient or had family in one of our facilities and they know there needs to be change.

鈥淭his (contract) is an incredible step forward for nurses, so we can work with the hospital to make patient care better for our community,鈥� Ruckle says. 鈥淏ut it shouldn鈥檛 have taken this long. We were determined, we kept pushing, and all Ascension did was drag out the process.鈥�

One of the nurses鈥� most significant wins was safe staffing ratios enforceable through a nurse-led Professional Practice Committee. In Austin, hundreds of nurses spent more than a year in contract negotiations and organizing efforts, participating in two strikes to focus attention on their demands including guaranteed lower nurse-to-patient staffing ratios. At all three facilities, Ascension management responded to the nearly 2,000 nurses鈥� historic one-day joint strike on June 27 with a three-day lockout.

Mission-Driven Ascension

Based in St. Louis, Missouri, Ascension is one of the largest health systems in the U.S., boasting 140 hospitals and 40 senior living facilities in 18 states and the District of Columbia. Becker鈥檚 Hospital Review listed Ascension as No. 2 in its 2019 list of 100 of the largest hospitals and health systems in the U.S. and the largest nonprofit health system by hospital count. The nonprofit Catholic health system鈥檚 stated mission is to deliver 鈥渃ompassionate, personalized care to all, with special attention to persons living in poverty, and those most vulnerable.鈥�

A deeply researched analysis from the National Nurses Organizing Committee and NNU, 鈥�,鈥� questions how closely Ascension hews to that mission, particularly in communities with high poverty rates and a disproportionate number of Black and Latino residents. Ascension, the report states, is one of the nation鈥檚 worst offenders in closing obstetrics units and obstetrics services. Over the past decade, Ascension has eliminated obstetrics services at 16 hospitals and slashed more than a quarter of the labor and delivery departments that it had been providing in 2012, a rate three times higher than the national average of 6 percent.

Since 2022 alone, Ascension has closed five maternity wards, all health care markets where Ascension maintains a monopoly or near-monopoly on health services. Half of the hospitals where Ascension closed labor and delivery units are in counties with a higher proportion of low-income residents and people of color, and higher rates of infant mortality than the national average (also known as 鈥減ersons living in poverty, and those most vulnerable鈥� 鈥� see Mission Statement above).

Profits over Patients?

By now, the statistics are familiar to anyone paying attention: the U.S. has the highest rate of death among pregnant women and infants of any wealthy country; maternal mortality is more than 10 times and infant mortality almost double the average among comparably wealthy nations. It is no longer even a nasty secret that Black women are nearly three times as likely to die in childbirth as white women.

As 鈥淒angerous Descent鈥� points out, for the first time in two decades, infant mortality has risen in the U.S., largely due to pregnancy-related complications, which experts attribute to limited access to specialists who deal with complicated pregnancies. According to the Centers for Disease Control and Prevention, more than of pregnancy-related deaths in the U.S. are preventable 鈥� and healthcare leaders have a major role to play in improving these outcomes. Tragically, many systems focus their eye most keenly on the fiscal bottom line rather than the fundamental health of their patients.

Hospital consolidation has been on the march over the last two decades, with more than 67 percent of U.S. hospitals now belonging to a larger system, compared to 45 percent in 2000. NNU鈥檚 report cites numerous studies that have shown that such highly consolidated markets can lead to price increases and diminished patient outcomes. Hospital corporations say such consolidation creates 鈥渆fficiencies鈥� that enable them to cut costs. What they don鈥檛 say as loudly is that steps such as eliminating and obstetrics services 鈥� both major casualties of hospital cost-cutting 鈥� also improves their profits. In practice, consolidating labor and delivery limits access to care for many patients in low-income areas who may not have vehicles or good access to public transportation. Increased distance to medical care can result in missed prenatal appointments or an inability of patients to get to the hospital in time to deliver their babies safely.

According to the , more than 400 maternity services closed in the U.S. between 2006 and 2020. Between March and June 2022, 11 health systems announced they were closing their obstetrics services. When birthing units close, obstetricians and nurse-midwives are more likely to go elsewhere, exacerbating the epidemic of maternity care deserts in the world鈥檚 largest and most robust economy.

鈥淲hat was really striking to us,鈥� says Elana Kessler, author of NNU鈥檚 鈥淒angerous Descent鈥� report, 鈥渋s that this is a mission-driven hospital system under the Catholic church that is to care for the poor and to create a more just society. Their actions are not in line with that mission statement. By closing labor and delivery units in Medicaid-heavy areas with higher proportions of Black and Latino patients, they鈥檙e hiding behind their mission while they鈥檙e increasing their profits.鈥�

Health reporting news site stated in a 2021 investigation that Ascension, 鈥渁 wealthy, religious, tax-exempt health system,鈥� had migrated toward behaving like a Wall Street firm, using its wealth to create a sophisticated investment strategy that includes a partnership with the private equity firm, TowerBrook Capital Partners. Ascension stands out from other nonprofit hospitals that have dabbled in private equity investing in the sophistication and expansiveness of its $1 billion partnership with TowerBrook, the STAT investigation found.

On its 2021 federal tax return, Ascension reported that CEO Joseph R. Impicciche received a salary of $13 million. In 2022, the reported that Ascension had spent years reducing its staffing levels to improve profitability even though the chain is a nonprofit organization with nearly $18 billion in cash reserves. At that time, its charity care accounted for 1.9 percent of operating expenses (against a national average of 2.6 percent).

Even with the additional revenue from its investments, Ascension pursued cuts to safety-net hospitals in Washington, D.C., and Milwaukee, Wisconsin, abruptly closing its Labor and Delivery unit in December 2022, leaving Milwaukee鈥檚 south side, home to a large immigrant community, completely without a hospital to deliver babies. The move prompted a scorching letter from Wisconsin Sen. Tammy Baldwin, who demanded answers from Ascension on its questionable priorities that funnel cash to its investment funds and executives, putting providers and patients at risk. In her letter, Sen. Baldwin called on Ascension to reinvest its cash reserves in hospitals that serve vulnerable communities and to increase pay and improve working conditions for its 鈥渂urned out and overextended health care workforce.鈥�

In an April 19 email response to Early Learning Nation magazine, Sen. Baldwin stated that Ascension had replied to her letter. 听鈥淲hile I鈥檓 encouraged that Ascension appears to be taking the communities鈥� concerns seriously and working to rebuild relationships,鈥� she wrote, 鈥淚 remain concerned that their business practices appear more like a private equity firm than a nonprofit hospital whose stated mission is to serve the public.鈥�

Understaffed NICUs and Obstetrics Units

鈥淚t鈥檚 been like working in a MASH unit,鈥� Ruckle said, describing his experience in Ascension St. Joseph鈥檚 NICU. Mobile army surgical hospitals (MASH) units, which were phased out in the early 2000s, were known for their primitive conditions, grueling work schedules and frustrating lack of resources. As reported in 鈥淒angerous Descent,鈥� nurses at multiple Ascension hospitals have noted the perpetual crisis caused by staffing cuts and equipment shortages.

鈥淚t鈥檚 heart-wrenching to go home and wonder if you were able to help that critically ill baby as best you could and worry that they aren鈥檛 going to have the best outcome,鈥� he said.

The result for nurses can be not only stress and frustration but, according to Zenei Triunfo-Cortez, one of NNU鈥檚 presidents, moral harm.

鈥淎s nurses, we have an obligation to advocate for our patients, to do what鈥檚 best for our patients,鈥� she says. 鈥淏ut the situation we鈥檙e being put in, especially Ascension nurses, is that we know we have to do the right thing and are being prevented from doing so because of the situation in our hospitals. Then we suffer from moral injury. Our hearts are breaking because we want to do what鈥檚 best, but our employers are not providing what we need to do so.

鈥淲e start asking, 鈥業s this really worth my health?鈥欌�� says Triunfo-Cortez, who has been a registered nurse for 44 years. 鈥淭he majority of our nurses will be out there fighting for our patients and fighting for what鈥檚 right, but it does make us question.鈥�

Recommendations from NNU

Pointing out that Ascension enjoys hundreds of millions of dollars in tax breaks thanks to its nonprofit status yet continues its abandonment of low-income mothers, parents and newborns, NNU and the National Nurses Organizing Committee recommend systemic changes that would align Ascension with its mission:

• Come to the table and listen to nurses; staff every unit to ensure the best care for patients.
• Commit to reopening closed labor and delivery wards.
• Provide obstetric services at all new hospitals Ascension opens or acquires.

Ascension has the opportunity and resources to become an industry leader, says Kessler, the report鈥檚 author. 鈥淎s nurses advocating not only for nurses but for the patients they serve, we know that safe staffing and readily accessible care are completely entwined in the work nurses do 鈥� they鈥檙e one and the same.

鈥淎scension will say, 鈥楥onsolidation is part of our business strategy. It鈥檚 better for the patient,鈥� but at the end of the day,鈥� she says, 鈥渋t doesn鈥檛 happen that way. It creates barriers for patients to face 鈥� transportation, child care 鈥� and when there is not ready access to obstetrics services, pregnant patients are less likely to get prenatal care, which then has a cascade of harmful effects.鈥�

础蝉肠别苍蝉颈辞苍鈥檚 1 in 50 Report

In late April, Ascension released a in which it reported that one in 50 U.S. babies is now born at an Ascension hospital, no doubt in part to what The Wall Street Journal (WSJ) cited as the corporation鈥檚 role as the 鈥渕ost active dealmaker鈥� in its hospitals鈥� expanding into wealthy areas while shunning poorer ones. Nonprofit hospitals now account for half the $1 trillion U.S. hospital sector. Across the sector, the 奥厂闯鈥�s investigation found, though they receive local, state and federal tax breaks in exchange for providing charity and benefiting communities, nonprofits are less generous in providing aid than their nonprofit rivals.

Though the Ascension report states that its commitment is 鈥渞ooted in the loving ministry of Jesus as healer鈥� and the 32-page report details positive health outcomes throughout the system, NNU鈥檚 Kessler says the report doesn鈥檛 tell the full story of how those numbers arrived.

“Outcomes for patients no longer served by Ascension wouldn’t be included in the hospital’s data, so the report is incomplete,鈥� she says, 鈥渇ailing to consider the impact on communities where Ascension has shuttered obstetrics services under the corporate strategy of ‘consolidation.’

鈥淎scension asserts that one in 50 babies are born in their care, which only underscores the importance of Ascension keeping obstetrics services open for the thousands of expectant mothers they serve each year.听Furthermore, a snapshot of data from one year, in one health system, doesn鈥檛 tell the whole story of the impact of 础蝉肠别苍蝉颈辞苍鈥檚 decision to close services. It should also be noted t听could weigh the data in favor of showing better than average outcomes.”

鈥淭here鈥檚 a good amount of research looking at associations between the neighborhood environment and various health outcomes,鈥� says Julia G. Carter, lead author on the study, , published in JAMA Obstetrics and Gynecology. 鈥淲hen I was reviewing the literature, I saw a lack of research on the mother鈥檚 subjective experience, which is what our study looks at.鈥�

Because individuals who live in the same community can encounter the same environment in radically different ways, Carter says the research team from Northwestern University鈥檚 Feinberg School of Medicine wanted to go beyond the data about exposure to crime and other adverse conditions to look at how the mother鈥檚 view of her personal safety affected her and her infant鈥檚 well-being.

The researchers took their data from the (PRAMS), a project of the Centers for Disease Control and Prevention (CDC) which, along with state, territorial and local health departments, collects targeted, population-based attitudes on maternal attitudes and experiences surrounding pregnancy. The survey asked set questions of respondents in the participating 46 U.S. states, territories, District of Columbia and New York City, which creates data on 81 percent of all live births in the U.S. Individual states have the option of selecting additional questions to deepen their understanding of their own populations.

For their study, the Northwestern researchers analyzed responses PRAMS had gathered from 2016 to 2020 from the states that had asked respondents how they perceived their neighborhood safety.

Eight states 鈥� Illinois, Louisiana, Minnesota, Missouri, Pennsylvania, Rhode Island, Virginia and Wisconsin听 鈥� asked respondents, 鈥淒uring the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?鈥� Answers were then categorized as always or often unsafe, sometimes unsafe, rarely unsafe and never unsafe. To assess interpersonal physical and emotional abuse, one item asked whether respondents had been pushed, hit, slapped or physically hurt by another individual in the 12 months before they got pregnant. After 1829 exclusions, 29 987 respondents were included in the Northwestern study. Most of the respondents (78 percent) reported that they never felt unsafe. At the other end of the scale, 3 percent said they always or often felt unsafe.

The researchers then analyzed respondents鈥� birth outcomes including low birth weight, self-reported depression during pregnancy or postpartum, attending more than eight prenatal care visits, attending a postpartum visit, and breastfeeding for at least eight weeks.

After controlling for maternal age, race and ethnicity, and other sociodemographic factors to test the independent significance of perceived neighborhood safety, the researchers found that, compared with respondents who never felt unsafe in their neighborhoods, those reporting that they always or often felt unsafe had nearly 25 percent higher odds of having a low birthweight baby and 100 percent higher odds of perinatal depressive symptoms. The group that felt unsafe had 10 percent lower odds of attending more than eight prenatal care visits.

Although the Northwestern researchers鈥� cross-sectional study didn鈥檛 assess the factors that could determine why a pregnant person might choose not to seek prenatal care, their study cited an in-depth Canadian published in the BMC Journal of Pregnancy and Childbirth that analyzed the motivators associated with inadequate prenatal care among eight inner-city Winnipeg, Manitoba, neighborhoods. Researchers from the University of Manitoba found that, although the women in their study lived in the same group of disadvantaged neighborhoods, psychosocial, attitudinal, economic and structural barriers and a variety of motivators, separated those women who received adequate prenatal care from those who did not. The study highlights the diversity among inner-city women with respect to their experiences with prenatal care and their perceptions of factors that help or hinder them in accessing this care.

Psychosocial issues that increased the mothers鈥� likelihood of not receiving adequate care included feeling stressed, having family problems, being depressed and worrying that child welfare officials might take the baby. Being abused by their husband or boyfriend also prevented several of the women from obtaining adequate prenatal care. Structural barriers included not knowing where to get prenatal care or having a long wait to get an appointment. Problems with transportation or child care were mentioned by nearly half the women who didn鈥檛 receive adequate prenatal care.

The good news, Carter says, is that these factors have policy implications, which means they can be addressed. Solutions are more likely to be found in such initiatives as providing access to social workers who can help with scheduling and follow up, providing mental health resources, or addressing systemic issues such as the lack of bus stops near clinics.

A reverse image of the neighborhood perception study can be found in the paper, 鈥�,鈥� published in the International Journal of Environmental Research and Public Health, which looks at the relationship between favorable social and environmental neighborhood conditions and perinatal outcomes.

Researchers from the University of Albany looked at nearly 300 mother-infant pairs in small cities, suburban regions and rural areas in upstate New York. The neighborhoods were analyzed according to the (COI), a multidimensional indicator of a neighborhood鈥檚 favorable social, environmental and educational community attributes. The study, the first to analyze the COI in association with pregnancy health and birth size, demonstrated that positive neighborhood attributes cumulatively contributed to healthy pregnancies and favorable birth outcomes.

While the idea that better neighborhoods make for better health may seem like a foregone conclusion, the contrast among the studies underscores an important point. The factors that give one neighborhood a high COI score and make other neighborhoods a source of fear and concern for mother and child, are all malleable and subject to change.

In their neighborhood perception paper, the Northwestern researchers point out that social and economic interventions that combat neighborhood and domestic violence may be more beneficial in reducing adverse pregnancy outcomes than biomedical interventions. Reducing expensive, often counterproductive police crime-prevention initiatives and mass incarceration in favor of resources that strengthen low-income communities may go further to create a sense of safety not only for pregnant people, but for the entire community.

鈥淭he main question,鈥� Carter says, 鈥渋s what are we going to do about it? That is outside the scope of our study, but assessing the situation is the first step in having this conversation. There are still a lot of steps to make improvements and develop solutions.

鈥淲ith these social determinants of maternal health, the truth is, there鈥檚 no quick fix. But to have the data and the commitment to collectively do something about it makes a big difference.鈥�

Further Reading

听Children from neighborhoods perceived as unsafe by parents engaged in one less day per week in physical activity. Children from neighborhoods perceived as unsafe were less likely to use recreational facilities compared with children from neighborhoods perceived as safe, and children from less affluent families across rural and urban areas had half the odds of using recreational facilities compared with children from the wealthiest families living in urban areas.

Neighborhoods can be a potential source of psychosocial stressors associated with childhood asthma. Parents who perceive their neighborhoods as sometimes or never safe reported asthma at higher rates than those living in neighborhoods parents perceived to be always safe.

Babies born to mothers on Medicaid died at almost twice the rate of babies born to mothers with private health insurance.

That may read like an indictment of the federal Medicaid program, but it isn鈥檛. Rather, it鈥檚 a reflection of the program鈥檚 limitations, the complicated circumstances of mothers experiencing poverty, and sometimes a simple matter of geography.

鈥淢edicaid is fantastic and undoubtedly has improved outcomes for mothers and babies. But even though it鈥檚 beneficial, it isn鈥檛 as good as private insurance,鈥� says Dr. Colm P. Travers, neonatologist and assistant professor of pediatrics for the University of Alabama at Birmingham School of Medicine. 鈥淏abies don鈥檛 get to choose who their parents are, how much money their parents make or what they do for a living. The baby shouldn鈥檛 suffer because of their parents鈥� socioeconomic status.鈥�

Travers led a recent study on how insurance status relates to infant outcomes in the U.S. The study, 鈥�,鈥� was published in the October 2023 issue of JAMA Network Open. The study used data from the birth and infant death records database of the Centers for Disease Control and Prevention (CDC) from 2017 to 2020. Researchers analyzed data of more than 13 million infants; 54% born to mothers with private insurance and 46% to mothers with Medicaid. The study found that those with private insurance had a significantly lower risk of infant mortality 鈥� almost half the rate of mothers with Medicaid 鈥� as well as a lower risk of low birth weight, vaginal breech delivery and preterm birth. They were more likely to receive prenatal care in the first trimester compared with those with Medicaid.

Prenatal care is foundational for positive outcomes because the first trimester is such a crucial time for both mother and baby, says the study鈥檚 first author, Desalyn Johnson, a soon-to-be MD from the University of Alabama at Birmingham.

鈥淔rom a biological standpoint for the fetus, that first trimester is when organogenesis occurs,鈥� Johnson says. 鈥淭he other two trimesters see more growth of the body, but the first trimester is when the heart, the lungs 鈥� all the organs 鈥� are formed. It鈥檚 also a time for recognizing the mother鈥檚 baseline risk factors that might put a pregnancy at risk, such as high blood pressure or diabetes. You really want mothers to have access to prenatal care at that critical time.鈥�

Presumed Eligible

Because the prenatal period is so crucial, many states provide presumptive eligibility for low-income mothers, meaning that they can start prenatal care as early as possible in their pregnancy. General guidelines for Medicaid eligibility are set by the federal government, but each state sets up their own requirements for eligibility, which differ from state to state. In states that don鈥檛 allow presumptive eligibility, the process for approval can send applicants through an administrative tangle that takes weeks and involves multiple steps to navigate the bureaucracy 鈥� at a time when the clock is ticking for both mother and fetus.

鈥淥ne of the big differences we found in infant outcomes was that the Medicaid population had delayed or inadequate prenatal care, possibly because of the process they have to go through before they can even get an appointment for their first prenatal visit. That can mean by the time they get approved, they鈥檙e delayed in their prenatal care, or they haven鈥檛 received adequate care in those first months. They鈥檙e already behind,鈥� she says.

Sometimes whether an expectant mother can receive adequate care boils down to whether she can get to it, Johnson adds.

鈥淗ere in Alabama, a lot of our population is very rural,鈥� she says. 鈥淪ome must travel great distances to receive healthcare. When you鈥檙e trying to access Medicaid services, it adds to the barrier when you have to go to this county clerk or that building to fill out paperwork and then back and forth. It can be difficult.

鈥淎 lot of times, researchers look at urban health, which is very important, but we also need to consider this rural aspect, especially in the Southeast.鈥�

Nowhere to Go

Once a pregnant person does get signed up for Medicaid, there is no guarantee that they will be able to find a health professional to care for them or their babies. According to a research letter published in JAMA Network Open, 鈥�,鈥� in 2020, the number of general pediatricians in the entire U.S. was 56,800. Only 2,900 of these doctors worked in rural counties; 86 worked in completely rural counties, which the defines as a county with open countryside, fewer than 500 people per square mile and no towns with more than 2,500 population. Nationwide, 1,391 counties had no pediatrician; 1,156 of these were rural counties; 331 counties had neither general pediatricians nor family medicine physicians (FMPs).

The March of Dimes鈥� 2022 report, 鈥�,鈥� finds that about 36% of all U.S. counties have no maternity care, whether obstetric providers, certified nurse midwives, or hospitals or birth centers offering obstetric care 鈥� a number that appears to be growing. Maternity care deserts are associated with a lack of adequate prenatal care during pregnancy, treatment of pregnancy complications and an increased risk of maternal death. More than 2.2 million U.S. women of childbearing age 15 to 44 live in maternity care deserts.

Among all highly industrialized countries, the March of Dimes report states, the U.S. is considered one of the most dangerous developed nations in the world in which to give birth.

, counties with neither general pediatricians nor FMPs were more likely to have higher percentage of non-Hispanic Black children, higher child uninsured rates, higher child poverty levels and fewer children enrolled in K-12. The issue of health professional deserts is so pervasive now in the U.S. it even gets its own acronym, HPSA (health professional shortage areas).

This shortage helps explain 鈥� though not entirely 鈥� why babies, especially post-neonatal intensive care unit (NICU) babies, born under Medicaid don鈥檛 receive the same level of postnatal care, such as oxygen monitors and ventilators, as babies born to privately insured mothers. The babies born on Medicaid also face increased risk of dying from trauma, accidents, and 鈥� a serious neonatal illness most common in premature babies, especially NICU babies who don鈥檛 get human milk.

Lifesaving Alternatives

These negative outcomes don鈥檛 have to be assumed for mothers living in poverty, the researchers say. Multiple studies have shown that expanding Medicaid prenatal care can dramatically improve things for both mothers and babies. For example, found that expanding Medicaid to cover prenatal care for undocumented immigrant women in Oregon was associated with more prenatal care visits and improved care, a reduction in the number of babies born with extremely low birth weight, and lower infant mortality rate. Additionally, the mothers鈥� access to prenatal care was associated with an increased number of well child visits and increased rates of recommended screening and vaccines during the child鈥檚 first year.

A study of Medicaid-sponsored provided strong evidence that the program improves the lives and health of mothers and babies. A team of nurses, social workers and other specialists work with the pregnant person鈥檚 doctor and local providers to care for mother and child throughout pregnancy and the child鈥檚 first year, including a well-regarded . The study found that enrollment in the program significantly reduced the odds of babies dying within their first year.

Ruling Out Race

Aware of important racial disparities in infant outcomes in the U.S., researchers adjusted their health insurance study for race, so the results reflected the difference between mothers on Medicaid and mothers with private insurance, not race-based differences.

鈥淩ace is largely a social construct,鈥� Travers says. 鈥淚ncreasingly, medical and genomic studies are showing that there is little basis for race-based medicine in the U.S. In this study, we adjusted for the effect of race in our analysis, not to eliminate race, but to try to take it out of the equation. We purposely looked at insurance and adjusted for race so that we could get at the question of socioeconomic status and insurance specifically.鈥�

For example, a recent from the National Institute of Child Health and Human Development found that newborns of Black patients had the worst perinatal outcomes. But once the study adjusted for insurance status, the difference was no longer significant.

The researchers also adjusted for sex of the newborn, maternal pregnancy risk factors, education level and tobacco use to analyze the differences between the two groups. The difference boiled down to who had the better health care. In other words, infant mortality outcomes are not fully explained by those external factors but are associated with the mother鈥檚 socioeconomic status, and access to insurance and adequate health care. Populations that are entirely self-pay, such as undocumented immigrants, may have even poorer outcomes than Medicaid patients 鈥攁 subject for future study, the researchers say.

The results reflected in these studies don鈥檛 point to Medicaid鈥檚 failure but to the work remaining to be done to ensure that pregnant women of all socioeconomic circumstances receive the timely, adequate care they and their babies need.

鈥淭he draw of pediatrics for us as doctors is that when we鈥檙e working with children, we can lay the foundation for them to have healthy and successful lives,鈥� Johnson says. 鈥淏ut if you don鈥檛 lay that foundation in the dawn of life, it can have repercussions for their entire lifespan. 听鈥淲e鈥檝e now documented that, yes, these findings are what we expected. The next steps now are to decide how we as physicians, as policymakers, can address these issues and improve the outcomes for these babies.鈥�

Further Reading

: In 2020, 42% of all births in the U.S. were covered by Medicaid. About one in nine women of childbearing age (11.6%) in the U.S. was uninsured. About one in 18 children younger than 19 was uninsured.

An interactive map showing which of the states have adopted Medicaid expansion coverage for nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and the 10 states that have not done so.

Given that the U.S. is now drenched with advice on how to optimize our children鈥檚 learning, language and lives, parents often feel heavy pressure to see that their kids 鈥� even at a very early age 鈥� are keeping up or even 鈥渆xcelling鈥� (whatever that means for an infant). This can lead to well-intentioned but ultimately unhelpful attempts to steer the young child鈥檚 learning.

Observing this overly controlling behavior, even with babies as young as six months, lead researcher Dr. Lucy King, a psychologist specializing in developmental science, to set up a study to observe what factors might influence them to engage in intrusive behavior with their little ones. The study, 鈥�,鈥� published in the journal Developmental Psychology, found that caregivers鈥� goals influence their interactions with their infants and have a direct effect on intrusive, controlling behavior.

鈥淥ver the course of doing lots of observations of parents interacting with their babies in our labs, my colleagues and I observed that some parents engage in overly controlling, intrusive behavior, even with babies as young as 6 months,鈥� King says. 鈥淲e wondered whether that was partly due to a sense of pressure or the need to have their babies perform in a certain way.鈥�

She added, 鈥淭here鈥檚 a lot of rhetoric and advice in our society about how to help your kids develop optimally and a lot of pressure for achievement. We were interested in whether we could induce that (intrusive) behavior in the lab.鈥�

For the experiment, 66 mothers and their 6-month-old infants participated in a 10-minute 鈥渇ree play鈥� interaction, observed in two-minute segments for parental intrusiveness. Before the final segment, mothers were randomly assigned to receive instructions to focus on teaching something to their infants or learning something from them. A control group received no instruction.

Caregiving behaviors that are considered overly controlling are based on the caregiver鈥檚 agenda rather than the child鈥檚 interests and needs. This can look like taking over the focus of the play or task, interrupting the child鈥檚 exploration, or overstimulating the baby. For example, a parent might try to get the baby to understand that the little cup goes inside the big cup and be determined to instill that lesson when the baby is more interested in the cup鈥檚 mouthfeel and how it sounds when whacked on the floor.

The researchers found that manipulating the parents鈥� explicit goals by instructing them to teach their baby significantly increased the degree to which they exhibited intrusive behaviors. Mothers’ intrusiveness decreased when they were instructed to focus on learning something from their infants. Mothers in the control group who received no instructions had no significant change in their degree of intrusiveness.

鈥淚t can be tempting as an adult to interfere and show the child the right way to do something,鈥� King says. 鈥淭hat鈥檚 how we鈥檝e developed as adults, focusing on getting the right information and doing things correctly. But babies are in a completely different stage of life where they鈥檙e just exploring.鈥�

The irony of this push to have the baby master the material is that it can have the opposite effect and shut down the child鈥檚 natural drive to learn and understand. Infants are full of wonder 鈥� they wonder about everything in this world that is so new to them. Their minds are eager, and their brains are elastic. In fact, the researchers write, there is evidence that young children outperform older children and adults on tasks that require cognitive flexibility. Interesting or surprising events cue their brains: There鈥檚 something new to learn here. They thrive on exploration, and when an adult interrupts that process to try and impose a lesson on them, 鈥�No, no. You need to push the button, not lick it,鈥� it鈥檚 not so fun anymore.

鈥淚n my experience of watching a lot of these interactions very carefully 鈥� we鈥檝e videotaped hundreds of them 鈥� if the parent鈥檚 controlling behavior is intense, the child can end up checking out,鈥� King says. 鈥淥r they get distressed and upset because it overwhelms them.鈥�

The researchers鈥� findings extend far beyond the laboratory. As U.S. society experiences greater income inequality, competition increases to make certain one鈥檚 children have the competitive edge to be a success story. Our society emphasizes formal education as a primary way of determining success and even economic survival, making it unsurprising that we expect our caregivers to practice in a manner thought to promote a child鈥檚 early learning, e.g., teaching colors, numbers and social behavior expected in a school setting.

鈥淧ressure on children to perform has continuously increased,鈥� King says, 鈥渁nd we expect children to be learning really quickly at a younger age and reach a desired outcome. It鈥檚 stressful for everybody and parents worry that if they don鈥檛 push their kids to learn, they鈥檙e failing their children somehow.鈥�

Though it wasn鈥檛 the purpose of King鈥檚 study, it might relieve those stressed parents to know that their child is learning every minute of the day, and relaxing and following their lead is not only more fun, it鈥檚 also better for the baby鈥檚 development.

Previous studies have shown that infants and toddlers who experience more intrusive caregiving have been found to have smaller vocabularies, more difficulty solving math problems, and less knowledge of colors, letters and numbers when they reach preschool than children who have been allowed to take the lead in their explorations. Other research has found that families with high socioeconomic status may be especially focused on achievement, which can lead to more intrusive interactions and unintended negative consequences.

Earlier studies focusing on the preschool age have shown that mothers engaged in more controlling interactions with their infants when they were told their child would be tested. Caregivers who were told their child鈥檚 memory would be tested engaged in more adult-centered conversations than caregivers who were told their children would be asked later about their perspective. King鈥檚 study is the first to investigate how directing parents鈥� goals regarding infant learning influences intrusive caregiving behavior.

Dr. Alison Gopnik argues in her 2020 study 鈥�,鈥� published in The Royal Society鈥檚 Biological Sciences journal, that the 鈥渆xtended curious childhood鈥� of primates, in general, and humans, in particular, provides a protected time to extract information from the environment and to explore 鈥渦nlikely hypotheses.鈥�

鈥淓ven very young human children learn by formulating and testing structured causal hypotheses about the world,鈥� Gopnik writes, 鈥渦pdating them in the light of new evidence.鈥� In other words, the baby may look like he鈥檚 just gnawing the triangle from his shape sorter toy, but in reality, he’s exploring its physical dimensions, textures and, yes, maybe even its flavor. If you leave him be or ask him questions, you can bet he鈥檒l develop a theory about it 鈥� Hmm. Not food 鈥� after he鈥檚 tested his unlikely hypotheses.

An essential pathway to this learning-from-baby approach is our old friend , that back-and-forth that transpires between adults and even tiny infants that has been shown to grow the 鈥�white matter鈥� of a child鈥檚 brain.

鈥淚t may be obvious to us as adults that this is how you play with this toy with buttons,鈥� King says. 鈥淭he baby isn鈥檛 at all aware of that purpose. It鈥檚 OK for the adult to reach out and press the button and show the baby, but then take a moment to see what the baby does next with the toy rather than continue to instruct them to push the button.

鈥淢aybe they just want to touch in different ways or pick up the toy and look at it. You can build off whatever the baby does and have fun with that back and forth.鈥�

Sometimes, following the baby鈥檚 lead means noticing that he鈥檚 had it with these buttons and wants to go taste the triangle again. It鈥檚 all about paying attention to their cues.

Of course, King notes, there are times when instruction is essential. For safety鈥檚 sake, children can鈥檛 always lead. And sometimes, they just need to get their socks on so you can get them to child care.

鈥淭he reality is that it鈥檚 just not possible to do this all the time,鈥� King says with a laugh. The good news is that it isn鈥檛 the end of the world if a caregiver sometimes takes control of the conversation.

鈥淭here are endless opportunities to follow their lead,鈥� she says.

is bridging that gap with a one-of-a-kind new program to make certain Latino fathers see the difference they can make and have the tools and information they need to provide a strong foundation for their infants鈥� and young children鈥檚 early learning.

Though they鈥檙e so small and winsome, it might be hard to think of Latino infants and toddlers as something so serious sounding as 鈥渁gents of change,鈥� but that鈥檚 exactly what are. By any demographic measure, it鈥檚 plain that this population will have profound effects on every aspect of life in the U.S. and will be the engine of change at all levels of U.S. society. For our society to thrive, Latino children need to thrive.

Unfortunately, that isn鈥檛 necessarily the case. Though U.S.-born Latino babies are driving the nation鈥檚 population growth and shaping the makeup of its child population, they remain doubly invisible as one of the most under-recognized and under-served of U.S. population groups. According to the , as of October 2021, Hispanic children had the lowest enrollment rates in early childhood education (ECE), after Pacific Islanders, compared to all other population groups.

It’s an urgent, all-hands-on-deck moment for those who want to see Latino children take their place as fully engaged, fully resourced, equal contributors to U.S. society. UnidosUS is committed that Latino fathers be a part of that effort.

鈥淲ith a population of more than 62 million people on its way to becoming 110 million in the coming decades, sharing information about the importance of early learning and dual language development with Latino families is a crucial mission for us,鈥� says Dr. Robert Stechuk, UnidosUS鈥檚 director of Early Childhood Education initiatives.

Incorporating key scientific findings in the fields of infant development, early reading and dual language learning, the nonprofit has produced Vital and Valuable: Latino Fathers and Their Infants, their latest topic brief in the organization鈥檚 Latino Infant Initiative (operated in partnership with Abriendo Puertas/Opening Doors). This powerful, practical program is designed to break down myths and misunderstandings fathers might have about early learning and put the latest research into the hands of Latino fathers in an actionable way.

Father engagement is an active concern within UnidosUS, which serves as the nation鈥檚 largest Hispanic civil rights and advocacy organization and has an affiliate network of almost 300 community-based organizations throughout the U.S. and Puerto Rico.

鈥淎t least 50 of our affiliates have early childhood programs or offerings,鈥� Stechuk says. 鈥淪everal affiliates have been telling us within the last year or two that they鈥檝e been launching fatherhood initiatives. Others have said they鈥檝e been working on father engagement but stopped because of a shortage of materials relevant to Latino dads.

鈥淲hen I went to the National Head Start Association鈥檚 conference at the end of 2022, many of the sessions were on father engagement,鈥� he said. 鈥淪o, there鈥檚 a lot of interest in bringing fathers into the picture. The challenge is that there are websites with literally thousands of resources and a lot of it has even been translated into Spanish. But there is minimal information related to early language, early literacy, the important of early reading: all the developmental information that can show dads how to build their children鈥檚 vocabulary, language skills and love of reading/books that underlie successful literacy.鈥�

To counter this dearth of information, UnidosUS launched its Vital and Valuable brief in May and is distributing it to all of its affiliates nationally and through various channels to reach the UnidosUS community and other stakeholders.

Fathers want the information, Stechuk says.

In 2022, five parent focus groups were held at UnidosUS affiliates to learn more about the experiences of Latino parents and their families. The fathers who joined had important concerns about how to do the best for their children. They talked about wanting to step outside the traditional cultural roles they grew up with and having an active role in supporting their children鈥檚 development.

鈥淚 have a baby and want to be there for my child,鈥� one said. 鈥淲hen I was growing up, my dad abandoned us, so I want to be there for my child.鈥�

Another said, 鈥淚 grew up Latino in Chicago but turned my back on my culture and was totally alienated from my heritage. Now, I appreciate my culture and want my children to have that. I want them to be bilingual and to do well in school. I鈥檓 hungry for more information.鈥�

Being Bilingual

Vital and Valuable encourages fathers to support their children in being bilingual despite any messages they might have heard to the contrary. It鈥檚 a great asset for babies鈥� brain development and language learning 鈥� in any language. In numerous studies, researchers have found that bilingual babies learn English at the same rate as monolingual infants and develop vocabularies that equal or exceed those of English-only babies. Juggling two languages doesn鈥檛 confuse babies, as the pernicious myth goes, it enhances their executive function 鈥� the set of mental skills and self-regulation that helps people plan, problem-solve and respond in an orderly way to the world around them.

The Latino community has long been affected by systemic racism, with the suppression of their Spanish language one of its most damaging aspects. Latino families have been told by school personnel that they could damage their children鈥檚 development and academic success by speaking Spanish to them, and children have been and still are being bullied or teased for using Spanish in class or on the playground.

Vital and Valuable provides easy-to-follow pointers, such as, 鈥淚f you speak Spanish, interact with your baby in Spanish. If you speak Spanish and English, interact with your baby in either language.鈥� The most important thing, the brief says, is for dads to speak with their babies every day in whatever language they choose because providing experiences with language right after baby is born is the best way to start building reading success.

Another myth Vital and Valuable lays to rest is the idea that talking to babies doesn鈥檛 matter because they can鈥檛 speak yet. Reading success is built from Day One in a child鈥檚 life, and the brief boils down the research supporting how a rich daily bath in language, or more than one, with lots of 鈥渟erve and return鈥� interactions, builds the foundation of reading comprehension.

Fathers鈥� Play 鈥� Different and Essential

Fathers鈥� growing interest in being more connected with their young children coincides with a growing body of research into dads鈥� unique contribution to early learning. They aren鈥檛 just moms with deeper voices; they bring unique characteristics to infant speech development. Studies have observed that fathers use more rare words and fewer common words with their babies than mothers do, and their speech is often more diverse and challenging to the child. Fathers use significantly more wh words (why? what? who?) and ask for clarification more often than mothers do 鈥� strategies that may be unconscious but that researchers believe foster children鈥檚 reasoning abilities as well as strengthening their vocabulary.

For decades, researchers and psychologists 鈥� even families themselves 鈥� have assumed that the mother-child bond was the most important in the child鈥檚 life, while overlooking the profound contribution fathers make in their children鈥檚 development.

鈥淚n speaking with fathers,鈥� Stechuk says, 鈥渋t鈥檚 very clear that virtually all dads want their children to be academically successful. So, we want to engage fathers there to talk about what they want for their children. We want to talk about reading as essential for that success.

鈥淥nce children fall behind grade level, they tend to stay behind,鈥� he says. 鈥淔ailure to read is a real poison. It poisons children鈥檚 achievement, poisons their self-concept and self-esteem. Poisons their futures, really.

鈥淎nd guess what? The antidote is early language development. By spending a few moments every day talking back and forth with their children and using some language strategies that don鈥檛 cost any money, fathers are giving their children the foundation for long-term reading success.鈥�

Fathers themselves may be the ones who are least aware of how much they matter to their children鈥檚 early development. After reading Vital and Valuable, there will be no room for doubt.

With the state legislature approving $30 million in funding in April, TennCare will seek approval from the Centers for Medicare & Medicaid Services for the diaper benefit, which it hopes to receive in early January.

According to the (NDBN), one in three U.S. families is financially unable to provide all the diapers their children need, which exposes the child to potential health risks, makes it less likely for them to be accepted at child care where parents must bring diapers for each day, and increases the financial, physical and emotional stress on parents. The NDBN estimates that diapers for one Tennessee child for one month cost about $80, a crippling amount for struggling families 鈥� particularly those with two or more children.

Diapers are not covered by any federal assistance program, though they are a keystone for families鈥� health and financial well-being. For a parent or caregiver making minimum wage, roughly 8 percent of their income will go toward diapers. Most families who are challenged with diaper insecurity fall short by 20 diapers a month, a number that can make the difference between having a job and being unemployed.

A study by the noted an increase of $11 in personal income for every dollar鈥檚 worth of diaper aid that a family received, due to better health outcomes for babies and less time missed from parents鈥� work and school. It鈥檚 an investment that ultimately increases a state鈥檚 tax revenues as families鈥� financial picture stabilizes as they participate more fully in the workforce. The U.S. Health and Human Services鈥� , named unmet diaper need as a health equity issue. found that babies experienced 77 percent fewer days of diaper rash when funding for diapers and diapering supplies was provided.

In Tennessee, more than 300,000 of the state鈥檚 population are children under age 3 and about 49 percent live in families earning less than 200 percent of the federal poverty level (about $30,000 for a family of four). As part of its expanded services, TennCare will adjust its income threshold for pregnant women to 250 percent of the federal poverty level, making the program available to an additional 2,400 new mothers per year.

In addition to helping families afford diapers, TennCare鈥檚 additional benefits will establish continuous health coverage for children for at least their first year, regardless of changes in the parents鈥� circumstances or eligibility, helping an estimated 10,000 children remain enrolled. It will also make permanent Tennessee鈥檚 full year of postpartum coverage including dental and pharmacy benefits, which began as a pilot program in 2021, and will add lactation supports for enrollees.

鈥淲e鈥檙e able to provide all these benefits and add additional people to our TennCare program through a unique waiver that we negotiated with the federal government, TennCare III,鈥� the program鈥檚 director, Stephen Smith said in a statement. 鈥淭he concept of this waiver is that Tennessee is rewarded for its efficient management of our Medicaid program, and that reward comes in the form of shared savings. These are additional federal dollars that we can reinvest back into the program to enhance benefits and services, and serve more people to accomplish these important objectives.

鈥淎 real benefit of this approach,鈥� Smith said, 鈥渋s that we not only can provide more benefits and serve more Tennesseans, we can do it at no additional taxpayer expense.鈥�

Medicaid waivers are vehicles that states can use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children鈥檚 Health Insurance Program (CHIP). Tennessee is one of 10 states that has chosen not to expand Medicaid under the Affordable Care Act, electing to receive federal funds via a modified block grant. Under the waiver agreement negotiated with the federal government, the state will retain half of any federal savings its Medicaid program achieves. Tennessee鈥檚 waiver was approved in January 2021 and is valid for 10 years.

Tennessee received $330 million of shared savings in its first full year of the waiver, says Amy Lawrence, TennCare鈥檚 director of communications, savings that will be turned back into the Medicaid program.

TennCare recipients will not be taxed for the diapers they receive, Lawrence says. Tennessee’s tax rate on diapers is 7 percent to 10 percent depending on the locality 鈥� one of the highest rates in the country. A bill to eliminate the tax on diapers, formula and baby wipes for all Tennesseans was introduced this year but failed to make it out of committee.

Michele Johnson, executive director of the Tennessee Justice Center, said the diaper benefit is welcome as far as it goes, but it doesn鈥檛 go nearly far enough. The Nashville-based nonprofit advocates for Tennessee鈥檚 approximately 1.3 million low-income families through class-action lawsuits and works to shape public policy. Medicaid expansion has been one of the center鈥檚 key missions on behalf of the more than 300,000 uninsured Tennesseans.

鈥淲hile we are grateful for any baby step towards a healthier state,鈥� Johnson says, 鈥渢he state’s investments in minor tweaks to the TennCare program are a far cry from meeting their moral responsibilities to the people who send them to Nashville to solve problems and lead.

鈥淲e continue to be at the bottom of the nation in most every metric of health and well-being due to leadership failures. We desperately need leaders willing to set aside politics and prioritize joining the rest of the industrialized world in choosing evidenced-based approaches to sound and equitable health policy.鈥�

A spokesman for Tennessee鈥檚 House Democratic Caucus said that covering the cost of diapers and other provisions TennCare is promoting are necessary steps but, like Johnson, urged that Tennessee go farther.

鈥淲e know the need is there,鈥� said Ken Jobe, press secretary for the caucus, in an email. 鈥淭ennCare鈥檚 proposed funding numbers are encouraging. However, until the program is fully implemented, we will not know the full impact and actual number of families receiving these resources.

Myelin is the fatty insulation that protects axons, the transmission lines of the nervous system that shoot information-bearing electrical impulses to various parts of the body (which is a much-abbreviated explanation of a fantastically complex process). Myelin helps these electrical impulses to travel efficiently along the axon. This is critical for effectively transmitting information throughout the brain with exquisitely precise timing.

Babies are born with brains full of axons located right where they need to be for various functions, such as hearing, seeing and movement. White-matter pathways associated with language are also present at birth, but their myelin continues to develop for many years after birth. By examining myelin development, scientists have discovered that these neural connections don鈥檛 simply grow, they are cultivated by their environments.

Parental input has been considered a key environmental factor for infants鈥� language development, as shown by a wealth of behavioral research. But few studies have looked at how parents鈥� verbal interactions with babies affect the physical development of their brains. Given the critical growth in children鈥檚 language-related activities in their first two years of life, a better understanding of what鈥檚 going on in their brains at this time is badly needed.

Thanks to a long-term intervention study of infant language-learning, researchers at the University of Washington鈥檚听听(I-LABS) have a trove of -device home recordings of child vocalizations and parent-child verbal interactions taken at regular intervals throughout babies鈥� first 24 months.

For their recent study on the effect of language experience on white-matter development, researchers invited all the families back to the lab for an MRI session when the children were around 2 years old. The MRIs imaged the white matter in the toddlers鈥� dorsal language system, a brain network that is tied to expressive language development and long-term language ability. They found that the frequency of parents鈥� verbal interactions with their infants, specifically conversational turns, uniquely predicted myelin density in this system.

鈥淐onversational turns鈥� are the back and forth between adult and child that can occur even before the child has actual words, a call and response that speaks 鈥渃onnection鈥� in every utterance. In their study described in a published March 1 in The Journal of Neuroscience, researchers found that parent-infant conversational turns link to white-matter growth (myelination) at age 2 and suggest that early interactive language experiences uniquely contribute to brain development associated with long-term verbal and cognitive ability. The more back and forth between babies and parents, the greater the growth of the brain in areas critical to language ability and sensory-motor integration that affect the child鈥檚 ability to learn language and build vocabulary. These effects carry through early childhood and predict cognitive and linguistic ability into adolescence.

In other words, conversational turns are a very big deal, and MRIs show it.

Not Words Alone

I-LABS researcher Dr. Elizabeth Huber, the paper鈥檚 first author, says the studies establish that the growth in white matter isn鈥檛 related simply to the amount of language a child is exposed to 鈥� the number of words that wash over a child 鈥� but the amount of high-quality verbal interaction they have with the adults in their lives. The effects of these interactions were apparent as early as six months, when the child is not yet speaking but vocalizes (鈥渂abbling鈥�) and the parent vocalizes back.

鈥淐onversational experience as early as 6 months is predicting what the brain looks like at age 2 years,鈥� Huber says. 鈥淚t was striking to me how early and potentially long-lasting these effects are.鈥�

It is impossible to overestimate the importance of those early years. White-matter pathways develop at their most dramatic rate during these years, though they continue to develop through adolescence. Language exposure during this window has been linked not only to vocabulary building but to multiple aspects of children鈥檚 cognitive development. Being exposed to conversational contingency 鈥� meaning interactions that acknowledge each other鈥檚 presence and take note of what鈥檚 happening in their shared physical environment (Do you see that kitty? How does a kitty go?) 鈥� encourages shared and sustained attention. If the adult is focusing on something and draws the child鈥檚 attention to it, the child is then able to focus on that thing distinct from everything else in the environment. Maybe not for long, but conversational contingency builds the muscle.

Conversational turns have been shown to stimulate more and higher-quality vocalizations from infants, including making sounds that are more consistent with the speech sounds and patterns of the adults around them (phonology). If you keep sharing conversational turns with your child in your Deep South accent, it鈥檚 a fair bet that their baby talk will have a drawl.

Through this conversational give and take, babies learn to listen and adjust their vocalizations in response to another person, a critical ability in all human interactions.

So Much More to Learn

Huber stresses that this research really has just begun. The current study was limited to native English speakers and families without known risk factors such as lower social economic status or a family history of dyslexia. The sample size was relatively small, and future work will look at larger and more diverse samples, including a larger control group of families that didn鈥檛 take part in an enriched language intervention.

鈥淩ight now, we鈥檙e really excited about the idea of adding brain scans with 6-month-old, or even younger, infants,鈥� Huber says. 鈥淐an we already see these effects (on white matter) at a much younger age? Or is there something special about what鈥檚 happening in the brain around 2 years, as toddlers are starting to really use language to communicate in a more sophisticated way? Are there incremental changes in the white matter that connect to what an infant is currently experiencing, or do environmental effects show up at certain points in development more strongly than others? What we see right now is that conversational turns in infancy predict white-matter density in the 2-year-old, but that raises a lot of follow-up questions.鈥�

Another area that鈥檚 ripe for research, Huber says, is looking at the effects of environmental factors such as poverty or trauma, which can interrupt the brain鈥檚 development, and potential ways to mitigate that interruption. The human brain is incredibly flexible, she says, and if there is some kind of a deficiency, researchers wonder if there are ways that deficiency can be mitigated.

It’s important to avoid thinking that all is lost if a child isn鈥檛 exposed to rich conversational interactions in their earliest years, Huber says. People working two jobs and giving their all to keep a roof over their heads and food on the table might not have as much time as they鈥檇 like to spend with their children.

鈥淭he rich early experience seems to be really important,鈥� she says. 鈥淭here are moments in development where we鈥檙e particularly sensitive to certain aspects of our environments, and where it鈥檚 easier to learn certain skills. So, for example, it鈥檚 harder to master a second language if you didn鈥檛 hear it or have some exposure as a very young child. I studied Spanish for years in college, but I speak it with a heavy Kansas accent, and I have to stop and search for words.

鈥淎t the same time, it isn鈥檛 as simple as saying, 鈥業f you have this amount or type of interaction at this exact age, you will excel in learning language, and otherwise you won鈥檛.鈥� Children learn in different ways, and there is still lots of flexibility to learn and adapt, even later in life.

鈥淯ltimately though,鈥� Huber adds, 鈥渋t鈥檚 exciting to me to think that we are starting to understand more about what matters for different aspects language development. If we can help parents and children so that a given child is coming into school on strong footing, that can make a difference for a child鈥檚 whole life going forward.鈥�

鈥淚t鈥檚 hard for parents to know who to trust these days,鈥� says Dr. Nia Heard-Garris, attending physician at the Lurie Children鈥檚 Hospital of Chicago. 鈥淵ou google cold symptoms, and it鈥檒l say that you have cancer. It can be hard to distinguish what information sources are legit and whether the sources you find know what they鈥檙e talking about.

鈥淔irst-time parents are often so intimidated,鈥� says Heard-Garris, who was one of the video series鈥� creators and part of a team of pediatricians, public health specialists, consultants and child development specialists who spent the much of the pandemic lockdown meticulously crafting the content for these seven minutes of reassurance. 鈥淗aving a baby is a lot to go through. I can鈥檛 tell you the number of parents I鈥檝e had in my office crying because they knew they couldn鈥檛 do it right.鈥�

In any medical practice, time is of the essence, and in pediatric practice especially there鈥檚 a lot to pack in as the clock is ticking. Dr. Carrie Quinn, executive director of the Mount Sinai Parenting Center, says the challenges are twofold:听Providers don鈥檛 have enough time in primary care to deliver all the information parents need or want, and providers are trained with a focus on illness and treatment. Questions about parenting and how parenting behaviors can shape a child鈥檚 success in relationships and school can affect their mental health, and even physical health and well-being are not always a priority.

鈥淭he science is exploding in the area of early childhood development and how the first few years of life are so important in building a strong foundation for the future,鈥� Quinn says.听鈥淎s health care professionals, we have an incredible opportunity as we are in front of parents from the moment they become a parent. And we have countless touchpoints with families in the months and years that follow. These are all opportunities for us to support parents, help them be the parent they want to be, and to give their child the best start in life.鈥�

The Sparks video series accomplishes the feat of making certain the family鈥檚 medical needs and milestones are met during well-baby visits while also providing the all-important guidance parents seek.

Designed with Parents in Mind

With input the team solicited from experts across the country, the videos blend information on social, emotional and cognitive development with such topics as sleep, safety, nutrition and medical concerns. Parent focus groups guided the creators to design messages in the language and framing that would resonate best. Each video is available in Spanish and English, and the series features an important diversity of families and speakers.

鈥淚n selecting the parents to appear in the videos, [we sought] a wide variety,鈥� says Kathy Kinsner, senior manager of parent resources at Zero to Three. 鈥淲e have same-sex couples, older couples, people who are first-time parents, and a wide range of ethnicities. It鈥檚 not a scholarly lecture, but rather, normal parents asking normal things, showing that there鈥檚 not just one approach, but many paths to the same parenting goal.鈥�

In accompanying the child鈥檚 progress at regular intervals, the videos help shape the mothers鈥� and fathers鈥� evolution into parenthood. Few people in our society have much experience with small children when they start their journey with a newborn, Kinsner says. Moms and dads transform in remarkable ways into this being called 鈥渁 parent,鈥� and the videos foster that process.

鈥淜ids evolve day to day,鈥� she says, 鈥渁nd just when you think you鈥檝e mastered infancy, suddenly you have a toddler on your hands. And that evolution goes on for the next 18 years. So having the videos there, step by step, keeps delivering the message, 鈥榊ou can do this. You can do this.鈥欌��

The series also provides a welcome alternative to the way pediatric practices once approached advice on parenting. Whatever vestiges of 鈥渕y way or the highway鈥� might linger from a more hierarchical, paternalistic past are dispelled with Mount Sinai鈥檚 approach generally; this series embraces equity and trusts parents to know their own culture and mores.

鈥淭oo often in history, families have been told that there is one, defined 鈥榬ight way鈥� of being a parent. We say now that great parenting can look very different from family to family and from culture to culture,鈥� says Rebecca Parlakian, senior director of programs at Zero to Three. 鈥淔or instance, in the section on dual-language learning, families talk about how they approach introducing two languages to their children 鈥� in very different ways. We鈥檝e worked to show that there are lots of healthy, loving approaches 鈥� healthy and loving being the secret sauce 鈥� to achieving the same goal.鈥�

Just as recent science has demonstrated the powerful impact negative early experiences can have on children鈥檚 physical and emotional health, it has also shown that positive parenting can buffer these adverse events. A guiding principle at Mount Sinai Parenting Center is to maximize any opportunity to promote strong parent-child relationships during routine care, to fold coaching and information naturally into every occasion parents have to interact in a pediatric environment. (ELN recently wrote about Mount Sinai鈥檚 Parenting Center鈥檚 groundbreaking environmental transformation partnership with the Bezos Family Foundation, Vroom and Mind in the Making.) Its first major initiative, , was an online, self-directed curriculum for residents designed to model ways do just that. From an initial pilot with eight pediatric residencies in 2018, the curriculum has flourished to the degree that it is now used by 82 percent of pediatric residency training programs and 18 percent of family medical residency training programs in the U.S.

Building Residents鈥� Knowledge Base

The video series will also extend the parenting message to pediatric residents, many of whom have never been parents before.

鈥淲e see this as a really important tool for educating residents,鈥� Parlakian says. 鈥淲e intentionally elevated parents鈥� voices in these videos equivalently to those of the pediatricians鈥� voices because surveys of parents show that while they trust and appreciate information from professionals, they also put a lot of stock and trust in other parents.

鈥淭hese parent voices and the tactical strategies we鈥檙e offering parents in these videos can spark learning in the residents as well,鈥� she says. 鈥淢ost pediatricians recognize that it鈥檚 essential to build relationships with parents, but sometimes it鈥檚 hard to know what to say and how to frame the issues in ways that will resonate with parents.鈥�

User guides offer a set of discussion questions to help residents deepen their understanding and ability to apply the concepts to their work with families, with prompts including, 鈥淲hat struck you in the video? Are you seeing any of these things in your child?鈥� as well as encouraging the residents to talk with the parent about their struggles and achievements.

The video series is flexible to any health care setting and will be offered free to anyone who is interested. Video is a familiar format that doesn鈥檛 require a particular literacy level, which makes the information widely accessible. Rather than hand a parent a three-page article on behavioral issues, for example, parents can watch videos of other parents discussing how they approached these challenges.

The user guides for providers offer various scenarios for how clinics can make use of the series. Pediatric practices can make it easy for parents to watch the videos 鈥� available via web, text or app 鈥� prior to their well-child visits, in the waiting room or while waiting in the exam room before a visit.

Having acquainted themselves with the videos can prepare the providers for any unanswered questions the parents have 鈥� or just normalize for them the fact that new parents have a lot of questions, and that any question is a good one.

One of the video series鈥� key purposes, says Dr. Lisa Satlin, chair of the pediatrics department at Mount Sinai鈥檚 Icahn School of Medicine, is to create partnership among the providers and parents, and to provide a real-life education for all parties.

鈥淭he ready access of information from professionals and other parents that the series provides promises to build the strong parent-child relationships critical for a听child’s physical, mental and emotional development,鈥� she says.

The series saw a soft launch in the fall and will be widely released and promoted this spring. Dr. Heard-Garris predicts it will be a huge hit for providers, residents and especially for parents. 听

鈥淣ever in my years of working at any pediatric institution has there been such extensive guidance for parents on how to navigate these first five years of their child鈥檚 life.鈥�

Both research teams used the nonprofit LENA鈥檚 to glean their findings. The wearable device delivers detailed information on what children hear throughout the day. It measures the number of words spoken near the child in addition to the child鈥檚 own language-related vocalizations.

It also counts child-adult interactions, called 鈥渃onversational turns,鈥� which both research groups say are critical to language acquisition.

鈥淚t is the conversational turns that drive brain development,鈥� said Brown鈥檚 Sean Deoni, adding he鈥檚 concerned for the long-term success of children born after the pandemic began. 

The joint finding is the latest of discovered when researchers compared babies born before and after COVID. 

Deoni is principal investigator at Brown鈥檚 Advanced Baby Imaging Lab. He and other staffers there first spotted the problem when they noticed that children who visited the lab after March 2020 took longer to complete cognitive tasks.

鈥淭hey were not as attentive, or at least not performing as well as we normally have seen,鈥� Deoni said. It was this change that prompted him to take a new look at various data points gathered from the nearly 800 children his facility has worked with in recent years. After examining their neuroimaging and neurocognitive results, he and his team found child motor and language scores decreased sharply in 2021 and 2022, prompting them to search for an explanation for the decline.

The inquiry led them to analyze information gathered from children ages 12 and 16 months who were born before 2019 鈥� well before the COVID outbreak 鈥� and after July 2020, months into its spread. The results showed a major drop in verbal functioning between the two groups. Those born after COVID demonstrated slower verbal growth over time.

Tests showed, too, these babies experienced a significantly slower rate of white matter听development versus the children from studies done before the pandemic.

鈥淲hite matter is basically the wiring of the brain,鈥� Deoni said. 鈥淚t鈥檚 what carries information throughout the brain and to different cortical regions where it is processed. White matter damage, for example, is a hallmark of multiple sclerosis. Reduced white matter development is associated with reduced cognitive development.鈥�

Deoni and his team also found a significant drop in adult words per hour and conversational turns between the two groups of children. The deficit will have a significant impact on kids he said, citing his own group鈥檚 earlier research. 

Neither research team focused on the cause of the drop in caregiver interactions with babies, only the outcome, though Deoni cited the heightened stress, depression and burnout associated with the pandemic as possible explanations. 

Jill Gilkerson, a linguist specializing in early language acquisition and LENA鈥檚 chief research and evaluation officer, said the reasons might differ from one household to the next. 

鈥淚 don鈥檛 think we are going to be able to find a single cause to point to, and I鈥檓 not sure that we need to,鈥� she said. 鈥淲e hope this data validates concerns caregivers may be having, helps them know they are not alone in those feelings and furthers the conversation about the need to invest in support for families at every level.鈥�

LENA鈥檚 study showed child vocalizations dropped significantly across all groups of children, but particularly among those from the lowest socioeconomic level. The frequency of caregiver/child conversations also decreased dramatically, particularly among children from the poorest families, it found.

鈥淚t鈥檚 often the case that when these adverse events happen, it鈥檚 those who are already the most vulnerable that are hit the hardest鈥� and I think that we are seeing this here,鈥� Gilkerson said.

The connection between economic security and language acquisition was very much a pre-pandemic concern as well. A found that children growing up in low-income households hear 30 million fewer words than their peers from high-income backgrounds. A 2018 study raised questions about the extent of the gap, but the science is clear that children鈥檚 first three years are the most critical time for brain development.

LENA, based in Boulder, Colorado and founded in 2004, aims to improve children鈥檚 futures through early talk technology and data-driven programs. Its software measures a child鈥檚 language environment and provides feedback to parents and professionals vested in preparing them for school.

Its study of 136 COVID-era babies included only those who started gestating on or after the start of the pandemic in mid-March 2020: All were born after December 15 of that year. The findings from this group were compared to a pre-COVID pool, which captured recordings between 2017 and March 2020 and included 494 kids.

These language deficits, once shared with caregivers, are possible to correct. But, Gilkerson said, it鈥檚 important for groups like hers to suggest practical, easily applicable solutions.

鈥淲e need to 鈥� provide parents with strategies for integrating talk 鈥� interactive talk, quality talk 鈥� with their children during their regular routine,鈥� she said, rather than add a new task to their already stress-filled lives.

LENA鈥檚 latest research builds off earlier findings the group published in the journal in October 2018: That study showed early talk and interaction, particularly for children ages 18 to 24 months, can predict school-age language and cognitive outcomes. In that paper, LENA examined day-long audio recordings for 146 infants and toddlers completed monthly for six months.

LENA鈥檚 Language Environment Analysis software measured the total number of adult words and adult-child conversations. LENA conducted follow-up evaluations at 9 to 14 years of age. It concluded that adult-child conversations influence a child鈥檚 IQ, verbal comprehension and vocabulary scores 10 years later.

And while it鈥檚 true, both researchers acknowledged, that children are resilient, recent data does not yet reflect the bounceback from the pandemic.

鈥淲e are not seeing them hit a floor and all progressively get better,鈥� Deoni said. 鈥淲e are seeing them continue this downward trend.鈥�

And it鈥檚 not just a language acquisition problem. Reduced verbal development is being driven by poor motor development, Deoni said: This early foundational skill could have a lasting impact on children, one that can be hard to correct for as they age.

鈥淚鈥檓 worried about how we set things up going forward such that our early childhood teachers and early childhood interventionalists are prepared for what is potentially a set of children who maybe aren鈥檛 performing as we expect them to,鈥� he said.

Although it鈥檚 been a while for anyone reading this article, try to imagine all that it takes to go from being an infant lying on a blanket to being a little human who can flip over, rock back and forth, engage your core, take off and crawl to that dog bowl that鈥檚 just out of reach. Then to pull up, stand and finally take those first wobbly steps? What an astonishing achievement.

Those first steps are more often the side-to-side lurch best known to drunken sailors and adults navigating icy patches, but with practice, babies鈥� movement becomes more efficient and coordinated. They鈥檙e able to cover some ground; over time, they learn to navigate their environment in ways mere crawlers could never imagine. Today the dog dish, tomorrow the world!

Though a long-standing body of research and caregivers鈥� empirical observation shows that infants鈥� walking skill improves with time spent walking, researchers with New York University鈥檚 wanted to learn more about the factors that influence the development of walking skill.

They found that, even though the amount of time elapsed since a baby begins walking is a strong predictor of their skill at walking, other factors also affect how quickly infants progress in their mastery. One of the more eye-opening findings is the difference made by the amount of space a baby has for practice.

Imagine trying to learn complicated dance moves on a disco floor crowded with revelers and you鈥檒l get some sense of the challenges for a baby staggering into their first attempts to get from Point A to B.

鈥淚f an infant learning to walk doesn鈥檛 have the physical space to practice, whether it鈥檚 a crowded home or their day care, that can affect how quickly they develop their walking skills,鈥� says New York University doctoral candidate Christina Hospodar, lead author of 鈥淧ractice and Proficiency: Factors that Facilitate Infant Walking Skill.鈥� 鈥淥f the factors we tested, it was one of the most robust and relevant factors contributing to an infant鈥檚 walking skill.鈥� Adjusting for all other factors, more crowded homes predicted shorter steps and wider step widths 鈥� which indicate less mature walking. More space meant the longer, narrower steps associated with being an experienced walker.

The study compared two different groups of infants from the greater New York City area. All the infants were healthy and born at term with roughly half born at Langone Health Center and half at Bellevue Hospital. Babies in the study were from 13 to 19 months old.

Caregivers brought their infants to the lab where they played for 20 minutes, then walked on a sensor-rich, pressure-sensitive that allowed researchers to track the timing and location of their steps. Step width, length and speed are traditional indicators of walking skill, Hospodar says, so these were measured along with the percentage of the session the infant spent walking, how many steps they took per walking minute, and the percentage of walking bouts that were 3 steps or less. Along with these data and basic demographic information, including the number of rooms in their homes and the number of adults and children living there, parents reported when their baby had started walking. Walking onset was defined as the first day caregivers saw their babies walk three meters across a room without holding onto anything, stopping or falling.

In what they believe is the first study to locate any factor aside from months walking that strongly predicts walking skill, the researchers found that each additional person per room decreased the baby鈥檚 walking skill by approximately one month of walking. Co-authors of the paper are post-doctoral fellow Justine E. Hoch, Do Kyeong Lee, Patrick E. Shrout and Dr. Karen E. Adolph, NYU鈥檚 Julius Silver Professor of Psychology and Neural Science. The researchers measured children鈥檚 race, ethnicity, the family鈥檚 primary language and caregivers鈥� education, but these sociodemographic factors didn鈥檛 hold statistical value, Hospodar says.

Ultimately, crowded environments had more bearing than other factors in the babies鈥� development of walking skills. The U.S. Census classifies homes as 鈥渃rowded鈥� if they contain more than one person per room. By that definition, she says, all the homes of Bellevue infants and half of the Langone infants would be classified as crowded. Previous studies found a reduction in gross motor skills among infants in crowded homes. In a different research group鈥檚 study of infant activity recruited from the same population as the Bellevue sample, only half of mothers gave their infants daily 鈥渢ummy time,鈥� essential to strengthening the child鈥檚 core muscles (again with the core!), only 34% placed their pre-walking babies on the floor and 57% reported that their babies were constrained for more than one hour a day, spending their time in equipment such as high chairs, car seats and playpens. Nearly half reported they were concerned about giving their babies unrestrained access to the floor because they feared possible injury due to the presence of other children, pets or vermin. That reluctance, Hospodar says, may be a logical explanation for why the Bellevue babies in the recent study would have a later onset age for walking.

Even within the parameters of living space, she says, individual babies respond to the challenge of walking in different ways; some choose to really go for it while others hang back. The researchers found that the babies鈥� weight and height did not predict their walking skill, though some studies have found that heavier babies tend to crawl and walk somewhat later than others. In other studies, factors such as race, ethnicity and socioeconomic status have been found to affect infants鈥� age to start walking because they鈥檙e associated with caregiving practices, such as keeping babies cradle-bound for most of their early infancy. In cultures that endorse rigorous handling and deliberate exercise, babies begin walking several weeks to months earlier than cultures without such practices, researchers say.

The transition from crawling to walking allows the infant to go farther, faster and expands their vantage point from the floor below them to the room around them, which provides endless opportunities to play and learn. The good news is that babies who鈥檝e gotten a later start tend to catch up, though Hospodar says the research on long-term consequences is limited.

鈥淧arents really shouldn鈥檛 get hung up on the exact age their babies start walking,鈥� she says. 鈥淚n terms of U.S. norms, typically if a baby isn鈥檛 walking by 16 months the pediatrician would be on alert 鈥� and that might just mean they need some physical therapy or early intervention services. The fact that a baby is late to start walking doesn鈥檛 necessarily mean they鈥檙e disadvantaged. There may be other factors that we didn鈥檛 study or measure, and there will always be trade-offs.

鈥淚f an infant isn鈥檛 walking yet,鈥� she says, 鈥渕aybe they鈥檙e working on other developmental skills and may be more cognitively developed than younger infants.鈥�

Whenever they get started, once babies have the distinction of 鈥渨alking,鈥� they鈥檙e off to the races. Just make sure they have some room to roam.

鈥淏abies have physics on their side,鈥� researcher Danyang Han says with a laugh. Han鈥檚 recent paper, 鈥�,鈥� coauthored with Dr. Karen Adolph, looks at the role of babies鈥� missteps as they learn to walk. The researchers hypothesized that understanding babies鈥� falling could provide a window into the role that errors play in how babies acquire basic skills 鈥� useful information not only for researchers wanting to know more about babies, but for scientists and engineers looking for the best way to approach machine learning and artificial intelligence.

鈥淏abies natural way of falling protects them from serious injuries. Their bodies are close to the ground; they鈥檙e moving slowly and they鈥檙e very light weight,鈥� Han says. 鈥淪o, they don鈥檛 hit the ground very hard 鈥� and when they do, their bodies are 30% baby fat, and their bones are really strong. If an adult had 30% body fat, that would be obesity, but for babies, that鈥檚 padding.鈥�

Like junior judo masters, babies naturally engage in the art of ukemi, breaking falls by absorbing the impact throughout the body. Babies automatically engage in a suite of reactive behaviors when they begin to fall 鈥� taking small steps to regain balance, grabbing for any nearby support to slow down the speed of the fall, bending their knees and reaching out with their hands to break the fall or landing on their bottoms if they鈥檙e falling backward. Nobody teaches them this and they don鈥檛 have to think about it. When they first start walking, and therefore falling, that knowledge is instantly present.

The same physics that render babies鈥� falls inconsequential are precisely those that can make falls so devastating for older people who take a spill. Elderly people are not so low to the ground; they have greater body mass, their bones are brittle and when they reach out to break their fall, it鈥檚 frequently their wrists or hips that break instead.

In fact, it was a fellow researcher鈥檚 documentation of elderly people鈥檚 falls that led Adolph to consider much more detailed data on infants鈥� falling. NYU鈥檚 Julius Silver Professor of Psychology and Neural Science, Adolph has studied infants鈥� movement for 30 years. She had always made note of falls as part of her apparatus and walking studies. When Canadian researcher Dr. Stephen Robinovitch, a world expert on falls among the elderly, spent a sabbatical in her lab and she saw the massive amount of data he had collected from falls in hundreds of older people in nursing homes, she realized that she already had a trove of data that could be analyzed to deepen researchers鈥� understanding of babies鈥� falls.

Deploying the tools of NYU鈥檚 high-tech Infant Action Lab, Adolph began to take a deeper dive into every aspect of infants鈥� falling. For the study for that formed the basis for Han and Adolph鈥檚 鈥淔all Like a Baby鈥� paper, 138 families recruited from the New York City area brought their walking infants aged 13, 15 and 19 months to the lab, where they were observed for 20 minutes of spontaneous activity in a large playroom. (Details of the study can be found in Han鈥檚 and Adolph鈥檚 , which is available to the public.) None of the falls in the laboratory resulted in injury and severity was gauged by whether infants fussed, whether caregivers showed concern, and how long it took infants to recover and return to play. Researchers recorded 563 spontaneous falls during the course of the study. The babies fussed only 4.26% of the time, and caregivers expressed concern in only 7.64% of the babies falls.

鈥淎 lot of the parents鈥� language was about encouragement,鈥� Han says. 鈥溾�橸ou鈥檙e fine. It鈥檚 fine. There鈥檚 a ball, can you go get the ball?鈥� And a lot of it was advice, 鈥極ops. You fell. You gotta be careful with those stairs, love.鈥� But mostly, the babies just fell and got back up again.鈥�

An undeniably adorable of this persistence can be found in the study鈥檚 video, 鈥�15 Falls with the Stroller,鈥� which can be viewed on the NYU Databrary site. In it, a toddler is pushing a pink doll stroller. She falls, she gets up, she falls, she gets up, she falls, she gets up 鈥� 15 times in 20 minutes. Even when she falls and bumps her head, she fusses briefly, is comforted by her mom and then within seconds, enough of that and she鈥檚 back to that pink stroller. This little person is totally goal oriented and in it for the locomotion.

And mostly, that鈥檚 how falling is for babies. It鈥檚 trivial.

However, Adolph stresses, falling itself isn鈥檛 trivial for babies. In fact, it鈥檚 a leading cause of accidental injury and death in little babies.

鈥淭hat鈥檚 why you have to keep your windows shut and block the stairs when they鈥檙e learning to crawl and walk,鈥� she says. 鈥淭hey don鈥檛 understand what a bad fall can be.鈥�

What babies don鈥檛 do is stop and consider that they just fell and maybe they鈥檇 better not try that again. Because the consequence of their falls is no big deal, they don鈥檛 even pause. Even babies whose parents reported significant falls before the study showed no inhibition about just going for it 鈥� toddle, toddle, tumble, toddle. Language learning in infants is the same process, Adolph says. Making 鈥渕istakes鈥� while they鈥檙e learning to talk doesn鈥檛 even slow them down, as anyone within earshot of a babbling 1-year-old can attest.

Based on their research, Han and Adolph assert that babies learn basic skills like walking and talking by relying primarily on positive feedback when they accomplish their goals and discounting errors so that mistakes barely figure into the equation. What they don鈥檛 say is that all learning takes place this way. As we get older and our body of knowledge and needed skills become more complex and challenging, our errors are more costly and have more impact. 鈥淥h well,鈥� is not an adequate response to mistakes made learning to drive a car or climb a mountain.

But from a systems standpoint, the model of baby learning might offer an alternative to the reinforcement learning model for decision-making, which Microsoft describes, in part, as 鈥渁lgorithms and systems for technology that learns from its own successes (and failures).鈥� If machine learning were to follow a model truly patterned after human learning, the model would be heavily weighted toward positive rewards and negative feedback would be inconsequential. Researchers in Adolph鈥檚 lab have run such a study with simulated robots and found that with machine learning as with infant learning, no penalty for mistakes is the best approach for getting flexible, generative learning and building more capacity to transfer learning to new situations.

The NYU researchers are now collaborating with a group of computer scientists and robotics engineers at Oregon State University on a project inspired by their work on infant falling. The reinforcement learning model that penalizes errors is ubiquitous in machine learning and artificial intelligence (AI), so the no-harm, no-foul model of the Infant Action Lab researchers might encounter resistance. But one of these days, who knows? Maybe robots and AI of the future will learn to fail like a baby.

The capacity to synchronize movement with another human is central to social interaction. When children jump rope, when one player passes and the other blocks, or when partners grab hands for the next round of West Coast swing, all those actions involve the ability to move in relation to one another.

Scientists have studied this 鈥渂ehavioral synchrony鈥� primarily during stationary, face-to-face interactions between infants and adults, observing the matchup between facial expressions and vocalizations that make up the social dance between baby and caregiver. Drs. Justine Hoch and Ori Ossmy, postdoctoral fellows with New York University鈥檚 department of psychology, and Dr. Karen E. Adoph, NYU professor of psychology and neural science, wondered if that dance continues once the infants have begun to find their own way around the dance floor.

To find out, they set up a large playroom in their laboratory outfitted with toys, risers, slides with stairs and platforms, and observed 30 pairs of infants aged 13 months to 19 months and their mothers for 20 minutes. The mothers were instructed to play with their children as they normally would in their homes. From the moms鈥� and toddlers鈥� perspective, it was a fairly low-tech challenge. The children didn鈥檛 have to wear any monitoring devices and the mothers didn鈥檛 have to keep track of anything except keeping baby from doing a faceplant off the little slide. Behind the scenes, however, was whirring along.

Using wall-mounted and hand-held video cameras, researchers tracked mothers鈥� and babies鈥� even-miniscule movements, which were then analyzed by cutting-edge recording technology and machine-learning. The lab is among the first to document in this ultra-high-tech way what babies see, hear and do in their everyday lives, and how the input changes when infants acquire new knowledge and skills as they develop.

The lab developed , a free, open-source coding tool, to powerfully annotate this video data and founded听听a secure web-based video library, now available for other scientists to use in their research on human movement.

What the researchers discovered in the mother-child synchrony study was the mother-child dyads do engage in a coordinated, related way as they moved through the playroom, though not all synchronize in the same way.

鈥淚n this lab playground environment with things to climb on and things babies maybe could fall off of, we found that moms and babies synchronize their locomotor activity,鈥� Hoch says. 鈥淢ore interesting is that we found two distinct groups that accomplished that synchrony differently. One group had a leader-follower dynamic and the other had a dynamic where both the baby and the mother went away and then came back to their partner.鈥�

The mothers and babies didn鈥檛 mirror each other鈥檚 movements, but their locomotion was coordinated and correlated, indicating that they scaled their movements to each other. Patterns of locomotion differed among the mother-child duets with about half the moms keeping pace with their infants and following whenever the child veered in a certain direction (see 鈥渇aceplant鈥� above). The other half of mom and baby duos 鈥測o-yoed鈥� to and from each other, with the infants doing most of the back-and-forth, often in an attempt to get Mama鈥檚 attention or just to touch base for a little dollop of social interaction. And then off they would go again.

Differences in how much the children moved and the ground they covered were not influenced by differences in age, experience or walking skills. Predictably, the babies moved much more than the mothers did and covered more ground relative to their size, with moms able to cover the territory they just galloped over with three big steps to their 30. (Some of the lab鈥檚 earlier research found that the average toddler clocks more than two and a half miles a day.)

鈥淚n general, mothers move about a third as much as their babies do,鈥� Hoch says, 鈥渂ut how much they move is correlated with their babies鈥� movement. The best predictor of how much moms move is how much their babies move.鈥� Baby leads, Mama follows, moving in close when they climb too high or get too close to edges. In turn, mothers sometimes take the lead in ways that expand the child鈥檚 horizons鈥攅ncouraging them to take a look at this or that thing just out of their reach. 鈥淲hat鈥檚 over here?鈥� 鈥淟ook at this!鈥�

In addition to supporting the theory that mothers and babies synchronize their movements, this and related studies provide a few other important takeaways, the researchers say. One is that toddlers don鈥檛 need a destination to get in motion: They just move to be moving.

鈥淲e have found that a lot of our 鈥榗ommonsense鈥� assumptions are just wrong,鈥� Adolph says. 鈥淟ike everyone else, we thought, 鈥榃ell, babies move for the same reason we do. To get to a destination. And, of course, they can. But if you put toys or snacks on the floor, about half the time, they鈥檒l just walk to the other end of the room.鈥�

Another takeaway from observing the babies is how they play with different types of toys. 鈥淲hen the babies have things like a stroller or balls, a broom and rolling carts, not having their mom right there isn鈥檛 a big deal,鈥� Adolph says. 鈥淏ut when the toys are manipulative, like shape sorters or a Pop-Up Pal, the babies just carry them around. When the caregivers come play with them, it depresses locomotor activity and boosts manual play.

鈥淭hat鈥檚 how caregivers play with little babies. They don鈥檛 do a lot of, 鈥楲et鈥檚 run, run, run. Chase me!鈥� stuff. They鈥檙e more like, 鈥榃hat鈥檚 this? Look at this thing? What鈥檚 this called? Let鈥檚 put that shape here 鈥︹�� Which is what you want if you want your child to learn manual and fine motor skills. Babies are going to learn how to run and walk and explore the larger environment without their caregiver. But to learn the toys requiring fine motor skills, they need a knowledgeable adult with them to help them discover what to do.鈥�

Another important takeaway, Adolph says, is how adept babies are at making their own fun. Left to their own devices with just about anything they can manipulate with their hands 鈥� a building block, a crumpled piece of paper, the dog food bowl 鈥� they鈥檙e going to have fun with it whether it comes with a 鈥淢ade for Babies鈥� label or not. (This information should gladden the heart of anyone working on a holiday gift list for the 3-and-under set: Get them a set of plastic measuring cups and some nesting mixing bowls and don鈥檛 go crazy with trending toys from big name brands.)

Their paper, 鈥淒ancing鈥� Together: Infant-Mother Locomotor Synchrony,鈥� proposes that both the face-to-face and locomotor synchrony that researchers have observed serve a similar function in the child鈥檚 development. They create a pathway 鈥� a scaffold 鈥� to the child鈥檚 interactions with the outside world. In coordinating face-to-face with mother or other caring adults, babies learn social skills, how to coordinate their attention with another human, how to interact with objects 鈥� how to be social beings in the complex world they now inhabit. And once they get their walking papers, whole new realms open. With Mother鈥檚 support and synchrony, they can move beyond the blanket and start investigating boundaries.

The work being done at the Infant Action Lab shines a bright light on the mother-baby social dance that gives infants what they need to make their way in the big, wide world.