PEDIATRICS recent issues

Evaluation and Management of the Infant Exposed to HIV in the United States

Pediatricians play a crucial role in optimizing the prevention of perinatal transmission of HIV infection. Pediatricians provide antiretroviral prophylaxis to infants born to women with HIV type 1 (HIV) infection during pregnancy and to those whose mother’s status was first identified during labor or delivery. Infants whose mothers have an undetermined HIV status should be tested for HIV infection within the boundaries of state laws and receive presumptive HIV therapy if the results are positive. Pediatricians promote avoidance of postnatal HIV transmission by advising mothers with HIV not to breastfeed. Pediatricians test the infant exposed to HIV for determination of HIV infection and monitor possible short- and long-term toxicity from antiretroviral exposure. Finally, pediatricians support families living with HIV by providing counseling to parents or caregivers as an important component of care.

Neonatal Opioid Withdrawal Syndrome

The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.

Routine Neuroimaging of the Preterm Brain

Neuroimaging of the preterm infant is a common assessment performed in the NICU. Timely and focused studies can be used for diagnostic, therapeutic, and prognostic information. However, significant variability exists among neonatal units as to which modalities are used and when imaging studies are obtained. Appropriate timing and selection of neuroimaging studies can help identify neonates with brain injury who may require therapeutic intervention or who may be at risk for neurodevelopmental impairment. This clinical report reviews the different modalities of imaging broadly available to the clinician. Evidence-based indications for each modality, optimal timing of examinations, and prognostic value are discussed.

Current Research in Pragmatic Language Use Among Deaf and Hard of Hearing Children

In this article, we provide a narrative review of research literature on the development of pragmatic skills and the social uses of language in children and adolescents, with a focus on those who are deaf and hard of hearing (DHH). In the review, we consider how pragmatic skills may develop over time for DHH children and adolescents depending on age, language context, amplification devices, and languages and communication modalities. The implications of these findings for enhancing intervention programs for DHH children and adolescents and for considering ideal contexts for optimizing the pragmatic development of DHH children are considered.

Relational Factors in Pragmatic Skill Development: Deaf and Hard of Hearing Infants and Toddlers

In this article, we review relational factors in early childhood believed to contribute in unique ways to pragmatic skill development in deaf and hard of hearing (DHH) infants and toddlers. These factors include attending to infant interactions with caregivers and others, supporting development of theory of mind through play and use of mental state language (ie, describing one’s own or others’ thoughts, feelings, and beliefs), and providing accessible opportunities for social interaction. On the basis of a review of the literature and clinical experience, we offer prescriptive strategies for supporting DHH children’s development in these areas. To improve outcomes for DHH children, medical care providers and allied health professionals have a responsibility to support the development of young DHH children’s pragmatic abilities by understanding these variables, coaching caregivers regarding their importance, and facilitating referrals for support when necessary.

Early Pragmatics in Deaf and Hard of Hearing Infants


A set of important pragmatic skills emerge during infancy and pave the way for later language learning. It is thought these early social communication skills develop through infant–caregiver interaction. In a microanalysis, we tested whether deaf and hard of hearing (DHH) infants (typically at high risk of reduced access to rich communicative interaction in infancy) are less likely to engage in gestural and vocal pragmatic behaviors.


We coded the naturalistic communication of 8 DHH infants who had no additional needs, who were not preterm or low birth weight, whose parents were hearing, monolingual English speakers, and who had spoken English as their primary target language. The frequency of use of 5 types of infant communication known to positively predict later language development (show gestures, give gestures, index-finger pointing, communicative vocalizations, and early word use) was compared with that of 8 typically hearing infants matched for age, sex, and socioeconomic status.


Hearing loss had a significant negative effect on the frequency with which infants engaged in all types of early communication that predict later language development.


DHH infants are at high risk of delay in the gestural and vocal communicative skills that lay the foundations for later language. Delay in the gestural domain suggests this is not simply a consequence of difficulties in imitating auditory stimuli. There is significant potential to lift DHH infants onto a positive developmental trajectory by supporting caregivers to nurture interaction from the first year.

Early Intervention, Parent Talk, and Pragmatic Language in Children With Hearing Loss


Pragmatic language skills form the foundation for conversational competence, whereas deficits in this area are associated with behavioral problems and low literacy skills. Children who are deaf or hard of hearing demonstrate significant delays in this critical area of language. Our purpose with this research was to identify variables associated with pragmatic language ability in children who are deaf or hard of hearing.


This was a longitudinal study of 124 children with bilateral hearing loss between 4 and 7 years of age living in Colorado. As part of a comprehensive speech and language assessment, pragmatic language skills were evaluated annually by using the Pragmatics Checklist.


The children’s pragmatic skills increased significantly with age. Higher levels of pragmatic language ability at 7 years of age were predicted by (1) meeting Early Hearing Detection and Intervention 1-3-6 guidelines (hearing screening by 1 month, identification of hearing loss by 3 months, and receiving intervention by 6 months of age), (2) greater quantity of parent talk, (3) higher nonverbal intelligence, (4) lesser degrees of hearing loss, and (5) higher maternal education.


With the findings of this study, we underscore the importance of pediatricians and other health care professionals counseling parents about the value of adherence to the Early Hearing Detection and Intervention 1-3-6 guidelines with regard to intervention outcomes. The strong association between amount of child-directed parent talk in the first 4 years of life and pragmatic language outcomes at 7 years of age emphasizes the need for professionals to encourage parents to talk to their children as much as possible.

Using Gesture To Identify and Address Early Concerns About Language and Pragmatics

Speakers and signers naturally and spontaneously gesture when they use language to communicate. These gestures not only play a central role in how language is used in social situations but also offer insight into speakers’ and signers’ cognitive processes. The goals of this article are twofold: (1) to document how gesture can be used to identify concerns in language development and (2) to illustrate how gesture can be used to address those concerns, particularly with respect to pragmatic development. These goals are explored in this article, with a focus on deaf and/or hard of hearing (DHH) children. Medical providers and allied health professionals, as well as educators and parents, can use the information gleaned from the gestures of DHH children to determine if intervention is needed. Gesture can also be used to design interventions, including interventions in which children who are DHH are presented gestures in combination with speech or signs and interventions in which they are encouraged to gesture themselves. Children’s gestures not only increase their learning potential but also create opportunities for medical and health professionals, as well as educators and parents, to gain access to a DHH child’s unspoken and unsigned ideas, capitalizing on the opportunity to provide intervention when it is likely to be effective.

The Assessment of Pragmatic Skills in Young Deaf and Hard of Hearing Children

The development of pragmatic skills does not often receive attention by professionals who are recommending or undertaking assessment of deaf and hard of hearing (DHH) children, yet social communication is vital for linguistic, social, emotional, and academic development. We acknowledge the challenges that DHH children have with pragmatic skills, advocate for monitoring of pragmatic development for all DHH children by medical professionals, and provide direction for assessment of pragmatic skills in young DHH children, particularly for clinicians and teachers who are tasked with that work. Pragmatic assessment is challenging because it must involve observations of the child in interaction with a communication partner, either directly during a specific interaction or through the reflections of a familiar adult. In this article, we recommend two complementary assessment procedures for young DHH children who use spoken language. Assessment 1 recommends that a parent or caregiver completes The Pragmatic Checklist to provide a picture of the child’s functional communication. In assessment 2, the information gained through the checklist is complemented by using direct observations of a child in interaction with an adult or a peer. The Pragmatic Protocol uses a video-recorded conversation sample between the child and familiar person that is analyzed by a DHH professional for 30 different pragmatic behaviors. We conclude this article with a recommendation for pediatricians and health care professionals to monitor pragmatic developmental milestones in DHH children, to refer them for pragmatic assessments, and to collaborate with researchers to develop valid, reliable tools that adequately capture the pragmatic skill strengths and needs of DHH children.

The Impact of Pragmatic Delays for Deaf and Hard of Hearing Students in Mainstream Classrooms

Increasingly, across the globe, deaf and hard of hearing (DHH) students are educated in mainstream schools using spoken language for communication. Classroom interactions require the use of sophisticated pragmatic language skills. Pragmatic skills can be delayed in DHH students and create challenges for the social and emotional adjustment of DHH students at school. School-aged DHH children may present to pediatric health care providers with concerns about communicating effectively and forming friendships with hearing school peers. This review of pragmatic research between school-aged DHH students and their typically hearing peers reveals that this group of students displays some well-developed pragmatic skills such as turn taking, questioning, seeking general clarifications, and using a range of turn types. In it, we identify key areas in which DHH students experience significant challenges in both the social use of language and expository interactions (involving descriptions or explanations) that characterize classroom communication. DHH students tend to dominate interactions and have challenges with being contingent on their partners’ contributions. In addition, many DHH students display some difficulty with sequencing instructions and may use referents poorly, making it difficult for peers to follow their instructions and fully grasp their meaning. The conversation model is presented in this article as a guide for pediatric health care providers, clinicians, educators, and parents and/or caregivers to understand these pragmatic challenges. The model guides medical and education practitioners with the development of targeted intervention that will support these students’ ability to interact with others, learn more effectively, and develop friendships.

Pragmatics and Peer Relationships Among Deaf, Hard of Hearing, and Hearing Adolescents


The goals of the current study were to (1) examine differences in pragmatic abilities and peer relationship behaviors among deaf and hard of hearing (DHH) adolescents who use spoken language, in comparison with their hearing peers; and (2) explore the contribution of pragmatic skills and speech (ie, articulation and intelligibility [AI]) to social aspects of school functioning among DHH and typically hearing adolescents.


Thirty-three DHH adolescents and 34 adolescents with typical hearing participated. All DHH adolescents attended mainstream school settings and used spoken language. Teacher reports were obtained on prosocial behaviors, peer problems, pragmatic abilities, and speech AI of the adolescents. Adolescents self-reported on the supportiveness of their peer relationships and their school emotional engagement.


Multiple hierarchical regression analyses revealed that DHH adolescents had greater difficulties with peers than their hearing counterparts. Increased pragmatic difficulties were related to more peer problems and decreased prosocial behaviors, regardless of adolescents’ hearing status. A significant positive correlation was found between pragmatic competence and adolescents’ perceptions of peers’ support. Finally, better speech AI were associated with higher levels of school emotional engagement.


The results emphasize the significant role of pragmatics for both DHH and typically hearing adolescents. Medical care providers and allied health professionals should be aware of possible difficulties that DHH adolescents may have in complex and nuanced pragmatic skills. Some adolescents may require a referral to specialized services to support the development of their pragmatic understanding and their skills.

The Lived Experience and Legacy of Pragmatics for Deaf and Hard of Hearing Children

In this article, we discuss deaf and hard of hearing (DHH) children’s pragmatic difficulties and strengths from within the lived experiences of 5 hearing parents of DHH children and 5 DHH adults (one of whom is also a parent of a deaf child). We define lived experience as both a specific form of knowledge (first-hand stories from everyday life) and a unique way of knowing (reflecting and telling from insider perspectives). The parents and DHH adults involved coauthored the article alongside 2 experienced researcher-practitioners. Key themes include what pragmatic challenges feel like for a DHH person, why they arise, how they might result in longer-term consequences (such as implications for well-being) that can continue into adulthood, what might be pragmatic strengths in this population, and what might be done to ameliorate pragmatic difficulties. We end the article with reflections on the significance of individual parents and DHH adults in the coproduction and execution of research on this topic and make suggestions for future directions of inquiry.

Pragmatics Development in Deaf and Hard of Hearing Children: A Call to Action

Although major strides have been made in supporting the linguistic development of deaf and hard of hearing (DHH) children, a high risk of pragmatic delay persists and often goes unrecognized. Pragmatic development (the growing sensitivity to one’s communication partner when producing and comprehending language in context) is fundamental to children’s social-cognitive development and to their well-being. We review the reasons why DHH children are vulnerable to pragmatic developmental challenges and the potential to create positive change. In this call to action, we then urge (1) medical providers to recognize the need to monitor for risk of pragmatic difficulty and to refer for timely intervention (beginning in infancy), (2) allied health professionals involved in supporting DHH children to incorporate development of pragmatic abilities into their work and to foster awareness among caregivers, and (3) the research community to deepen our understanding of pragmatics in DHH children with investigations that include pragmatics and with longitudinal studies that chart the paths to positive outcomes while respecting the diversity of this population. By working together, there is substantial potential to make rapid progress in lifting developmental outcomes for DHH children.