Introduction and summary
The first three years of a child’s life mark a foundational period of social and cognitive development that sets the stage for lifelong learning, health, and well-being. Public policy decisions in the United States frequently group early childhood into a single, isolated stage, which often fails to prioritize the unique needs of babies and toddlers.
During the first year of life, the brain forms more than 1 million neural connections each second, as infants rapidly consume input from their environment and the people in it.1 Quality interactions with responsive caregivers, as well as early learning activities such as storytelling and singing songs, help strengthen neural connections during infancy that build the foundation for social and emotional development and speech and language learning throughout life.2 By age 3, the brain grows to more than 80 percent of its adult volume, and children have the capacity to engage in complex cognitive abilities and to consider the relation between cause and effect.3
Early experiences and the environments in which babies grow up have strong impacts on brain development. Having access to opportunities for enrichment from birth and a safe environment in which to grow up promotes healthy later learning and development. Conversely, disparities that exist at birth, including neglect and overly stressful experiences during infancy and toddlerhood, can disrupt early development of the brain and other biological systems and lead to chronic health issues, including heart disease, diabetes, substance abuse, depression, and anxiety disorders later in life.4 Decades of developmental research make clear that the first few years are critical for determining long-term health and well-being and are therefore a prime period in which to focus interventions to promote enduring positive outcomes.
An interconnected and cascading set of policy solutions that likewise treats the lifespan as continuous is necessary for supporting strong outcomes.
Public policy choices also often neglect to recognize that human development is a continuous and cascading process, during which the cognitive, social, behavioral, and physical changes in each developmental period lay the foundation for success and well-being in the next. An interconnected and cascading set of policy solutions that likewise treats the lifespan as continuous is necessary for supporting strong outcomes. Specifically, aiming policy interventions at addressing the intersecting social determinants of health and well-being that underscore educational and professional attainment, family economic security, and broader quality of life promotes a holistic model of both individual and community health. This report adopts a comprehensive view of infant and toddler well-being as shaped by these determinants, putting this stage of development into context between the perinatal period and early childhood.
Read more of CAP’s previous work on this issue
Five domains of social determinants of health and well-being serve as the framework for this report:
- Health care: access to developmental monitoring and screenings, preventive well-baby pediatric visits, childhood immunizations, insurance coverage, home visiting services, mental health support, and the dyadic health care model
- Neighborhood and physical environment: neighborhood health and safety, housing insecurity, housing conditions, home safety, exposure to environmental pollution, and climate change
- Education: access to affordable high-quality infant and toddler care, early learning opportunities, and child care options that meet a wide range of family needs
- Economic stability: poverty status, food insecurity, diaper insecurity, and the infant formula shortage
- Social and community context: impact of COVID-19; considerations of discrimination related to race, disability status, and gender identity; incarceration status; and community violence
Read more here
This page features previous CAP work on social determinants of health.
Access to preventive health care, proper nutrition, and socioemotional support during infancy and toddlerhood are critical components of child and family health and well-being. Yet access to health care in the United States, particularly for low-income people and people of color, is limited by systemic inequities that also crosscut other social determinants of health. These inequities have only been exacerbated by the COVID-19 pandemic, leading to a range of negative outcomes for infants and their families, including a rise in infant and maternal mortality.5
Regular well-baby checkups and key social service supports, such as the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, deliver essential information to families about infant safety, nutrition, and learning; screen for developmental delays; administer recommended childhood vaccines; and identify early signs of neglect and abuse.6 Early diagnoses of developmental delays and disorders7 allow children to receive tailored intervention services that promote lifelong learning and development and mitigate academic and social challenges down the road.8 During the pandemic, the overall rate of missed preventive child wellness visits increased by nearly three times the pre-pandemic rate.9 Lower-income families were significantly more likely to miss visits than were middle- and higher-income families, and Black and Latinx families were significantly more likely to miss visits than were white families, due to lack of access to health care coverage, a health care provider, or transportation. Although the rate of attendance for well-baby visits has increased since 2020, significant disparities remain, especially among children in lower-income families, Black and Latinx children, and disabled children.10
The Maternal, Infant, and Early Childhood Home Visiting program
The MIECHV program was established in 201011 and is administered by the Health Resources and Services Administration (HRSA), in collaboration with the Administration for Children and Families (ACF). Many local MIECHV programs have adopted the Early Head Start (EHS) home visiting model to help increase access to preventive health care and parenting resources for low-income families who may be more likely to miss routine wellness visits for their infants and toddlers. Most home visiting programs under MIECHV that have adopted the EHS model are adding home-based options to existing Early Head Start programs in order to reach more low-income, high-risk families.12 MIECHV is recognized as one of the more rigorously evaluated social service programs, using a two-generational approach with well-documented effectiveness on outcomes important to promoting healthy families.13 The program also successfully transitioned to virtual services during the COVID-19 pandemic, allowing families who were disproportionately affected to continue accessing critical holistic early care.14 Federal funding for MIECHV has not increased since fiscal year 2013, limiting its ability to reach millions of current and expectant parents who would benefit from these services.15 Currently, only 150,000 families are served out of an estimated 18 million families who would benefit from services.16 The bipartisan Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 passed the House on December 2, 2022.17 If the bill passes the Senate, it will increase funding and expand access by doubling investments over five years, authorize the continued use of virtual services, and significantly increase funding for tribal communities.18
Infant and toddler vaccinations
Childhood vaccinations are critical to protect infants and toddlers from serious and potentially life-threatening diseases, but health officials have reported that childhood immunization rates are at their lowest in 30 years, raising concerns about the resurgence of life-threatening but preventable childhood illnesses such as smallpox, measles, polio, and tetanus.19 Low-income babies and young children can receive free vaccines through the Vaccines for Children Program to prevent against 16 childhood diseases.20 However, a combination of pandemic-related barriers, including a decline in well-child visits, and a growing anti-vaccination movement based on dis- and misinformation, has driven down routine childhood immunization rates by an estimated 10 percent to 35 percent.21 Measles cases have spiked in recent years despite the availability of a safe and cost-effective vaccine,22 of which children can receive their first dose from 12 through 15 months of age.23 In 2019, the Centers for Disease Control and Prevention (CDC) reported the highest number of measles cases in the United States since 1992, with 86 percent of cases linked to densely populated areas with low vaccination rates.24
In 2021, approximately 73 percent of babies completed recommended vaccines according to schedule, with only 66 percent of babies from lower-income families receiving recommended vaccines.25 Vaccine rates are also lower among uninsured families and Black and Hispanic families, an effect driven by structural factors and a long history of medical discrimination, mistreatment, and unethical experimentation that have reduced access to quality health care and increased distrust of the medical system.26 Unvaccinated young children, especially those with pre-existing health issues, are at the highest risk for complications due to preventable childhood illnesses,27 which can include brain swelling that may damage developing neural systems or even cause death during infancy or toddlerhood.28
Health insurance coverage
Continuous health insurance coverage is an important factor in whether infants and toddlers have access to preventive care and other health services during a critical period in their development. While young children are insured at a higher rate than other age groups—thanks in large part to expansions to Medicaid and the creation of the Children’s Health Insurance Program (CHIP) in the late 1990s29—low-income children and children of color disproportionately face coverage gaps and insurance churn that present a risk to both healthy development and family financial stability.30 Even short gaps in coverage may cause a child to miss out on needed treatment for a chronic illness or disability or result in family financial hardship and medical debt.31 Loss of coverage is particularly common among families whose income source is variable—hourly or seasonal workers, or families whose salaries fluctuate and may temporarily place them above the child Medicaid or CHIP eligibility thresholds.32 Continuous eligibility policies help prevent coverage gaps and ease family stress around obtaining necessary health care, supporting school readiness, healthy development, and health equity. In fact, states that have not expanded Medicaid see rates of uninsured children nearly twice those of expansion states.33 Approximately two-thirds of states have 12-month continuous coverage for children in Medicaid and/or CHIP, but Oregon is the first state to continuously cover children from birth through age 6, regardless of changes in family circumstances or time of first eligibility.34
Continuous eligibility policies help prevent coverage gaps and ease family stress around obtaining necessary health care, supporting school readiness, healthy development, and health equity.
The rate of increase in Medicaid and CHIP enrollments during the COVID-19 pandemic
Temporary continuous eligibility provisions enacted during the COVID-19 pandemic have kept millions of Americans enrolled in critical public health insurance, but an estimated 15 million people—including 6 million children—could lose coverage when the public health emergency ends.35 Medicaid and CHIP enrollment increased by 26 percent during the pandemic, driven both by increasing rates of economic insecurity and the fact that states received extra federal funding on the condition that they kept all current and new Medicaid and CHIP recipients enrolled through the duration of the public health emergency.36 Before the pandemic, annual renewal processes resulted in many people losing coverage due to changes in income or simple administrative reasons.37 Although some individuals who will lose coverage when the public health emergency ends may be eligible for insurance through the Affordable Care Act (ACA) Marketplace, administrative barriers and gaps between Medicaid and ACA Marketplace eligibility will inevitably leave many families without health care coverage.38 Reducing administrative barriers, making American Rescue Plan Act (ARPA) enhanced Marketplace premium tax credits permanent beyond 2025, improving coordination between state Medicaid and Marketplace plans, and increasing automatic Marketplace enrollment for those who lose Medicaid eligibility could help reduce coverage gaps when the public health emergency ends.39
Mental health and well-being
Even before the pandemic, there was growing concern about the ongoing national mental health crisis in the United States, particularly among young people of color and people living in poverty.40 Nationally representative survey responses collected from April 2020 to September 2022 demonstrate that caregivers with young children have consistently struggled with well-being and emotional distress during the pandemic—and 42 percent of families overall listed this as a top challenge they were facing.41 Parents’ mental health is predictive of their children’s mental health, even during infancy and toddlerhood,42 and interventions that address the socioemotional health of parents with young children also have the benefit of improving overall family health and well-being. Families typically interact with the health care system most frequently during their child’s first three years of life through pediatric visits, creating an opportunity for health care professionals to conduct socioemotional monitoring and screening and provide dyadic services—services aimed at addressing the needs of both parents and their children—during a particularly sensitive and vital developmental period.43
The proportion of families reporting mental health challenges as a top concern they faced during the pandemic
California has made recent steps to prioritize infant, toddler, and family well-being through direct investments in dyadic health care Medi-Cal benefits. The state’s 2022 budget included $800 million over five years to promote the delivery of simultaneous caregiver support services through well-child visits.44 Dyadic treatment models have been operating in California and other states for several years, but these have been limited to local implementation through philanthropic funding or local First 5 commissions.45 The rigorously evaluated HealthySteps dyadic care model, for instance, has already demonstrated wide-reaching benefits of this approach for infants, toddlers, and their families, including fewer child behavioral issues, higher child social-emotional development scores, higher preventive well-child visit attendance, lower rates of maternal depression, and more secure child attachment to caregivers.46 Families who participated in the dyadic care model also had higher satisfaction with preventive care visits and were more likely to trust and adopt their health care provider’s advice.47
Neighborhood and physical environment
A safe, nurturing environment is essential to healthy growth and development during infancy and toddlerhood. Environmental factors, including housing conditions, housing security, exposure to environmental pollution and toxins, and home safety, have well-documented effects on health and development during infancy and toddlerhood.
Families with children were already more likely to face housing instability than were families without children before March 2020, but the COVID-19 pandemic and its economic fallouts have heightened rates of material hardship, pushing many households living paycheck to paycheck over the edge.48 Although pandemic-related eviction moratoriums and relief measures helped many families avoid displacement, these protective measures were temporary, and most have since expired. Moreover, there is now a severe shortage of affordable housing options, with available housing often far outside what most families can afford.49 Housing instability and eviction rates further reflect the impact of racist, anti-Black housing policies and systemic barriers that have resulted in racial wealth disparities. Nearly twice as many Black renters with children report being behind on rent compared with white renters.50 As of 2020, more than 50 percent of all families with children experiencing homelessness were Black.51 Housing instability and homelessness have well-documented negative impacts on child health, well-being, and development. Longitudinal studies of infants and toddlers experiencing housing insecurity have found significant associations between multiple moves and poor child health, developmental risk, and low birthweight.52 Infants in families experiencing homelessness have a higher risk for physical health issues, including respiratory problems and low weight, compared to infants who have access to secure housing.53
State action on housing insecurity
Some states have taken positive steps to address childhood housing insecurity. In California, the state-funded and locally administered Bringing Families Home program provides financial assistance and housing-related wraparound services to families involved in the welfare system who have been or are at risk of facing homelessness.54 More than 1,200 families have secured permanent housing through the program since its inception in 2016.55 In Oregon, the state legislature passed several bills in 2021 to increase access to affordable housing, assist unhoused families, and protect renters, including $550 million for new and existing affordable housing and emergency shelters.56 In Connecticut, Head Start is partnering with local and national organizations on a pilot program aimed at ending homelessness and promoting family outcomes through housing vouchers and programmatic support—and the pilot has already helped 20 Head Start families secure stable housing.57
The United States continues to have a severe housing shortage.58 With the federal minimum wage barely meeting one-third of what is required to afford an average-priced two-bedroom rental, many low-income families are priced out of housing in every state in the country59 and are forced to settle for less-than-ideal housing conditions.60 While poor housing conditions can be harmful at any age, infants and toddlers are at a developmental stage where they are particularly vulnerable to household dangers and toxins such as lead, asbestos, and mold, which are more common in low-income and subsidized housing units, where landlords have little incentive to update housing to health code standards.61
Today, nearly 760,000 young children, disproportionately children of color,62 live in public housing, and another 2 million live in housing subsidized by the federal Housing Choice Voucher Program.63 A large percentage of affordable housing units were built prior to 1970, when lead paint and asbestos were commonly used as building materials.64 Exposure to these materials can cause long-term negative health consequences, especially during infancy and toddlerhood, including damage to the nervous and endocrine systems, developmental delays, hearing and speech problems,65 respiratory conditions, and later-developing cancers.66 Older and poorly maintained buildings have a higher risk for mold, which may result in allergic reactions and, in more severe cases, asthma and chronic lung conditions.67 Infants and toddlers also explore their environments through touch and taste, frequently putting things in their mouths as a way of gathering information about them,68 which exposes them more directly to these home toxins at a key point in early development.69
A child born in 2020 may experience 2 to 7 times as many extreme events such as wildfires, tropical cyclones, floods, crop failures, and droughts and 36 times as many heat waves as a child born in 1960.
Most homes and neighborhoods across the country are also infrastructurally unprepared to handle the increasing stresses of climate change.70 Projections mapping lifetime exposure to the effects of climate change demonstrate that young children today will experience significantly more extreme weather events and natural disasters than did previous generations.71 A child born in 2020 may experience 2 to 7 times as many extreme events such as wildfires, tropical cyclones, floods, crop failures, and droughts and 36 times as many heat waves as a child born in 1960.72
The increased prevalence and severity of heat waves present a danger for very young children, whose bodies are more vulnerable to extreme temperatures, increasing risk of respiratory diseases, heatstroke, and dehydration and decreasing the safety of outdoor play.73 Periods of extreme cold due to climate change also present a danger for families who do not have access to heating or may struggle to afford it.74 Heating and cooling infrastructure has thus become an important home safety feature. However, 18 percent of households below the poverty line do not have any form of air conditioning, and energy costs continue to be a strain for many low-income households.75 Flood risk has already proved detrimental to child and family health, particularly for low-income families of color. In September 2021, the torrential rains of Hurricane Ida flooded thousands of homes in New York City, drowning 11 people in their basement apartments.76 An estimated 100,000 families in New York City live in unsafe basement apartments, which primarily house low-income immigrant families.77
Parent safety behaviors
Parents play an essential role in keeping children safe in the home, especially during the first few years of life, but dangers can arise when families lack resources and knowledge about child safety. An estimated 3,500 infants in the United States die each year due to sleep-related accidents,78 and the average household also poses risks for other accidents related to drowning, burns, and falls.79 Some strategies for protecting infants and toddlers involve removing an immediate risk, but other home safety considerations have to do with more enduring features of the home, such as installing or replacing smoke and carbon monoxide detectors, removing poisonous cleaning supplies from infants’ reach, baby-proofing stairs or fireplaces, and ensuring that the home is free of loose wires.80
The evidence-based guidance, support, and screening services that families receive through MIECHV and other home visiting programs have increased health and well-being outcomes for millions of young children.
Well-baby pediatric visits can provide families with essential child safety information, but attendance rates saw sharp declines during the pandemic.81 For this reason, home visiting programs offer unique access to critical family education around child safety that helps reduce preventable injuries, emergency visits, and deaths in early childhood.82 The evidence-based guidance, support, and screening services that families receive through MIECHV and other home visiting programs have increased health and well-being outcomes for millions of young children.83 Ensuring that parents have foundational knowledge of children’s development, particularly during infancy and toddlerhood when children are becoming increasingly mobile and independent, and access to tools to ensure their homes are safe environments helps protect the safety and well-being of young children.
In 2021, more than 1 out of every 20 babies in the United States lived in a neighborhood that was considered unsafe based on self-reported caregiver scores.84 Unsafe neighborhoods, which may include dangers due to violence, pollution, or generally unsafe conditions in the surrounding community, disproportionately affect lower-income85 and Black, and children,86 presenting direct and indirect risks for infants and toddlers, both in terms of their physical safety and long-term health and development. Safe neighborhoods and supportive communities, on the other hand, have been shown to reduce some of the negative health impacts of adverse childhood experiences and racial health inequities that start during the early years and can persist throughout the lifespan.87
1 in 20
The number of babies in the United States living in unsafe neighborhoods in 2021
One study found that 12-month-old infants living in communities with lower levels of neighborhood safety had fewer hours of consolidated sleep than did infants in neighborhoods with higher neighborhood safety indicators.88 Good-quality sleep is essential to the developing brain, and poor infant sleep has been associated with later risk for the development of a mental health disorder.89 Childhood exposure to air pollution and environmental toxins from power plants, truck exhaust, and industrial sources have been found to harm cognitive and motor development while increasing risk for diseases, including respiratory conditions and childhood cancer.90 Additionally, community access to safe drinking water has been affected by climate change and pollution; over the past decade, an estimated 63 million Americans have been exposed to unsafe water supply, with communities of color most likely to be affected.91 Families in unsafe neighborhoods may also be more likely to restrict their children’s outdoor play; such play has important benefits for child social development, learning, and mental health outcomes.92
Infant and toddler care and education has long been siloed as separate from the public education system and thought to fall under the private purview of the family.93 Yet misconceptions about infant and toddler child care as unskilled babysitting fail to acknowledge the importance of the early years in learning and development and thus undermine the skilled-yet-historically undervalued work of early childhood educators, who are overwhelmingly women of color.94 More than half of the 12 million infants and toddlers living in the United States and 43 percent of children in poverty regularly attend nonparental child care.95 Most children have all available parents in the workforce,96 and increasingly, mothers—particularly women of color—serve as either co-breadwinners or the sole breadwinners for their families, making their working contributions foundational to their families’ economic survival.97 Infant and toddler care is therefore an essential service that allows families to work and exposes children to critical learning and socialization that feeds their growing brains.98
Promoting equity in education requires a focus on continuous learning across each stage of development, including infancy and toddlerhood.
A wealth of developmental research demonstrates that even the very youngest children need developmentally appropriate learning experiences. In fact, inequitable access to high-quality child care perpetuates many of the opportunity gaps that K-12 schools spend years attempting to counteract.99 Interventions that occur after kindergarten have had some positive impacts on children’s later achievement, but the results are much weaker than those of early intervention.100 Several key studies have shown that providing families that have low socioeconomic status access to high-quality, affordable child care before children reach age 5 can buffer early learning gaps and improve long-term academic, social, economic, and health outcomes.101 However, accessible, affordable, and high-quality child care options are lacking, particularly for historically marginalized families.102 The ongoing COVID-19 pandemic has only exacerbated inequities in access by increasing wealth disparities and decreasing the supply of available child care, which has cascading impacts on family economic security and on children’s development and learning.103 Promoting equity in education requires a focus on continuous learning across each stage of development, including infancy and toddlerhood.104
Infant and toddler care shortage
The United States’ child care desert crisis is primarily driven by a lack of licensed child care options for infants and toddlers.105 While child care workers in general already face low wages that fall barely above the federal poverty line, teachers in infant and toddler classrooms earn even less; on average, full-time teachers in infant and toddler classrooms earn $10.86 per hour compared with $17.07 per hour in preschool-age classrooms—less than the $32.80 average wage for kindergarten teachers.106 Black and Hispanic early childhood educators earn even less than white educators.107 Low wages and high demand, coupled with more competitive employment offers in other sectors, have driven hundreds of thousands of workers out of the early childhood field, driving a staffing shortage and reducing the number of child care slots that providers can offer, particularly for the youngest age groups.108
The average hourly pay for teachers in infant and toddler classrooms
A significant challenge for providers of infant and toddler care programs is that costs are inherently higher. Smaller caregiver-to-child ratios are necessary to ensure health and safety because infants and toddlers require more hands-on physical care than their older peers.109 Very slim profit margins and the need for robust staffing leave providers struggling to pay a living wage. As a result, nearly half of child care workers are eligible for some form of public assistance,110 and more than one-quarter take on second jobs to make ends meet.111 Some programs offset the higher costs for infant and toddler care through tuition payments or subsidies from the families of older child cohorts, for which operating costs tend to be lower. However, chronic federal underinvestment coupled with mounting costs edge families out of being able to afford infant and toddler care and disincentivize programs from providing services to subsidy-eligible families. The rising popularity of free universal preschool programs, which offer slightly higher pay, is also drawing educators from the infant and toddler care field, further drawing on an already limited supply of professionals in the workforce.112
Ensuring that child care providers have the necessary resources to offer high-quality infant and toddler care, boosting worker compensation, and building supply will give parents the options they need to care for their babies and young children.
Unfortunately, the pandemic has exacerbated infant and toddler child care deserts, as more programs have been forced to shut down permanently.113 Ensuring that providers have the necessary resources to offer high-quality infant and toddler care, boosting worker compensation, and building supply will give parents the options they need to care for their babies and young children.
Access to high-quality infant and toddler care
Far too many American families are faced with difficult decisions regarding insufficient, costly, and mediocre care options for their young children. In 30 states and Washington, D.C., tuition for a seat in a center-based infant or toddler child care program is more than in-state tuition and fees at a public university.114 While financial assistance is available, it is not enough to meet families’ needs: Only 4.2 percent of low- and moderate-income infants and toddlers receive tuition assistance through the Child Care and Development Fund (CCDF).115 A large portion of families who qualify for subsidized care are unable to receive it because of such low supply. High costs and low supply often force families to settle for less-than-ideal child care options that do not support their babies’ learning and development. Despite providers’ best efforts, limited resources have resulted in an estimated 75 percent of toddlers in center-based care and 93 percent in home-based care receive low- or mediocre-quality care.116
Unfortunately, the children who are likely to benefit the most from high-quality care, including low-income babies and babies of color, are the least likely to have access to high-quality care, due predominantly to the significantly high cost associated with these care arrangements.117 In order to rectify the care crisis, congressional leaders need to pass legislation that includes substantial funding to support providers and expand access and lower costs for parents. Without additional resources, there will continue to be persistent trade-offs among workers’ wages, affordability, and the quality of care.118
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Early Head Start
For more than 25 years, Early Head Start has provided high-quality health and education services to low-income families with children from birth to age 3 at no cost to the family.119 Through its home visiting and group socialization programs, trained professionals regularly engage families and children in direct early learning activities, provide parents education about their children’s health and learning, and connect families with community supports. Early Head Start also offers center-, home-, and family-based child care programs to meet families’ diverse needs, in addition to some home visiting services.120 Children in Early Head Start programs score higher on kindergarten readiness indicators and have higher gains in social-emotional, language, and cognitive development than do their peers who do not participate in Early Head Start.121 Despite the program’s clear benefits, limited funding only allows 11 percent of eligible children and pregnant people to receive Early Head Start services each year.122 Some efforts have sought to extend services for low-income babies and toddlers through grantee partnerships with local child care providers, but additional federal funding is needed to reach all eligible families.123
A comprehensive child care system includes a range of mixed-delivery options to meet the diverse needs of families with young children. Many families prefer home- and family-based child care options for their infants and toddlers,124 especially as these programs are typically embedded within a community and allow providers to have a uniquely close relationship with the families they serve.125 This strength of home-based child care (HBCC) is often an appeal for communities of color and families in rural areas,126 whose children benefit from culturally responsive and familiar care127 and whose parents benefit from the typically lower cost and greater flexibility of scheduling HBCC, relative to center-based care. Despite the importance of HBCC in expanding equitable access, its availability has decreased in recent years. An estimated 90,000 licensed home-based programs closed from 2005 to 2017, while center-based care increased capacity.128 The number of low-income children who received child care assistance in a home-based setting decreased by 35 percent from 2011 to 2016.129
Home-based programs exemplify that not all high-quality care options look the same, and measures of quality will vary between settings. Policies and regulations must acknowledge the unique strengths and challenges of home-based programs in order to create a range of options for parents of young children.130 Home Grown, an organization focused on improving access to and availability of HBCC, has developed an evidence-based framework including a set of benchmarks to improve network quality.131 Home-based providers have received some increased attention at the federal and state levels through CCDF allocations to home-based care, partnerships with Early Head Start, and Preschool Development Grants Birth Through Five.132 However, startup and operating costs continue to be an issue, as do persistent staffing costs, and home-based programs face regulations and licensing that vary widely between states.
Economic stability is a foundation for overall family health and well-being. It is also structurally tied to racial wealth gaps and systemic racism, which place children of color at greater risk of being born into poverty, facing food insecurity, and suffering material hardship into adulthood. Persistent gender wage gaps also stymie mothers’ abilities to establish strong financial futures for themselves and their families, who are increasingly dependent on breadwinning mothers for their economic security.133 Experiencing multiple ongoing stressors at once during infancy and toddlerhood can have extremely damaging impacts on child health and development, which increases health care, judicial, and social services-related costs down the road.134 The economic fallouts of the COVID-19 pandemic have affected many families with young children, increasing material and financial strain and widening racial wealth disparities. At the same time, COVID-19 relief funding and the expansion of existing social service programs have proved effective at buffering financial and material hardship. Child poverty, as calculated by the Supplemental Poverty Measure, fell to its lowest level on record, declining from 9.7 percent in 2020 to 5.2 percent in 2021, largely due to temporary expansions in the child tax credit (CTC) and food benefit programs.135
Living in poverty has long been documented as an adverse childhood experience that can both directly and indirectly affect long-term health and development, with measurable impacts on brain development even in early infancy.136 Nearly 11 million children in the United States, or 1 in 7 children, live in poverty, and Black, Hispanic, and American Indian/Alaska Native children face disproportionately high rates of poverty.137 Children living in poverty are also more likely to experience other related adversities, such as food and housing insecurity.138
The COVID-19 pandemic has heightened experiences of hardship, particularly for families with young children, but it is important to note the systemic issues that cause such high rates of child poverty in the United States existed long before the start of the pandemic.139 Child poverty is solvable, but it requires action and investment from the federal level.140 Making permanent the expansions to the CTC under the American Rescue Plan Act, for example, would lift millions of children out of poverty, decreasing child poverty rates from 14.2 percent to an estimated 8.4 percent.141 The CTC kept 3.6 million U.S. children out of poverty in October 2021, a nearly 5 percentage point drop in the estimated child poverty rate without CTC expansions, most of whom fell back into poverty when the CTC expansions under the ARPA expired in December of that year.142 Research also estimates that improvements would have been even larger had the government done more to ensure all eligible families received the benefit, especially low-income families who did not owe federal income taxes.143 Structural reforms that focus on mitigating generational poverty and closing the racial wealth gap by raising the minimum wage, creating quality jobs with benefits, and increasing investments in safe and affordable housing would help families build economic stability, significantly reducing child poverty.144
Food and nutrition insecurity
As many as 1 in 7 households with infants faced food insecurity even before the pandemic, and recent economic challenges have only increased this number.145 Food insecurity is more common among households with young children, and disproportionately affects low-income households, disabled households, and certain racial groups, including American Indian/Alaska Native, Black, and Hispanic households.146 Low-income status is also a primary contributor to residing in a food desert, where there is exceedingly limited access to nutritious foods; moreover, food deserts became more numerous during the COVID-19 pandemic.147 Living in a food desert is also associated with increased risk of several chronic health conditions, including obesity and cardiovascular disease, which often result from families turning to less nutritious foods that are accessible under these conditions.148 As nutritious foods are critical to early cognitive and physical development, food precarity during this developmental period can have long-term detrimental impacts on children‘s life outcomes.149 Many households will also face a hunger cliff when the public health emergency ends and expanded food benefits are terminated; Supplemental Nutritional Assistance Program (SNAP) participants, for example, are expected to lose $82 per month, on average.150 While food insecurity affects health and well-being at any age, infants and toddlers can be at an especially high risk for negative long-term health and developmental consequences due to inadequate food and nutrition.
Even in food-insecure households where children are not experiencing ongoing hunger, children may not be receiving the nutrients they need for healthy growth and development; over time and particularly during the first few years of life, inadequate nutrition can result in poorly developed immune systems, low infant weight, vitamin deficiencies, developmental delays,151 and a later risk for childhood obesity.152 Infants living in food-insecure families may struggle with attachment to primary caregivers, are less likely to be ready for school,153 and are at greater risk for later mental health conditions. Even mild levels of food insecurity during infancy and toddlerhood can result in developmental delays.154 Home visiting programs such as Maternal, Infant, and Early Childhood Home Visiting have proven benefits for low-income families’ health and nutrition, improving families’ adoption of nutritious diets and healthy infant feeding practices that promote long-term health and well-being.155
The nationwide baby formula shortage has created large-scale inequities in access to critical food and nutrition and revealed key weaknesses in U.S. production and distribution systems, particularly in times of emergency.156 Infant formula is an important, nutritionally sound source of food that many families rely on for a variety of reasons. By 3 months of age, less than half of all infants in the United States are exclusively breastfed, and an estimated 19 percent of infants receive formula during the first two days of life.157 Adequate supply is thus critical for ensuring that infants receive the nutrition they need for healthy development.
The proportion of families across the country reporting only a week or less of available supply of infant formula
In the early months of the infant formula crisis, producers hiked prices by more than 10 percent on average, and nationwide shortages peaked at nearly 75 percent, with some states reaching as high as 90 percent.158 In May 2022, more than 40 percent of infant formula supplies were out of stock across the nation,159 while some states faced rates of more than 50 percent.160 By the first week of October, that rate had dropped to about 20 percent, although persistent shortages still exist—more than 40 percent of families across the country report having a week or less of supply available in their homes.161 These shortages, driven by broader inadequacies in the country’s food supply,162 were catalyzed by pandemic-related supply chain issues and the temporary closure of a major formula production plant.163 The cost of formula, already too high for many families to afford, has spiked; in the past year, most formula products have experienced an almost 20 percent increase in cost.164
Although the Biden administration and the Food and Drug Administration have taken some steps to address the crisis, including the adoption of Operation Fly Formula,165 vulnerable families are still experiencing significant strain.166 Families whose infants need hypoallergenic and easy-to-digest formulas, those who rely on benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or SNAP, and those who live in rural or Tribal areas with fewer grocery store options are still struggling to access formula.167 This crisis has highlighted key flaws in current food production and distribution systems that affect young children and their families, including market concentration of formula producers; supply chain issues; and a failure to prioritize infants, working families, and people with disabilities.168
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Diapers are a costly but essential infant item that can be a burden for families already struggling to pay for other basic material needs. Newborn infants can use up to 10 diapers per day and may still use from 4 to 6 diapers per day after one month of age.169 Most families can expect to spend an average of $80 per month on diapers for one child.170 Babies living in homes facing diaper insecurity are more likely to wear diapers for too long, placing them at higher risk for rashes, urinary tract infections and other bacteria or viruses, and poorer sleep quality.171 Before the pandemic, an estimated 1 in 3 families struggled to afford diapers for their infants or toddlers, and diaper need increased substantially during the pandemic as material hardship increased. Despite diaper banks boosting distribution by more than 50 percent during the pandemic, they have not been able to meet the full need, especially as donations to diaper banks decreased over the past two years.172
Low-income families and families in poverty are most likely to face diaper insecurity,173 yet WIC and SNAP benefits cannot be used to purchase diapers or baby wipes.174 Temporary Assistance for Needy Families (TANF)—a federal support program for low-income families—does cover diapers, but only 23 percent of families living below the federal poverty line receive TANF benefits.175 Even families who do receive TANF assistance often have little money left over to purchase diapers after using funds on other essential costs such as rent and utilities.176 Center-based Early Head Start programs provide diapers, but most other child care centers require families to supply their own diapers.177 Across the United States, 57 percent of parents experiencing diaper need reported that they missed work or school during the past month because they were not able to supply enough diapers to their child care provider. On average, these parents missed four days of work in the past month.178 Expanded diaper access is an often-overlooked policy priority that could have significant positive benefits for families with infants and toddlers.
Social and community context
As during other periods of development, persistent discrimination based on race or ethnicity, poverty status, disability status, incarceration status, sexual orientation, and gender identity, as well as discrimination based on a combination of intersecting identities, causes significant negative effects on infants, toddlers, and their families. Young children are susceptible to the adverse effects of discrimination, and its impact on their development can have enduring consequences for their health and well-being.179 Parents’ caregiving strategies and emotional availability can buffer the effects of discrimination on children’s well-being. However, their own experiences of discrimination, which increase the likelihood for anxiety, depression, and intrusive parenting strategies, can still be a mechanism through which very young children are affected by racism, and it can have persistent and intergenerational impacts.180
It is often an overlooked fact that young infants can have trauma responses to highly stressful experiences. The stress of living in an environment with elevated rates of intimate partner violence (IPV) also negatively affects infants’ well-being from very early in life181 and has lasting consequences. Even as early as infants’ first year of life, they display trauma symptoms related to having heard or witnessed IPV,182 and exposure to IPV in childhood—increasingly recognized as a form of child maltreatment—has associated economic costs of roughly $50,000 per victim in accumulated health care spending, criminal behavior, and occupational outcomes.183 Moreover, the impact on infants’ well-being is profound, affecting early social-emotional and cognitive development by reshaping how infants’ stress regulation systems operate, and often increasing behaviors such as problems eating and sleeping, higher reactivity that increases amounts of infants’ screaming and crying, and poorer general health.184 Toxic stress as a result of racial weathering has also been implicated in children’s later immune health, even into elementary school, and shapes their broader socioemotional development. In fact, by their first year, infants show negative emotionality as a result of discrimination.185 In the short term, racial and ethnic and socioeconomic disparities yield opportunity gaps that result in Black and Latino children starting kindergarten with poorer school readiness—including measures of social and cognitive development—compared with white children or children from higher-income backgrounds.186
Over time, the consequences of discrimination experienced in infancy and toddlerhood and continuing into later life can snowball into significant physical health complications in adulthood, including lower cardiovascular health and increased insulin resistance associated with the development of diabetes.187 Instituting policies that mitigate disparities and combat discrimination, and eliminating harmful ones that perpetuate inequities, can promote infant and toddler well-being, as well as that of their families, in both the short and long terms.
COVID-19 and its impact on infant and toddler development
The COVID-19 pandemic has had widespread negative effects on people of all ages, but for young children born immediately before or during the pandemic, those effects have been particularly dire. The effects of the COVID-19 pandemic have only worsened existing inequities and placed infants and toddlers from marginalized communities on more precarious developmental footing.
Young children today show reduced school readiness, including lower social and cognitive competencies, than young children did prior to the pandemic,188 and many children born during the pandemic are showing delays in reaching important milestones, such as walking, talking, and interacting with others.189 Babies born in 2020 were found to have lower developmental screening scores, involving communication, fine and gross motor, problem-solving, and social skills, at 6 months—regardless of whether their mothers were exposed to the virus that causes COVID-19 while pregnant.190 Recent research does point to some promising findings. In one study with infants 6 months to 3 years, researchers found only some decreases in problem-solving skills among 6-month-olds that increased by 2 years,191 and in another study with a global sample, caregivers’ concentrated interactions with their children while quarantined in their homes seems to have had a protective effect on infants’ delayed vocabulary development.192
Nurturing, responsive relationships with an adult foster trust and positive social-emotional development during infancy, while also laying the foundation for future social relationships.
For infants and toddlers in particular, strong relationships with a primary caregiver are essential.193 Nurturing, responsive relationships with an adult foster trust and positive social-emotional development during infancy, while also laying the foundation for future social relationships.194 However, infants and toddlers are also particularly susceptible to caregiver stress and anxiety. During the pandemic, caregivers with infants and toddlers have reported heightened rates of emotional distress, and higher caregiver distress was consequently linked to higher symptoms of child distress.195 Research on past socio-historic events indicates that the family and its level of adaptability and resilience may be the key link between large-scale crises and observed child outcomes.196 Even one stable, responsive relationship with a caregiver or other adult can buffer some of the harmful impacts of stress in early childhood.197 However, families who experienced multiple and more severe stressors during the pandemic, as well as those who were already experiencing adversities prior to the pandemic, were likely to have less capacity to adapt when faced with new or worsening adversities and were particularly vulnerable to the worst effects of the pandemic on their social and economic well-being.
Policy changes designed to support families’ financial security, create opportunities for early care and learning, and provide wraparound supports such as home visiting services are critical for ensuring that families can withstand periods of significant upheaval.
Other work on social determinants in infancy and toddlerhood
Research on the impact of a range of social determinants of health on children’s short- and long-term outcomes has seen an uptick in recent years. A new report released by Zero to Three and Child Trends showcases many key examples of how the domains of social determinants of health intersect during infancy and toddlerhood, as well as provides a set of policy recommendations.198 The report, which serves as a supplemental brief to the 2022 “State of Babies Yearbook (SOBY),199 uses key state and national indicators to examine the social determinants framework as it relates to infants and toddlers and argues for a cross-sector approach to improving equity in early childhood. By mapping SOBY indicators—which include the adoption of Medicaid expansion, access to prenatal care, tax credits, and expansions in eligibility for child care subsidies—onto outcomes related to the intersecting social determinants, state leadership and other advocates can assess what actionable steps are needed to support children’s health and educational opportunities, and help families build stronger financial futures.
Infant and toddler social determinants of health and wellness in context: Policy and legislative priorities
The earliest years of development have profound and lasting impacts on later life. Holistic policymaking that considers the five social determinants of health and the critical ways in which they intersect ensures that infants, toddlers, and their families have the resources they need to thrive. Bringing together a wide range of social and economic policies and understanding the unique ways in which they affect children during the first few years of life help improve long-term and intergenerational child and family outcomes.
While infants and toddlers are often left out of the policy discussion, a breadth of developmental research highlights that these early years may have the largest impact on long-term health, well-being, academic, and economic outcomes.200 Early investments in social programs that reduce disparities and improve family security across a range of social determinants also have shown to have large returns on investment, decreasing later costs associated with the health care, criminal justice, and social services systems. Several state-based programs and policies have begun to prioritize the earliest years as a key intervention period for improving family and child health. For instance, the expansion of continuous Medicaid and CHIP eligibility during early childhood, investments in safe and affordable housing supply, increased funding for home visiting programs, and support for the dyadic health care model all promote healthy babies and families across a range of social determinants. However, greater national attention on the littlest among us, as well as support from the federal level, is needed to ensure infants, toddlers, and families have the resources they need to thrive in life.
The authors would like to thank Jill Rosenthal, Arohi Pathak, Stephanie Bailey, Shannon Baker-Branstetter, Emily DiMatteo, Maggie Jo Buchanan, Edwith Theogene, Mariam Rashid, and Akilah Alleyne for their support and guidance in the development of this report. The authors would also like to thank Zero to Three’s Patricia Cole, Kim Keating, and Daniel Hains for their partnership.
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