Clinical Focus

  • Pediatrics

Academic Appointments

Administrative Appointments

  • Chief, Division of General Pediatrics (2014 - Present)
  • Co-Director, Fellowship in Academic General Pediatrics (2012 - Present)
  • Co-Director, Center for Policy, Outcomes and Prevention (2013 - Present)

Boards, Advisory Committees, Professional Organizations

  • Council Member, Society for Pediatric Research (2011 - Present)

Professional Education

  • Medical Education:Stanford University School of Medicine (1994) CA
  • Residency:Stanford Hospital and ClinicsCA
  • Internship:Stanford Hospital and ClinicsCA
  • Board Certification: Pediatrics, American Board of Pediatrics (1998)

Research & Scholarship

Current Research and Scholarly Interests

As a general pediatrician with a joint appointment in the Center for Health Policy and Primary Care Outcomes Research, my research focuses on the field of health literacy. Informed by social cognitive theory, I conduct interdisciplinary research to understand child and parent health literacy as potentially modifiable determinants of child health disparities. I am principal investigator on an NICHD-funded, multi-site, randomized controlled trial to assess the efficacy of a low-literacy, early-childhood intervention designed to prevent obesity in the first two years of life. I recently completed a community-based, participatory research study to examine the effectiveness of child health promotion delivered across a large network of early child-care centers in underserved communities ( The aim of my current scholarship is to apply the health-literacy model to attenuate disparities for children with chronic illness and special health care needs.

My work is informed by a public-health perspective and by delivering front-line care in underserved communities. Between 2006 and 2011, I served as Medical Director of Children’s Medical Services South Florida, a Florida state agency that coordinates care for more than 10,000 low-income children with special health care needs. I founded Stanford's Reach Out and Read program, and for ten years served as Medical Director for Reach Out and Read Florida, a pediatric-clinic-based program that provides books and early-literacy promotion to more than 200,000 underserved children. Prior to joining the Stanord faculty, I co-directed the Jay Weiss Center for Social Medicine and Health Equity, which fosters a scholarly community committed to addressing global health inequities through community-based participatory research. I have served as an advisor to the Institute of Medicine, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the Academic Pediatric Association, and the American Cancer Society. Fluent in Spanish, I maintain an active general pediatrics practice, serving an socioeconomically disadvantaged population of patients, with a focus on behavioral health, obesity prevention, post-NICU care of premature infants, and the care of complex chronic conditions.


2014-15 Courses


Journal Articles

  • Assessing Patient Experiences in the Pediatric Patient-Centered Medical Home: A Comparison of Two Instruments MATERNAL AND CHILD HEALTH JOURNAL Knapp, C., Chakravorty, S., Madden, V., Baron-Lee, J., Gubernick, R., Kairys, S., Pelaez-Velez, C., Sanders, L. M., Thompson, L. 2014; 18 (9): 2124-2133
  • Teaching Health Advocacy to Medical Students: A Comparison Study JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE Belkowitz, J., Sanders, L. M., Zhang, C., Agarwal, G., Lichtstein, D., Mechaber, A. J., Chung, E. K. 2014; 20 (6): E10-E19
  • "Greenlight Study": A Controlled Trial of Low-Literacy, Early Childhood Obesity Prevention PEDIATRICS Sanders, L. M., Perrin, E. M., Yin, H. S., Bronaugh, A., Rothman, R. L. 2014; 133 (6): E1724-E1737


    Children who become overweight by age 2 years have significantly greater risks of long-term health problems, and children in low-income communities, where rates of low adult literacy are highest, are at increased risk of developing obesity. The objective of the Greenlight Intervention Study is to assess the effectiveness of a low-literacy, primary-care intervention on the reduction of early childhood obesity. At 4 primary-care pediatric residency training sites across the US, 865 infant-parent dyads were enrolled at the 2-month well-child checkup and are being followed through the 24-month well-child checkup. Two sites were randomly assigned to the intervention, and the other sites were assigned to an attention-control arm, implementing the American Academy of Pediatrics' The Injury Prevention Program. The intervention consists of an interactive educational toolkit, including low-literacy materials designed for use during well-child visits, and a clinician-centered curriculum for providing low-literacy guidance on obesity prevention. The study is powered to detect a 10% difference in the number of children overweight (BMI > 85%) at 24 months. Other outcome measures include observed physician-parent communication, as well as parent-reported information on child dietary intake, physical activity, and injury-prevention behaviors. The study is designed to inform evidence-based standards for early childhood obesity prevention, and more generally to inform optimal approaches for low-literacy messages and health literacy training in primary preventive care. This article describes the conceptual model, study design, intervention content, and baseline characteristics of the study population.

    View details for DOI 10.1542/peds.2013-3867

    View details for Web of Science ID 000337172600029

    View details for PubMedID 24819570

  • How do Breast Imaging Centers Communicate Results to Women with Limited English Proficiency and Other Barriers to Care? JOURNAL OF IMMIGRANT AND MINORITY HEALTH Marcus, E. N., Koru-Sengul, T., Miao, F., Yepes, M., Sanders, L. 2014; 16 (3): 401-408


    Research suggests that women with Limited English Proficiency (LEP) and ethnic minority women are at increased risk of being inadequately informed of their mammogram result. The purpose of this study is to explore breast imaging centers' communication practices and assess how these centers accommodate women with low literacy and LEP. A 35-question survey was distributed to a national association of more than 700 breast health centers. Descriptive analysis of the overall sample and Fisher's exact or Chi squared testing to distinguish differences between subgroups were performed. Respondents from 206 centers completed questionnaires. 29% of respondents stated that more than a quarter of their patients were black, 27% of respondents stated that more than a quarter of their patients were Hispanic/Latina, and 13% of respondents stated that more than a quarter of their patients had LEP. Overall, 18% of respondents reported they do not routinely telephone patients with results, 15% do not have multilingual staff or translators available to answer questions, and 69% send result letters in English only. Of note, 69% use patient navigators. Centers reported systemic strengths and barriers to clear communication of mammography results. Our findings are consistent with past investigations identifying a general need to improve the communication of breast imaging results and suggesting that result notification letters alone are inadequate in ensuring that every woman understands her personal results and follow-up plan.

    View details for DOI 10.1007/s10903-012-9771-7

    View details for Web of Science ID 000335771700010

    View details for PubMedID 23324987

  • Health Literacy and Injury Prevention Behaviors Among Caregivers of Infants AMERICAN JOURNAL OF PREVENTIVE MEDICINE Heerman, W. J., Perrin, E. M., Yin, H. S., Sanders, L. M., Eden, S. K., Shintani, A., Coyne-Beasley, T., Bronaugh, A. B., Barkin, S. L., Rothman, R. L. 2014; 46 (5): 449-456


    Unintentional injury is a leading cause of infant mortality.To examine the role of caregiver health literacy in infant injury prevention behaviors.A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety.Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9).Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

    View details for DOI 10.1016/j.amepre.2014.01.005

    View details for Web of Science ID 000334768400004

    View details for PubMedID 24745634

  • Measurement of Parental Self-Efficacy for Diabetes Management in Young Children CHILDRENS HEALTH CARE Marchante, A. N., Pulgaron, E. R., Daigre, A., Patino-Fernandez, A. M., Sanchez, J., Sanders, L. M., Delamater, A. M. 2014; 43 (2): 110-119
  • Racial and Ethnic Differences Associated With Feeding- and Activity- Related Behaviors in Infants PEDIATRICS Perrin, E. M., Rothman, R. L., Sanders, L. M., Skinner, A. C., Eden, S. K., Shintani, A., Throop, E. M., Yin, H. S. 2014; 133 (4): E857-E867


    To examine parental reports of feeding and activity behaviors in a cohort of parents of 2-month-olds and how they differ by race/ethnicity.Parents participating in Greenlight, a cluster, randomized trial of obesity prevention at 4 health centers, were queried at enrollment about feeding and activity behaviors thought to increase obesity risk. Unadjusted associations between race/ethnicity and the outcomes of interest were performed by using Pearson χ(2) and Kruskal-Wallis tests. Adjusted analyses were performed by using proportional odds logistic regressions.Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet "tummy time" recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P = .009), and report less tummy time (aOR = 0.6, P = .037).Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

    View details for DOI 10.1542/peds.2013-1326

    View details for Web of Science ID 000335343500033

    View details for PubMedID 24639273

  • Parental limited English proficiency and health outcomes for children with special health care needs: a systematic review. Academic pediatrics Eneriz-Wiemer, M., Sanders, L. M., Barr, D. A., Mendoza, F. S. 2014; 14 (2): 128-136


    One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

    View details for DOI 10.1016/j.acap.2013.10.003

    View details for PubMedID 24602575

  • Parent Health Literacy and "Obesogenic" Feeding and Physical Activity-Related Infant Care Behaviors JOURNAL OF PEDIATRICS Yin, H. S., Sanders, L. M., Rothman, R. L., Shustak, R., Eden, S. K., Shintani, A., Cerra, M. E., Cruzatte, E. F., Perrin, E. M. 2014; 164 (3): 577-?


    To examine the relationship between parent health literacy and "obesogenic" infant care behaviors.Cross-sectional analysis of baseline data from a cluster randomized controlled trial of a primary care-based early childhood obesity prevention program (Greenlight). English- and Spanish-speaking parents of 2-month-old children were enrolled (n = 844). The primary predictor variable was parent health literacy (Short Test of Functional Health Literacy in Adults; adequate ≥23; low <23). Primary outcome variables involving self-reported obesogenic behaviors were: (1) feeding content (more formula than breast milk, sweet drinks, early solid food introduction), and feeding style-related behaviors (pressuring to finish, laissez-faire bottle propping/television [TV] watching while feeding, nonresponsiveness in letting child decide amount to eat); and (2) physical activity (tummy time, TV). Multivariate logistic regression analyses (binary, proportional odds models) performed adjusting for child sex, out-of-home care, Women, Infants, and Children program status, parent age, race/ethnicity, language, number of adults/children in home, income, and site.Eleven percent of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk, (aOR = 2.0 [95% CI: 1.2-3.5]), immediately feed when their child cries (aOR = 1.8 [1.1-2.8]), bottle prop (aOR = 1.8 [1.002-3.1]), any infant TV watching (aOR = 1.8 [1.1-3.0]), and inadequate tummy time (<30 min/d), (aOR = 3.0 [1.5-5.8]).Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

    View details for DOI 10.1016/j.jpeds.2013.11.014

    View details for Web of Science ID 000331539100030

    View details for PubMedID 24370343

  • Parental Limited English Proficiency and Health Outcomes for Children With Special Health Care Needs: A Systematic Review ACADEMIC PEDIATRICS Eneriz-Wiemer, M., Sanders, L. M., Barr, D. A., Mendoza, F. S. 2014; 14 (2): 128-136
  • Glycemic control in young children with diabetes: The role of parental health literacy PATIENT EDUCATION AND COUNSELING Pulgaron, E. R., Sanders, L. M., Patino-Fernandez, A. M., Wile, D., Sanchez, J., Rothman, R. L., Delamater, A. M. 2014; 94 (1): 67-70


    This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM.Seventy primary caregivers of children (age 3-9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients' medical histories were obtained by medical chart review.Parental diabetes related numeracy (r=-.52, p<01), but not reading skills (r=-.25, p=NS) were inversely correlated with the child's glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child's HbA1c (r=-.47, p<01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F=12.93, p<.01) with both numeracy (β=-.46, p<.01) and parental perceived diabetes self-efficacy (β=-.36, p=.01) as significant predictors of HbA1c.Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM.Practitioners should assess parental health literacy and consider intervention when needed.

    View details for DOI 10.1016/j.pec.2013.09.002

    View details for Web of Science ID 000329887300010

    View details for PubMedID 24091252

  • Family, community and clinic collaboration to treat overweight and obese children: Stanford GOALS-A randomized controlled trial of a three-year, multi-component, multi-level, multi-setting intervention CONTEMPORARY CLINICAL TRIALS Robinson, T. N., Matheson, D., Desai, M., Wilson, D. M., Weintraub, D. L., Haskell, W. L., McClain, A., McClure, S., Banda, J. A., Sanders, L. M., Haydel, K. F., Killen, J. D. 2013; 36 (2): 421-435


    To test the effects of a three-year, community-based, multi-component, multi-level, multi-setting (MMM) approach for treating overweight and obese children.Two-arm, parallel group, randomized controlled trial with measures at baseline, 12, 24, and 36months after randomization.Seven through eleven year old, overweight and obese children (BMI≥85th percentile) and their parents/caregivers recruited from community locations in low-income, primarily Latino neighborhoods in Northern California.Families are randomized to the MMM intervention versus a community health education active-placebo comparison intervention. Interventions last for three years for each participant. The MMM intervention includes a community-based after school team sports program designed specifically for overweight and obese children, a home-based family intervention to reduce screen time, alter the home food/eating environment, and promote self-regulatory skills for eating and activity behavior change, and a primary care behavioral counseling intervention linked to the community and home interventions. The active-placebo comparison intervention includes semi-annual health education home visits, monthly health education newsletters for children and for parents/guardians, and a series of community-based health education events for families.Body mass index trajectory over the three-year study. Secondary outcome measures include waist circumference, triceps skinfold thickness, accelerometer-measured physical activity, 24-hour dietary recalls, screen time and other sedentary behaviors, blood pressure, fasting lipids, glucose, insulin, hemoglobin A1c, C-reactive protein, alanine aminotransferase, and psychosocial measures.The Stanford GOALS trial is testing the efficacy of a novel community-based multi-component, multi-level, multi-setting treatment for childhood overweight and obesity in low-income, Latino families.

    View details for DOI 10.1016/j.cct.2013.09.001

    View details for Web of Science ID 000329265300012

  • Impact of specific medical interventions in early childhood on increasing the prevalence of later intellectual disability. JAMA pediatrics Brosco, J. P., Sanders, L. M., Dowling, M., Guez, G. 2013; 167 (6): 544-548


    For the past 100 years, medicine in industrialized nations has become increasingly focused on specific medical interventions designed to improve the health of individual patients. Substantial evidence suggests that broader improvements in public health, nutrition, and economic well-being are more salient than medical or surgical interventions for the remarkable decrease in infant and child deaths since 1900. Less is known about the impact of specific medical interventions on morbidity such as intellectual disability (ID).To explore the impact of medical interventions in early childhood on increasing the prevalence of later ID, as reported in the literature from 1950 through 2000.We reviewed the medical literature and other data from 1950 through 2000 to construct estimates of the condition-specific prevalence of ID over time. We further explored the existing literature to document historically relevant influences on condition-specific prevalence, including the introduction of effective interventions, the timing of these introductions, and the likelihood of their widespread use.Twentieth century United States and Western Europe.Populations of children who received a life-saving intervention within the first 5 years of life and were evaluated for ID after 5 years of age.Case-specific prevalence of ID from 1950 through 2000.Low birth weight is associated with approximately 10% to 15% of the total prevalence of ID. No other new medical therapies introduced during this period were associated with a clinically significant increase in ID prevalence.Previous research has shown that specific medical interventions, such as newborn screening for congenital thyroid deficiency and phenylketonuria, have decreased the prevalence of ID approximately 16% in the United States since 1950. These results suggest that other medical interventions, particularly the advent of intensive care technologies, have also increased the prevalence of ID.

    View details for DOI 10.1001/jamapediatrics.2013.1379

    View details for PubMedID 23699900

  • Use of Farmers Markets by Mothers of WIC Recipients, Miami-Dade County, Florida, 2011 PREVENTING CHRONIC DISEASE Grin, B. M., Gayle, T. L., Saravia, D. C., Sanders, L. M. 2013; 10


    Farmers market-based interventions, including the Farmers' Market Nutrition Program of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), represent a promising strategy for improving dietary behaviors in low-income communities. Little is known, however, about the health-related characteristics of low-income parents who frequent farmers markets in urban settings. The objective of this study was to examine the relationship between family-health factors and the use of farmers markets by mothers of WIC recipients.We recruited a convenience sample of mothers of children seeking care at a primary care clinic in a large urban public hospital in Miami, Florida, in 2011 (n = 181 total). The clinic was adjacent to a newly established farmers market at the hospital. Each mother completed an interviewer-administered survey that included self-reported measures of maternal and child health, acculturation, dietary behaviors, food insecurity, and use of farmers markets.Reported use of farmers markets was independently associated with maternal history of diabetes (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.3-38.3) and increased maternal vegetable (but not fruit) consumption (OR, 3.5; 95% CI, 1.5-8.1). Intended future use of farmers markets was independently associated with being unemployed (OR, 2.4; 95% CI, 1.0-5.7), increased maternal vegetable consumption (OR, 2.5; 95% CI, 1.1-5.7), and food insecurity (OR, 3.6; 95% CI, 1.3-10.3).This study provides a snapshot of factors associated with farmers market use in a diverse population of urban low-income families. Understanding these factors may inform public health approaches to increase fresh fruit and vegetable consumption in communities at high risk for preventable chronic conditions.

    View details for DOI 10.5888/pcd10.120178

    View details for Web of Science ID 000329391900005

    View details for PubMedID 23764344

  • Health Literacy Assessment of Labeling of Pediatric Nonprescription Medications: Examination of Characteristics that May Impair Parent Understanding ACADEMIC PEDIATRICS Yin, H. S., Parker, R. M., Wolf, M. S., Mendelsohn, A. L., Sanders, L. M., Vivar, K. L., Carney, K., Cerra, M. E., Dreyer, B. P. 2012; 12 (4): 288-296


    Poor quality and variability of medication labeling have been cited as key contributors to medication misuse. We assessed the format and content of labels and materials packaged with common pediatric liquid nonprescription medications.Descriptive study. A total of 200 top-selling pediatric oral liquid nonprescription medications (during the 52 weeks ending October 30, 2009) categorized as analgesic, cough/cold, allergy, and gastrointestinal products, with dosing information for children <12 years (representing 99% of U.S. market for these products) were reviewed. The principal display panel (PDP) and FDA Drug Facts panel (side panel) of each bottle, and associated box, if present, were independently examined by 2 abstractors. Outcome measures were content and format of active ingredient information and dosing instructions of the principal display panel and Drug Facts panel.Although almost all products listed active ingredients on the Drug Facts panel (side panel), nearly 1 in 5 (37 [18.5%]) did not list active ingredients on the PDP. When present, mean (SD) font size for PDP active ingredients was 10.7 (5.0), smaller than product brand name (32.1 [15.0]) and flavor (13.1 [4.8]); P < .001. Most products included directions in chart form (bottle: 167 [83.5%], box: 148 [96.1%], P < .001); mean (SD) font size: 5.5 (0.9; bottle), 6.5 (0.5; box), P < .001. Few products expressed dosing instructions in pictographic form: 4 (2.6%) boxes and 0 bottles. Nearly all products included the Food and Drug Administration-mandated sections.The format and content of labels for nonprescription pediatric liquid medications could be improved to facilitate parent understanding of key medication information, including active ingredient information and dosing instructions.

    View details for Web of Science ID 000306620200008

    View details for PubMedID 22579032

  • Mammography Result Notification Letters: Are They Easy to Read and Understand? JOURNAL OF WOMENS HEALTH Marcus, E. N., Sanders, L. M., Pereyra, M., Del Toro, Y., Romilly, A. P., Yepes, M., Hooper, M. W., Jones, B. A. 2011; 20 (4): 545-551


    Federal law mandates that mammography centers notify women of their result in writing. The purpose of this study is to assess the readability and ease of use of the sample letters provided as a template for the notification letters centers send to patients.This is a cross-sectional analysis of the 43 mammography result notification template letters available from the American College of Radiology and two leading transcription software services. To assess readability, we used the Flesch-Kincaid grade level scale and the Lexile framework. To assess document suitability, we used the Suitability Assessment of Materials (SAM). Acceptable scores were based on established standards: ?6th grade for the Flesch-Kincaid level, ?900 for the Lexile analysis, and ?40% on the SAM scale. Means, standard deviations (SDs), and ranges were calculated by diagnostic category, as indicated by BI-RADS level. The Kruskal-Wallis test was used to assess differences in readability and suitability by diagnostic category.The Flesch Kincaid score ranged from 7.7 to 13.5, with a mean of 10.2. The Lexile score ranged from 880 to 1270, with a mean of 1113. The mean SAM score ranged from 16% to 36%, with a mean of 29%. Mean grade level, Lexile score, and SAM score did not vary significantly by diagnostic category. No single document had an acceptable suitability score, and only two had acceptable Lexile scores. Common deficiencies included use of the passive voice, vague wording, and technical jargon.The letters we analyzed were written at levels too difficult for many patients to understand. Future investigations should explore clearer ways of communicating mammography results.

    View details for DOI 10.1089/jwh.2010.2330

    View details for Web of Science ID 000289460400006

    View details for PubMedID 21428738

  • Evaluation of Consistency in Dosing Directions and Measuring Devices for Pediatric Nonprescription Liquid Medications JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Yin, H. S., Wolf, M. S., Dreyer, B. P., Sanders, L. M., Parker, R. M. 2010; 304 (23): 2595-2602


    In response to reports of unintentional drug overdoses among children given over-the-counter (OTC) liquid medications, in November 2009 the US Food and Drug Administration (FDA) released new voluntary industry guidelines that recommend greater consistency and clarity in OTC medication dosing directions and their accompanying measuring devices.To determine the prevalence of inconsistent dosing directions and measuring devices among popular pediatric OTC medications at the time the FDA's guidance was released.Descriptive study of 200 top-selling pediatric oral liquid OTC medications during the 52 weeks ending October 30, 2009. Sample represents 99% of the US market of analgesic, cough/cold, allergy, and gastrointestinal OTC oral liquid products with dosing information for children younger than 12 years.Inclusion of measuring device, within-product inconsistency between dosing directions on the bottle's label and dose markings on enclosed measuring device, across-product use of nonstandard units and abbreviations, and presence of abbreviation definitions.Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation.At the time the FDA released its new guidance, top-selling pediatric OTC liquid medications contained highly variable and inconsistent dosing directions and measuring devices.

    View details for DOI 10.1001/jama.2010.1797

    View details for Web of Science ID 000285303400022

    View details for PubMedID 21119074

  • Interventions Aimed at Decreasing Obesity in Children Younger Than 2 Years A Systematic Review ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Ciampa, P. J., Kumar, D., Barkin, S. L., Sanders, L. M., Yin, H. S., Perrin, E. M., Rothman, R. L. 2010; 164 (12): 1098-1104


    To assess the evidence for interventions designed to prevent or reduce overweight and obesity in children younger than 2 years.MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and references from relevant articles.Included were published studies that evaluated an intervention designed to prevent or reduce overweight or obesity in children younger than 2 years.Extracted from eligible studies were measured outcomes, including changes in child weight status, dietary intake, and physical activity and parental attitudes and knowledge about nutrition. Studies were assessed for scientific quality using standard criteria, with an assigned quality score ranging from 0.00 to 2.00 (0.00-0.99 is poor, 1.00-1.49 is fair, and 1.50-2.00 is good).We retrieved 1557 citations; 38 articles were reviewed, and 12 articles representing 10 studies met study inclusion criteria. Eight studies used educational interventions to promote dietary behaviors, and 2 studies used a combination of nutrition education and physical activity. Study settings included home (n = 2), clinic (n = 3), classroom (n = 4), or a combination (n = 1). Intervention durations were generally less than 6 months and had modest success in affecting measures, such as dietary intake and parental attitudes and knowledge about nutrition. No intervention improved child weight status. Studies were of poor or fair quality (median quality score, 0.86; range, 0.28-1.43).Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity. Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families.

    View details for Web of Science ID 000285009900008

    View details for PubMedID 21135337

  • No Follow-Up After Positive Newborn Screening: Medical Neglect? CHILD MALTREATMENT Merrick, M. T., Butt, S. M., Jent, J. F., Cano, N. M., Lambert, W. F., Chapman, A. V., Griffith, J. F., Ciener, D., Dandes, S. K., Sanders, L. M. 2010; 15 (4): 315-323


    The current study examined medical professionals' behaviors related to reporting medical neglect when a family is noncompliant with follow-up services after a positive newborn screening result. Pediatric medical professionals within an urban medical campus were provided with five case vignettes in relation to different diseases. Medical professionals rated the severity of family noncompliance with follow-up services and indicated whether they would report suspected medical neglect to Child Protective Services (CPS). Physicians were more likely to report medical neglect than the other mandated reporters in the study. Logistic regression analyses found that medical professionals' perceptions of the severity of family noncompliance with services were significantly predictive of decisions to report medical neglect. Respondent gender and the method by which families were notified of screening results also significantly affected reporting behaviors in certain instances. Although all vignettes included information that met legal statutes for reporting neglect, medical professionals indicated that they would only report neglect 40-61% of the time across vignettes. Continued investigation of the rationale behind medical professionals' decision-making process and training protocols designed to improve mandated reporter knowledge and reporting behaviors are needed to further reduce bias and improve objectivity when considering ethical and professional obligations to report medical neglect.

    View details for DOI 10.1177/1077559510384983

    View details for Web of Science ID 000282636800005

    View details for PubMedID 20930180

  • The Lure of Treatment: Expanded Newborn Screening and the Curious Case of Histidinemia PEDIATRICS Brosco, J. P., Sanders, L. M., Dharia, R., Guez, G., Feudtner, C. 2010; 125 (3): 417-419

    View details for DOI 10.1542/peds.2009-2060

    View details for Web of Science ID 000275945700001

    View details for PubMedID 20156889

  • Historical Trends in Low Birth Weight ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Brosco, J. P., Sanders, L. M., Guez, G., Lantos, J. D. 2010; 164 (1): 99-100

    View details for Web of Science ID 000273262900016

    View details for PubMedID 20048251

  • The health literacy of parents in the United States: a nationally representative study. Pediatrics Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., Dreyer, B. P. 2009; 124: S289-98


    To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1-4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6-7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

    View details for DOI 10.1542/peds.2009-1162E

    View details for PubMedID 19861483

  • Health literacy and child health promotion: implications for research, clinical care, and public policy. Pediatrics Sanders, L. M., Shaw, J. S., Guez, G., Baur, C., Rudd, R. 2009; 124: S306-14


    The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.

    View details for DOI 10.1542/peds.2009-1162G

    View details for PubMedID 19861485

  • Pediatricians and health literacy: descriptive results from a national survey. Pediatrics Turner, T., Cull, W. L., Bayldon, B., Klass, P., Sanders, L. M., Frintner, M. P., Abrams, M. A., Dreyer, B. 2009; 124: S299-305


    To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits.A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900).Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics.Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.

    View details for DOI 10.1542/peds.2009-1162F

    View details for PubMedID 19861484

  • Literacy and Child Health A Systematic Review ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sanders, L. M., Federico, S., Klass, P., Abrams, M. A., Dreyer, B. 2009; 163 (2): 131-140


    To assess the prevalence of low health literacy among adolescents, young adults, and child caregivers in the United States, the readability of common child-health information, and the relationship between literacy and child health.MedLine, Educational Resources Information Center, National Library of Medicine, PsychInfo, Harvard Health Literacy Bibliography, and peer-reviewed abstracts from the Pediatric Academic Societies Annual Meetings.A systematic review using the following key words: health literacy, literacy, reading skill, numeracy, and Wide Range Achievement Test.Descriptive studies that used at least 1 valid measure of health literacy, studies that assessed the readability of child health information, and observational or experimental studies that included a validated measure of health literacy, literacy, or numeracy skills and an assessment of child health-related outcomes.A total of 1267 articles were reviewed, and 215 met inclusion and exclusion criteria. At least 1 in 3 adolescents and young adults had low health literacy; most child health information was written above the tenth-grade level. Adjusted for socioeconomic status, adults with low literacy are 1.2 to 4 times more likely to exhibit negative health behaviors that affect child health, adolescents with low literacy are at least twice as likely to exhibit aggressive or antisocial behavior, and chronically ill children who have caregivers with low literacy are twice as likely to use more health services.Low caregiver literacy is common and is associated with poor preventive care behaviors and poor child health outcomes. Future research should aim to ameliorate literacy-associated child health disparities.

    View details for Web of Science ID 000262991800006

    View details for PubMedID 19188645

  • Conduct disorder. Pediatrics in review Sanders, L. M., Schaechter, J., Serwint, J. R. 2007; 28 (11): 433-434

    View details for PubMedID 17974708

  • Factors influencing community pediatrics training in residency JOURNAL OF PEDIATRICS Minkovitz, C. S., Chandra, A., Solomon, B. S., Sanders, L. M., Grason, H. A., Carraccio, C. 2007; 150 (2): 119-120

    View details for DOI 10.1016/j.jpeds.2006.10.047

    View details for Web of Science ID 000244111300001

    View details for PubMedID 17236883

  • Caregiver health literacy and the use of child health services PEDIATRICS Sanders, L. M., Thompson, V. T., Wilkinson, J. D. 2007; 119 (1): E86-E92


    Eighty million US adults have low health literacy, a risk factor for increased health care use among adults. The purpose of this work was to assess the association between caregiver health literacy and the use and cost of child health services.We conducted a cross-sectional study of caregiver-child dyads from a sample of children aged 12 months to 12 years presenting to the pediatric emergency department of an urban, public hospital. Caregiver health literacy was measured by the Short Test of Functional Health Literacy in their preferred language (English or Spanish). Child health care use was measured by a 12-month retrospective review of the public hospital system's electronic database and of state Medicaid billing records for 4 types of visits: preventive care, urgent care, emergency care, and hospital care. Cost of child health care use was provided by Medicaid billing records. Multivariate analysis included caregiver education, age, and language proficiency, as well as child age, special health care needs, ethnicity, and health-insurance coverage.A total of 290 dyads were enrolled in the study. Twenty-two percent of caregivers had low (inadequate or marginal) health literacy. Caregivers with low health literacy were more likely to have less than a high school education, to have limited English proficiency, and to have been born outside the United States. There were no differences in health care use or cost between children of caregivers with low health literacy and children of caregivers with adequate health literacy. Three caregiver characteristics were associated with increased use of child health care services: born outside the United States, age at child's birth <24 years, and limited English proficiency.One in 5 caregivers of young children has low health literacy. Caregiver health literacy, however, was not associated with disparities in the use of child health services in this inner-city, ethnic minority population.

    View details for DOI 10.1542/peds.2005-1738

    View details for Web of Science ID 000243191800013

    View details for PubMedID 17200263

  • Advocacy by any other name would smell as sweet ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Sanders, L. M., Takayama, J. I. 2006; 160 (4): 453-453

    View details for Web of Science ID 000236516500024

    View details for PubMedID 16585499

  • Child advocacy training - Curriculum outcomes and resident satisfaction ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Sanders, L. M., Takayama, J. I. 2005; 159 (9): 842-847


    Many health problems affecting children today are based in the community and cannot be easily addressed in the office setting. Child advocacy is an effective approach for pediatricians to take.To describe pediatric residents' choices of advocacy topics and interventions.Cross-sectional observational study.Residents from 3 pediatric training programs participated in the Child Advocacy Curriculum, which featured standardized workshops and the development of individual advocacy projects. To evaluate the curriculum, project descriptions and material products were analyzed to determine individual advocacy topics, topic themes, and targets of project interventions. Differences among programs were assessed. Residents also completed an anonymous questionnaire assessing their experience with the Child Advocacy Curriculum.Residents demonstrated a wide range of interests in selecting advocacy topics: 99 residents chose 38 different topics. The most common topic was obesity (13 residents) followed by health care access (9), teen pregnancy prevention (6), and oral health (5). Themes included health promotion and disease prevention, injury prevention, health care access, children with special health care needs, child development, at-risk populations, and the impact of media on child health. The project interventions targeted the local community most frequently (37%), followed by resident education (27%), hospital systems (21%), and public and health policy (15%). The vast majority of participating residents reported a positive experience with the Child Advocacy Curriculum.The wide range of topics and settings in which residents developed projects illustrates residents' extensive interests and ingenuity in applying needed advocacy solutions to complex child health issues.

    View details for Web of Science ID 000231653800007

    View details for PubMedID 16143743

  • Evidence-based community pediatrics: Building a bridge from bedside to neighborhood PEDIATRICS Sanders, L. M., Robinson, T. N., Forster, L. Q., Plax, K., Brosco, J. P., Brito, A. 2005; 115 (4): 1142-1147


    The American Academy of Pediatrics policy statement "The Pediatrician's Role in Community Pediatrics" encourages all pediatricians to partner with their communities to create and disseminate innovative programs that improve child health. This article describes 4 pillars of a bridge to evidence-based community pediatrics for pediatricians interested in pursuing effective community action: (1) collaborate with the community to establish a specific, short-term, health-related goal; (2) identify evidence-based best practice(s) for achieving the shared goal; (3) collaborate with the community to adapt this best practice to the community's unique assets and constraints; and (4) evaluate the project by using appropriate expertise. Practical elements of each pillar are described and illustrated by specific examples from community-based efforts of pediatricians and are accompanied by specific resources to aid pediatricians in their future community health work.

    View details for DOI 10.1542/peds.2004-2825H

    View details for Web of Science ID 000228108800008

    View details for PubMedID 15821298

  • Number of children's books in the home: An indicator of parent health literacy AMBULATORY PEDIATRICS Sanders, L. M., Zacur, G., Haecker, T., Klass, P. 2004; 4 (5): 424-428


    One in 4 US adults have poor health literacy, unable to read and understand written medical information. Current tools that assess health literacy skills are too lengthy to be useful in routine clinical encounters.To determine which of 7 screening questions is most useful for identifying parents with adequate health literacy.A cross-sectional study of an ethnically diverse sample of 163 parents of children aged 12 to 24 months presenting for routine care at 1 of 6 inner-city clinics. Literacy was measured by performance on the Short Test of Functional Health Literacy for Adults, which was categorized as "adequate" or "inadequate or marginal." The 7 screening questions concerned parents' educational achievement, educational expectations for the child, and home literacy environment.Eighty-three percent of respondents had adequate health literacy, which was highest among those who were African American, were born outside the United States, spoke English primarily at home, and had completed high school. Only 2 factors, however, were independently associated with adequate health literacy: more than 10 adults' books or more than 10 children's books in the home. "More than 10 children's books" had a positive predictive value of 91%.Having more than 10 children's books in the home is a useful, independent indicator of adequate parent health literacy. More research is needed, however, to find a better screening tool for identifying parents with increased health literacy needs.

    View details for Web of Science ID 000224035900006

    View details for PubMedID 15369414

  • Helping Families ImproveSelf-Management of Pediatric Asthma: A Guide for the Primary Care Physician. Pediatric case reviews (Print) Sanders, L. M., McCullough, J. R. 2002; 2 (2): 112-125

    View details for PubMedID 12865688

  • Prescribing books for immigrant children - A pilot study to promote emergent literacy among the children of Hispanic immigrants ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sanders, L. M., Gershon, T. D., Huffman, L. C., Mendoza, F. S. 2000; 154 (8): 771-777


    To assess book-sharing activities within first-generation Hispanic immigrant families, and to assess the effect of pediatricians giving books to their patients.Survey.Convenience sample of 122 predominantly Hispanic immigrant parents of children aged 2 months to 5 years. Of these parents, 56 had received children's books from the pediatrician, and 66 had not.House staff continuity clinic at a university children's hospital.Frequent Book Sharing (FBS) was defined as a parent's reporting more than 3 days per week of sharing books with the child. Main independent variables included the following: (1) exposure to the Reach Out and Read program, defined as having received a children's book from the pediatrician; (2) socioeconomics, as measured by parents' years of education and Medicaid enrollment; (3) acculturation, as defined by 4 questions relating to parents' proficiency with the English language; (4) parent's country of origin; (5) parent literacy, as measured by a parent's reporting more than 3 days per week of reading alone; (6) parent's age; (7) marital status; (8) household size; (9) child's age; (10) child's sex.Ninety percent of the parents were born outside of the United States (71% in Mexico), 85% spoke Spanish in the home, and 63% had completed less than a high-school education. Seventy-five percent of children's medical insurance was provided by Medi-Cal (Medicaid), and 9% of children were uninsured. Sixty-seven percent spoke exclusively Spanish at home, and 84% of parents want their children to learn to read in both English and Spanish. High FBS was reported among parents whose children had received books from the physician when compared with parents whose children had received no books. The odds ratio (OR) was 3.62 (95% confidence interval [CI], 1.40-9.37; P<.05). Also associated with FBS were parents reading frequently to themselves (OR = 9.52; 95% CI, 2.09-43.27; P<.05) and national origin outside Mexico (OR = 5.54; 95% CI, 1.59-19.27; P<.05). These findings were independent of parent's educational level, parent's employment, parent's age, acculturation, and family size.Pediatricians can promote literacy development among Hispanic immigrant children through the provision of free books at well-child visits. Our findings also suggest the independent effects of adult literacy and child age. Further research is needed to understand the effect of pediatric literacy programs on Hispanic immigrant children, their bilingual environments, and their readiness for school entry. Arch Pediatr Adolesc Med. 2000;154:771-777

    View details for Web of Science ID 000088655000003

    View details for PubMedID 10922272

  • Understanding the practice of ethics consultation: Results of an ethnographic multi-site study JOURNAL OF CLINICAL ETHICS Kelly, S. E., Marshall, P. A., Sanders, L. M., Raffin, T. A., Koenig, B. A. 1997; 8 (2): 136-149

    View details for Web of Science ID A1997XW32500003

    View details for PubMedID 9302631


    View details for Web of Science ID A1994NX37200003

    View details for PubMedID 8020272

  • ETHICS OF FETAL TISSUE-TRANSPLANTATION WESTERN JOURNAL OF MEDICINE Sanders, L. M., Giudice, L., Raffin, T. A. 1993; 159 (3): 400-407


    Now that the Clinton Administration has overturned the ban on federal funding for fetal tissue transplantation, old ethical issues renew their relevance and new ethical issues arise. Is fetal tissue transplantation necessary and beneficial? Are fetal rights violated by the use of fetal tissue in research? Is there a moral danger that the potential of fetal tissue donation will encourage elective abortions? Should pregnant women be allowed to designate specific fetal transplant recipients? What criteria should be used to select fetal tissue transplants? Whose consent should be required for the use of fetal tissue for transplantation? We review the current state of clinical research with fetal tissue transplantation, the legal history of fetal tissue research, the major arguments against the use of fetal tissue for transplantation, and the new postmoratorium ethical dilemmas. We include recommendations for guidelines to govern the medical treatment of fetal tissue in transplantation.

    View details for Web of Science ID A1993MA37000022

    View details for PubMedID 8236984

  • The ethics of withholding and withdrawing critical care. Cambridge quarterly of healthcare ethics Sanders, L. M., Raffin, T. A. 1993; 2 (2): 175-184

    View details for PubMedID 8293207


    View details for Web of Science ID A1992JX20900060

    View details for PubMedID 1424892

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