Priority: Foster healthy nutrition and physical activity through equitable system and policy improvements 

 

Objective 1 (NPM 4). By 2025, increase the percent of infants who are ever breastfed from 84.3% (2016 NIS) to 86% and the percent of infants who are breastfed exclusively through 6 months from 23.2% (2016 NIS) to 25%. 

Breastfeeding confers long-lasting benefits to both infants and mothers. It is associated with improved maternal-infant bonding and maternal mental health, and reductions in obesity and type 2 diabetes in children and gestational diabetes in mothers in subsequent pregnancies. The performance measure for this priority, NPM 4, reflects efforts to improve environments, systems, and policies that promote breastfeeding initiation and exclusivity to foster healthy nutrition beginning in infancy.   

 

In FY24 MA saw an increase in breastfeeding prevalence related to its NPM projections and the national prevalence. According to the most recent CDC National Immunization Survey results (NIS), 88.7% of MA infants born in 2021 were ever breastfed, higher than the national prevalence of 84.1%. Duration of breastfeeding in MA also trended higher than the national average among infants born in 2021, with 63.0% of infants breastfeeding at six months and 42.4% breastfeeding at 12 months, compared to 59.8% and 39.5% nationally, respectively. Exclusive breastfeeding at three months was reported among 48.3% of MA infants born in 2021 and 26.4% at 6 months, compared to 46.5% and 27.2% nationally, respectively. Although these data are used to compare breastfeeding measures with other states, it is important to note that the NIS is a retrospective survey where respondents with children aged 19-35 months are asked to recall breastfeeding information. The 2021 survey sample size was limited to 338 MA respondents and response rates from 2011-2022 ranged from 21.1% to 33.5%. 

  

MA birth certificate data reported a slight decrease in breastfeeding initiation from 2022, with 86.2% of infants breastfed during the hospital stay in 2023 vs. 88.7% in 2022. Prevalence was highest among Asian, Non-Hispanic (NH) mothers (90.0%), followed by Black, NH (88.9%), Hispanic (86.7%), White, NH (85.3%), and American Indian, NH (84.5%) mothers. Pregnancy Risk Assessment Monitoring System (PRAMS) 2023 data showed that 82.0% of mothers reported any breastfeeding for at least four weeks, and 75.0% continued breastfeeding for at least eight weeks, with some variation by race and Hispanic ethnicity. By eight weeks postpartum, the proportion of mothers reporting any breastfeeding was 71.0% for Hispanic mothers, 74.0% for White NH, and 78.0% for Black NH, compared to 84.0% for Asian NH mothers. Half of the mothers (50.0%) reported exclusive breastfeeding at four weeks and 43.0% reported exclusive breastfeeding at eight weeks.

  

WIC 

The prevalence of breastfeeding duration and exclusivity among MA WIC participants continues to be significantly lower than the overall breastfeeding prevalence in MA. WIC participants often have less access to workplace breastfeeding accommodations and return to work earlier in the postpartum period, hindering their ability to maintain breastfeeding, especially exclusive breastfeeding. The average breastfeeding prevalence at six months among MA WIC participants in FY24 was 41.4%, an increase from 40.6% in FY23, but lower than the overall MA average of 63.0%. Additionally, only 18.8% of WIC infants exclusively breastfed for three months, and 15.5% exclusively breastfed for six months, in FY24. Breastfeeding duration at six months is a key performance metric for both state and local WIC agencies. WIC is increasing its capacity to analyze its breastfeeding data by race and ethnicity to inform program activities.

   

In FY24, WIC offered virtual and in-person breastfeeding education and support to pregnant and breastfeeding participants. Breastfeeding Peer Counselors (BFPCs) were available in all 31 programs, with more than 65 peer counselors statewide. Virtual group support and education sessions were offered to participants both prenatally and postpartum to promote longer breastfeeding duration and approximately 10,600 contacts with parents were made each month. WIC is also committed to providing breastfeeding training to staff. MA WIC continues to utilize the USDA WIC Breastfeeding Curriculum for training new staff, including peer counselors. All staff have access to ongoing breastfeeding training modules through Lactation Education Resources to stay up-to-date and maintain professional credentials.    

 

Participants eligible for BFPC Program services included pregnant participants who indicated they plan to breastfeed at least partially, were unsure of their breastfeeding intention, and women who were already breastfeeding. In 2024, 74.8% of eligible WIC participants received BFPC services, approximately the same as in 2023 (74.0%), 2022 (75.0%), and 2021 (74.0%). Ongoing consultation with WIC staff about the importance of peer counseling and improvements in the documentation of peer counseling services continue to be prioritized. Eligible Spanish-speaking WIC participants had the highest prevalence of having at least one BFPC contact at 80.3%, followed by 76.6% of English-speaking participants.  Hispanic/Latinx WIC participants of any race were most likely to receive at least one BFPC service (78.0%), followed by NH participants of multiple races (76.7%) and White NH participants (72.1%).

 

Black NH WIC participants had the highest prevalence of any breastfeeding at three months postpartum (64.1%), followed by Asian NH (61.4%) and White NH WIC participants (57.5%). Hispanic/Latinx WIC participants of any race and NH participants of multiple races had similar prevalences of any breastfeeding at three months postpartum (53.5% and 55.8% respectively).   

Similar trends can be seen at six months postpartum, with 46.7% of Black NH participants reporting any breastfeeding at six months, followed by 43.0% of Asian NH participants, 40.8% of NH participants of multiple races, and 39.9% of White NH participants. Among these groups, Hispanic/Latinx participants of any race had the lowest prevalence of any breastfeeding at six months (37.2%). This prevalence was lower than the other groups compared to at three months.

White NH WIC participants had the highest prevalence of any exclusive breastfeeding at 46.0%, followed by 39.8% of NH participants of multiple races, and 32.4% of Black NH WIC participants. Of WIC participants who exclusively breastfed, Black NH participants, Hispanic/Latinx participants of any race, and Asian NH participants had similar prevalences at three months (15.8%, 15.4%, 14.9%, respectively), but lower than the prevalence among White NH participants (27.4%). At six months, Black NH participants had the lowest prevalence of exclusive breastfeeding (9.9%), then 10.4% of Asian NH participants and 11.9% of Hispanic/Latinx participants of any race. White NH participants had the highest prevalence of exclusive breastfeeding at six months (22.1%). After adjusting for race, language, maternal age, and education, WIC participants with a recorded BFPC service had 95.4% increased odds of initiating breastfeeding, compared to participants eligible for BFPC but without a service recorded.  

 

Among WIC participants who delivered an infant in 2024, participants with a BFPC service had 33.9% increased odds of any breastfeeding for six weeks, 40.5% increased odds of exclusive breastfeeding for six weeks, 34.5% increased odds of any breastfeeding for 13 weeks (3 months), and 36.6% increased odds of exclusive breastfeeding for 13 weeks, compared to WIC participants eligible for BFPC services but without one recorded. Improving the use and documentation of BFPC services remains a priority for WIC. Training WIC staff on the importance of referral and documentation of BFPC services is ongoing. WIC has increased its capacity to analyze BFPC data and will examine the impact of relationship type (e.g., text, prenatal group, in-person one-on-one) and frequency of BFPC’s contacts with the birthing parent on breastfeeding rates.   

  

Breastfeeding Initiatives 

Over the past 10 years, MA has experienced a significant number of birth hospital closures, mostly due to declining birth rates and the need for critical care due to COVID-19. In 2009, MA had 49 birthing facilities, compared to 39 in 2024. As of 2024, there were 17 Baby-Friendly hospitals in MA with approximately four more on the Baby-Friendly pathway. MDPH is actively engaged in the MA Baby-Friendly Hospital Collaborative, a working group that meets virtually bi-monthly to provide support and encouragement to birth hospital staff to improve maternity care practices related to breastfeeding. Hospitals continue to utilize the prenatal breastfeeding education videos that MDPH developed in 2022 and 2023. These videos are located on MDPH’s website and are available in Brazilian Portuguese, English, Haitian Creole, and Spanish. The education aligns with Baby-Friendly messaging and aims to prepare families with what to expect with breastfeeding in the hospital and how to access support post-discharge.

In 2024 MDPH continued to work on a statewide breastfeeding needs assessment by holding regular meetings with the internal breastfeeding workgroup. This workgroup includes staff from different divisions and bureaus that work in the perinatal health space. Activities included rolling out an Infant Feeding Survey, which was shared statewide with families in the Spring of 2024. MDPH also participated in the Community Evaluator Project through Tufts Interdisciplinary Evaluation Research (TIER). The project included recruiting families from southeastern communities in MA, which have historically had lower rates of breastfeeding than the rest of the state. In the Summer of 2024, MPDH worked with the Public Consulting Group to synthesize all input from the breastfeeding needs assessment into a report. This report is being used to facilitate the development of a statewide breastfeeding strategic plan to improve outcomes across the Commonwealth.   

  

Essentials for Childhood: Paid Family and Medical Leave   

Title V promotes Paid Family and Medical Leave (PFML), a policy effort that supports optimal health outcomes including breastfeeding. Research supports the conclusion that paid parental leave after the birth of a child improves breastfeeding initiation and duration rates, increases well-child visits and immunizations, and reduces re-hospitalization of both mother and infant.[1] 

In FY24, MDPH Title V staff in partnership with the Bureau of Family Health and Nutrition (BFHN) Essentials for Childhood staff collaborated with the Department of Family Medical Leave to promote equitable access to paid leave through outreach and awareness activities and supporting data analysis, sharing, and linkages to enable both Departments to better understand benefit utilization and the eventual impact of these benefits on health, well-being, and economic security of families, particularly families disproportionately impacted by structural inequities. Please see the Crosscutting Essentials for Childhood: Paid Family and Medical Leave domain for further details.  

 

Perinatal Neonatal Quality Improvement Network (PNQIN) 

“Eat-sleep-console” (ESC) has become an increasingly popular approach to care for infants at risk for neonatal opioid withdrawal syndrome, centered on family involvement and non-pharmacologic management. One of PNQIN’s Perinatal Opioid Project leaders, Dr. Elisha Wachman at Boston Medical Center, previously developed a robust ESC toolkit including resources for teaching and training. As more PNQIN hospitals began to explore ESC, PNQIN continued to offer support for interested teams through workshops, webinars, and training. Teams joining the PNQIN ESC effort are asked to participate in the core database and a supplemental ESC database, allowing for the collection of important data on this innovation. Many other hospitals and numerous other state collaboratives have asked to use the materials and toolkit developed by Dr. Wachman and our team, and many have joined PNQIN ESC workshops and webinars. Dr. Wachman continues to support PNQIN teams that have or are seeking to implement ESC. 

  

Pregnancy Risk Assessment Monitoring System (PRAMS) 

PRAMS continues to inform breastfeeding initiatives (see above) by collecting data on hospital practices during the delivery stay. In 2023, 46.0% of hospitals gave a gift pack with formula during the delivery stay, an increase from 42.0% in 2022 and higher than the previous high of 45.0% in 2020. Among the 2023 PRAMS respondents, 83.0% said that they breastfed as soon as possible after delivery, and 94.0% had the baby placed skin-to-skin as soon as possible after delivery. Breastfeeding support phone numbers were provided by the hospital to 87.0% of the mothers to call for breastfeeding help, 84.0% of the mothers said that hospital staff helped them learn how to breastfeed, and 91.0% said that hospital staff talked to them about how often and how long to breastfeed. MDPH shares PRAMS findings online at Pregnancy Risk Assessment Monitoring System (PRAMS) | Mass.gov, and continues to use PRAMS data to inform program development and quality improvement activities.

  

Early Intervention Parenting Partnerships Program (EIPP) 

Breastfeeding can be especially challenging for people with complex environmental, mental health, and social concerns such as homelessness, interpersonal violence, food insecurity, and postpartum depression. Exclusive breastfeeding is a key topic of discussion, education, support, and referral in EIPP. Home visitors collect data on breastfeeding at birth and six months. In FY24, of the 153 postpartum participants enrolled in EIPP, 59.5% breastfed their infant at birth, and 29.7% of these participants exclusively breastfed. At six months postpartum, 44.8% reported exclusively breastfeeding. Among the 261 EIPP participants, 59 were referred to WIC services and 3 were referred to lactation support. Key barriers to exclusive breastfeeding include personal reasons (16.4%), not enough milk (15.0%), and medical reasons (5.4%). 

EIPP staff continue to collaborate with community WIC programs, OB/GYNs, lactation consultants, and pediatricians to promote breastfeeding during the first six months through support groups, individual lactation support, and increased home visits during the first few weeks postpartum. EIPP sites bill MDPH directly for lactation consultation services. 

 

MA Maternal, Infant, and Early Childhood Home Visiting (MIECHV)  

There is considerable variation in rates of breastfeeding initiation, continuation, and exclusivity by race and ethnicity among MA MIECHV participants. Home visitors are well-positioned to support and engage parents to make informed decisions about breastfeeding and ensure families are linked to appropriate breastfeeding support systems that meet individual needs. During FY24, 34.1% of infants delivered to mothers enrolled in MA MIECHV prenatally were breastfed any amount at six months, comparable to 34.0% in FY23. Home visitors continue to provide education, brief intervention, and referrals to improve breastfeeding initiation and duration rates. MA MIECHV also continued to strengthen its partnership with WIC at the state and local levels to support cross-referrals and resource sharing among programs.

 

In FY24, MA MIECHV and WIC partnered on a project to strengthen collaboration and referrals between WIC and home visiting programs at the community level. Taking a continuous quality improvement approach, MA MIECHV and WIC reviewed referral data and engaged local implementing agencies and WIC programs with high- and low-rates of cross-referrals to identify barriers and facilitators to coordination. MA MIECHV communities of North Adams and Pittsfield were identified as communities to test potential strategies using Plan, Do, Study, Act (PDSA) cycles. MA MIECHV and WIC staff facilitated meetings with Healthy Families Massachusetts, Parents as Teachers, and two WIC providers in pilot communities to identify tests of change and monitor progress. The first PDSA cycle was initiated in March 2024 and included testing the use of QR codes to facilitate referrals to home visiting during WIC appointments. This project also aims to increase prenatal referrals to home visiting programs to better address inequities in maternal, infant, and child health outcomes.   

  

Welcome Family 

Welcome Family nurses offer breastfeeding support to new parents through education, brief intervention, and referrals to ongoing services as needed, such as breastfeeding support groups. Among the 1,712 families served by Welcome Family in FY24, 78.3% breastfed their infants all or some of the time at the time of the assessment, which occurs between two and eight weeks postpartum. This represents an increase from 70.0% in FY17. Among participants who reported breastfeeding their infants some or none of the time, the primary reasons for not exclusively breastfeeding were the mother’s belief that she does not have enough milk (40.0%), the baby was too hungry (20.0%), and the parent’s belief that the baby is weaned or had difficulty latching (17.0%). Nurses provided tailored education and support in response to these concerns. Welcome Family nurses reported that they have been able to successfully provide breastfeeding support during virtual visits as needed. There are some instances in which the nurses request to conduct a second visit with the family. Of the 18 second visit requests in FY24, 72.0% were to provide additional breastfeeding support or because of concerns about the infant’s weight.   

 

Additional activities to improve Perinatal/Infant health 

Other activities to improve infant health not specific to the performance measure are discussed below. 

Pregnancy Risk Assessment Monitoring System (PRAMS) 

PRAMS data were also used to inform Safe Sleep activities with the Injury Prevention and Control Program (see below). In 2023, 86.0% of mothers reported laying their infant to sleep in the recommended supine position, consistent with the prevalence of supine sleep in 2022 (86.0%). However, racial variations in supine sleep position remain in 2023. While the prevalence of supine sleep position increased among Black NH and Hispanic parents compared to 2022 (71.0% for both), these groups still reported the lowest prevalence of supine sleep, at 81.0% among Black NH and 75.0% among Hispanic mothers. The highest prevalence of supine sleep was reported among White NH and Asian NH mothers (93.0% and 85.0%, respectively). 

 

Injury Prevention and Control Program (IPCP) (also includes activities of the Injury Surveillance Program) 

In FY24, the IPCP analyzed statewide counts of all injury deaths (2022), hospital stays (FY22), and emergency department visits (FY22) among MA infants and children 0-17 years. The injury data counts were grouped in a matrix format across all injury causes (e.g., drowning, firearm, pedestrian) and intents (e.g., unintentional, assault, self-harm) using the CDC’s standard recommended groupings. Matrices were completed and disseminated on the Injury Surveillance Program’s (ISP) web pages for public distribution to inform advocates, practitioners, and policymakers of the magnitude of injury events among infants and children in MA. 

 

Child Fatality Review (CFR) 

IPCP is a Co-Chair of the CFR program, along with the Office of the Child Advocate, which aims to reduce the incidence of child fatalities and near fatalities. The program convenes 13 state agencies and several external organizations at the local and state levels to analyze individual deaths and trends in fatalities through a multidisciplinary approach to inform changes in practice and policy that will address behavioral risk factors and social determinants of health. Deaths are reviewed by local county-level teams that issue recommendations for members of the state-level team. The state-level team then aggregates input from across the state to develop broader recommendations for statewide changes in policy and practice. As the Co-Chair of the state team, the IPCP coordinates the team’s activities, provides technical assistance to the local teams, and sends representatives to local team meetings.  

 

In FY24, IPCP also continued to work with the ISP on the APEX database to improve data entry processes and tracking of programmatic data and reviewed cases. This will allow for more reliable sharing of recommendations and improve data quality and tracking of local team performance. In FY24, IPCP also participated in local quarterly CFR team meetings and provided data to the 2024 CFR annual report, which was voted on and approved at the CFR State Team meeting in October 2024, of which IPCP is a voting member.

 

Center for Unexpected Infant and Child Death  

The MA Center for Unexpected Infant and Child Death (The Center) provides bereavement support to individuals, families, and communities of infants and children who die suddenly and unexpectedly. The Center’s mission is based on providing individualized and compassionate responses to families and communities grieving the unanticipated death of a child. The Center supports families whose children have died of Sudden Unexpected Infant Death (SUID), motor vehicle accidents, suffocation, drowning, inflicted injury, trauma, or any other kind of unanticipated event. It also supports families who are grieving miscarriages, stillbirths, and deaths stemming from extreme prematurity or fetal demise.  
 
In FY24, the Center provided direct support to 55 bereaved families. The Center offers respectful, family-centered care and maintains a library of written resources available to families at no cost. Additionally, the Center:  

•      maintained an Annual Program Plan that covers emerging trends and data regarding child fatality, strategies for addressing family needs, and an action plan to address any barriers that may arise. 
•      facilitated an advisory board of 20 members including loss survivors, counseling professionals, funeral directors, healthcare providers, and first responders.  
•      participated in all local and statewide CFR Team meetings.  
•      hosted an annual full-day conference (Responding to SUID: Strategies for the Professional), with nearly 100 attendees from across the state. 
•      hosted an annual “Walk to Remember” to support families and communities who have been affected by infant, child, and prenatal death.  

•      published an annual “Book of Remembrance” for families to submit meaningful pictures, poems, stories, quotes, and other content in commemoration of their lost loved one. 
•      Launched a no-cost commemorative stained-glass virtual butterfly garden, in which families can design and receive up to two butterflies in honor of their deceased child and send photos to The Center to be added to an online gallery. This is in partnership with a professional stained-glass artist.

  

Birth Defects Monitoring Program (BDMP)  

BDMP has consistently met the highest data quality standards for the National Birth Defects Prevention Network since 2014. In FY24, BDMP data were completed and available through 2021 and integrated into other data systems including the Pregnancy to Early Life Longitudinal data system, the Environmental Public Health Tracking portal, and the Population Health Information Tool. Prenatal reporting, which was integrated into BDMP in 2011, substantially enhances its multi-source approach and improves the accuracy and completeness of case ascertainment. Additionally, prenatal reporting serves as a valuable tool for surveillance of emerging threats to pregnant women and infants, as evidenced during the Zika virus epidemic and the COVID-19 pandemic. 

 

Critical Congenital Heart Defects in MA continued to be monitored in FY24 by classifying and categorizing them by the time of diagnosis (prenatal vs. postnatal) and procedures with which they were confirmed. Several BDMP surveillance staff were also co-authors on a paper published in February of 2024 titled “Expanding the Massachusetts Birth Defects Monitoring Program to include additional pregnancy outcomes: Programmatic efforts and impacts on case ascertainment, 2012–2020.” In FY24, the program also worked towards producing another Birth Defects Surveillance Report focusing on the prevalence of birth defects in MA for 2019-2021 deliveries. In June 2024, three special projects were initiated. Two focused on performing an environmental scan of birthing facilities across MA to assess current practices implemented after families experience a stillbirth or infant death to better understand guidelines and supports offered to birthing people and their families. Finally, BDMP has obtained electronic remote access to medical records at 92.0% of hospitals. This expansion was accelerated during the COVID-19 pandemic and the restrictions imposed on abstractors’ hospital visits. Electronic remote access allows for rapid review of medical records, which benefits all case abstraction.   

 

Neonatal Abstinence Syndrome Surveillance

In FY24, BDMP transitioned the inclusion of neonatal abstinence syndrome (NAS) as a reportable condition into the surveillance system from a pilot program to a full-standing program, allowing for active, state-wide, population-based NAS surveillance. As part of NAS surveillance, BDMP medical record abstractors collect individual-level data on pregnant woman-infant dyads affected by NAS from medical records to obtain information on maternal demographics, maternal medication history, results of maternal and infant toxicology screens, infant symptoms and treatment, receipt of a family care plan, and with whom the infant was discharged. In FY24, the Division for Family Health Data and Analytics (DFHDA), which houses both BDMP and NAS surveillance systems, received an award from the Council of State and Territorial Epidemiologists to: 1) assess the feasibility of longitudinal NAS surveillance, 2) explore referrals to services for families with NAS, and 3) better understand current service utilization. DFHDA completed an environmental scan to identify potential data sources to leverage and completed interviews to assess the feasibility of supporting longitudinal NAS surveillance and better understand current service referrals and utilization for this population. As part of this project, DFHDA also assessed service utilization of infants with NAS in MA’s Early Intervention (EI) program by linking NAS surveillance data to EI program enrollment data. Overall enrollment rates could be improved, as only 53.6% of infants with NAS were enrolled in MA’s EI program. In FY24, DFHDA was also awarded a four-year grant from the CDC to establish a long-term NAS surveillance system and foster collaboration with a network of jurisdictions also conducting NAS surveillance. 

 

Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) 

In FY24, DFHDA wrapped up the COVID-19 Pregnancy Surveillance effort as part of their pregnant woman-infant linked longitudinal surveillance system (contributing to CDC’s SET-NET). DFHDA has been assisting the Bureau of Infectious Diseases and Laboratory Sciences with the hepatitis C arm of SET-NET by having two abstractors collect data on the pregnant woman-infant dyad through two years of life. For more information about SET-NET, refer to the Maternal/Women’s Health domain narrative

 

Child Care Health and Safety Consultation Program

During FY24, Title V BFHN staff began working with the MA Department of Early Education and Care on their Preschool Development Grant Birth – Five (PDG B-5). The goal of the PDG B-5 grant is to support ongoing work across multiple state agencies to strengthen systems and enhance the educational, health, and economic outcomes of young children and their families. BFHN’s responsibilities include developing a Child Care Health and Safety Consultation program for childcare programs across MA. Child Care Health Consultants (CCHCs) are health professionals (e.g., nurses and health educators) with experience and training specific to early education and care who “promote the health and development of children, families, and staff and to ensure a healthy and safe child care environment.[2]” Research shows that high-quality early learning environments provide an important foundation for school readiness and promote life-long health outcomes.[3] Research also outlines that CCHCs improve the health and safety of children in child care, including children with special health care needs, by fostering developmentally appropriate care, reducing the number of illnesses and injuries, and increasing health care access and early identification and referral for health, developmental, and behavioral concerns.[4] At the end of the reporting period, BFHN hired Dr. Mary Thompson, a pediatric nurse practitioner, to spearhead the development of the Child Care Health and Safety Consultation program. The project team developed the workplan and work began in earnest in FY25.

 

Essentials for Childhood (EfC): Earned Income Tax Credit 

Earned Income Tax Credit (EITC), combined with the Child Tax Credit and other credits, brings significant resources into communities, reduces poverty and exposure to adverse childhood experiences, and improves health outcomes, particularly among mothers and children. In FY24, the EfC Economic Opportunity team continued to support strategies and build partnerships to increase the number of eligible families who file for the EITC through Voluntary Income Tax Assistance sites. See Crossing Cutting Essentials for Childhood: Earned Income Tax Credit section for more details. 

 

[1] Van Niel, Maureen Sayres MD et al. The Impact of Paid Maternity Leave on the Mental and Physical Health of Mothers and Children: A Review of the Literature and Policy Implications, Harvard Review of Psychiatry: 3/4 2020 - Volume 28 - Issue 2 - p 113-126 

 [2] National Center on Early Childhood Quality Assurance [Internet]. Child care health consultants: Ensuring healthy and safe child care environments; 2021 April [cited 2024 August 29]. Available from: https://childcareta.acf.hhs.gov/sites/default/files/new-occ/resource/files/child_care_health_consultant_brief_final_1_508_compliant.pdf

 [3] Morrissey, T. The Effects of Early Care And Education On Children’s Health. Health Affairs Health Policy Brief, April 25, 2019 [cited 2024 November 1]. Available from: https://www.healthaffairs.org/do/10.1377/hpb20190325.519221/full/hpb_2019_rwjf_11_w-1686063070788.pdf

 [4] Honigfeld, L., Pascoe, T., Macary, S., Crowley, A., Promoting Children’s Health in Early Care and Education Settings by Supporting Health Consultation. Farmington, CT: Child Health and Development Institute of Connecticut. 2017 [cited 2024 July 26]. Available from: Child Health and Development Institute