Strong Beginnings, Successful Lives: A Prenatal-to-Three Policy Guidebook for Legislators

Brain research shows babies develop a million new neural connections every second. They are born learning, and what they learn and how they learn it lay the foundation for the rest of their life. Consequently, the science of early brain development is being used to inform policy decision-making at all levels of government. Some state legislators across the country are looking for ways to help parents provide enriching early experiences and ensure healthy development for their infants and toddlers.

To support state lawmakers, NCSL’s Prenatal-to-Three Legislative Advisory Group examined infant and toddler issues and policy options and produced this legislative guidebook, which includes the following framework. The guidebook is intended to provide a national context and help state legislators identify entry points for enacting infant and toddler policy in their state.

Lawmakers across the country are considering prenatal-to-three policy options because healthy physical, social, emotional and cognitive development place infants and toddlers on track for school readiness and success in life. The promise of positive returns on public investments in early childhood programs also is a selling point in many legislatures. Nobel Laureate James Heckman, an economist at the University of Chicago, found a return on investment of $6.30 for every dollar invested in high-quality early care and health programs.

Healthy Beginnings

• Access to Prenatal Care
• Breastfeeding Needs and Supports
• Public Awareness of Healthy Pregnancies

Strong starts in life begin with healthy pregnancies and building awareness of the importance of healthy pregnancies is a step toward better outcomes for mothers, infants and toddlers, and society. With increased awareness, expectant mothers are more likely to receive prenatal care and learn the importance of caring for themselves mentally, physically and emotionally.

Prenatal care can prevent costly pregnancy-related complications, preterm births and low birth weight. Prenatal care services assess the health of expectant mothers—including screening for chronic diseases and substance abuse—and encourage healthy behaviors.

Parent-child attachment is essential for healthy development and creating the conditions for mothers to bond with their infants is necessary for attachment to occur. It also supports breastfeeding and has a lasting positive impact on babies’ health. Mothers benefit as well, with lower risks of developing breast and ovarian cancers. Some states encourage breastfeeding and help mothers and children bond by reimbursing for lactation consultants and supplies.

Family Supports

• Parent Training and Education
• Family Economic Supports
• Access to Services and Resources

Many parents are stretched thin, particularly new or young parents and parents who are economically disadvantaged, lack stable housing or are food insecure. Providing voluntary home visits and other forms of training and support for families fosters better social and emotional outcomes for infants and toddlers.

Recent U.S. Census Bureau data shows that one in five infants and toddlers lived in poverty in 2017. Research shows the effects of poverty on brain development start early and can be detected in infancy.

Economic supports such as Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP) and child care assistance help parents of infants and toddlers work, attend school or job-training programs, and put food on the table. In addition, providing access to support services in a one-stop experience can reduce barriers to enrollment and ensure that parents and children receive the supports they need to thrive.

Early Learning, Development and Care

• Quality Matters
• Early Care and Education Professionals
• Screenings and Interventions

An estimated 11.5 million children from birth to age 3 spend some portion of their day in the care of someone other than their parents.³ Many of these children are in care settings that do not meet quality standards necessary for optimal development.⁴ Infants and toddlers need safe, stimulating and nurturing environments and positive relationships with caregivers to support healthy brain development and to lay the foundation for lifelong learning and overall well-being.

High-quality early care and learning requires a well-trained and supported workforce. Some states are trying to elevate the workforce that provides care to infants and toddlers by incentivizing or requiring higher levels of preparation through new compensation strategies. At the same time, the cost of child care already is a challenge for many families, and parents of infants and toddlers face the highest costs.

In addition, regular screenings and referrals to monitor growth and development ensure early detection of and response to developmental issues. A growing number of states are adopting guidelines to provide a blueprint for physicians and other professionals to follow as they administer health, developmental and behavioral screenings.

Conclusion

NCSL’s Prenatal-to Three Legislative Advisory Group developed this guidebook for state legislators and other policymakers to use when examining prenatal-to-three issues and policy options. Rich with examples and resources, it was designed to help establish baseline knowledge and identify entry points for understanding and enacting infant and toddler policies.

Backed by a growing body of scientific research, state lawmakers are considering an array of policy options to help ensure all children reach their full potential—starting early in life. At their core, these options promote healthy development, which includes physical, social, emotional and cognitive development and keep infants and toddlers on track for school readiness. They also help ensure a skilled and adequate workforce in the future, improved health outcomes and reduced crime.

In particular, new and compelling knowledge of how brains develop, prenatally and in the first three years of life, is motivating lawmakers to pursue investments in the early years. Policymakers are connecting the brain science to policy that supports healthy development and well-being and promotes positive developmental outcomes for infants and toddlers.

Many policymakers also are attracted by the financial returns on investments in early childhood programs. Economic Nobel Laureate James Heckman found a return on investment of $6.30 for every dollar invested in high-quality early care and health programs beginning at birth, with the largest societal return being long-term health benefits.

What Can Legislators Do?

Many legislators are playing important roles in helping infants and toddlers reach their full potential. They are enacting legislation, developing and approving budgets, and establishing committees and task forces to bring additional expertise and perspectives to state issues. They also convene constituents, community partners and stakeholders and support public awareness on issues in their community and among their legislative colleagues. Below we highlight four important functions of legislators.

Legislate

Nationwide, state legislators consider around 900 bills annually on a range of early care and education topics, including prenatal-to-three policies. In 2018, at least 120 bills were signed into law in 36 states that addressed child care, home visiting and parent support, and prenatal, infant and toddler issues. A 2019 NCSL report looks at recently enacted legislation to improve services and supports for infants, toddlers and their families. For example, in 2018, the Louisiana Legislature created a commission co-chaired by legislators to develop a plan to address affordable access to high-quality early childhood education for children from birth through age 4. Oregon, in 2019, enacted legislation that directs the Oregon Health Authority to implement a voluntary home visiting programs for all families with infants up to 6 months old and requires health plans to cover these services without cost-sharing.

Fund

State legislators are the decision-makers on funding support programs for families with infants and toddlers. State legislators can direct federal and state funds to be used to increase access to high-quality child care for infants and toddlers. Prenatal-to-three funding often involves a mix of federal, state, local and private funding. Some states have targeted funding for infant and toddler programs. For example, Kansas uses tobacco settlement funds for infant and toddler initiatives. Illinois provides a 20% birth-to-three funding set-aside by statute, and Nebraska’s Six Pence fund, which supports parents, family engagement and high-quality care for infants and toddlers, was established by the legislature in 2006.

Convene

State legislators convene stakeholders to exchange information on policy issues that affect infants and toddlers. For example, Minnesota state legislators and community stakeholders gather each quarter at the state’s Prenatal-to-Three Policy Forums to take a comprehensive look at issues facing the state’s infants and toddlers. The gatherings are an opportunity to share plans, knowledge and policy priorities for Minnesota’s youngest children.

Raise Public Awareness

Legislators help raise awareness among families in their districts and elsewhere of the importance of the prenatal-to-three years. Lawmakers also support outreach to promote programs that helps families thrive. For example, the Georgia Alliance for Early Education of Students led a public awareness campaign focused on the elements of high-quality child care and the state’s child care quality rating and improvement system (QRIS). Child care providers, parents, stakeholders, legislators and the governor were all involved in campaigning for the effort. Arizona lawmakers enacted legislation that requires the Department of Economic Security to provide child care subsidy recipients with information on the Earned Income Tax Credit (EITC).

• Access to prenatal care
• Breastfeeding needs and supports
• Public awareness of healthy pregnancies

The link between healthy infant-toddler development and the capacity to learn is well established. Positive parent-child attachment, which is rooted in “serve and return” interactions, is a stepping stone for building the executive function and self-regulation skills children need to succeed in school. Research shows that healthy children with age-appropriate development are less likely to be absent, have greater attention spans and fewer and less severe behavioral issues than children who experience toxic stress. All of this leads to greater academic achievement.

Healthy beginnings for infants and toddlers start with prenatal care for expectant mothers. Prenatal care includes health assessments and screenings for chronic diseases and behavioral health concerns, such as a substance use or mental health disorders. Prenatal care also promotes healthy behaviors and breastfeeding, which reduces the likelihood of postpartum depression and accelerates recovery when it does occur. Prenatal care also can prevent pregnancy complications, low birth weight and preterm births.

Some jurisdictions have funded information campaigns to raise public awareness about the importance of healthy pregnancies. In addition to educating the general population or specific populations, such campaigns also can build support for policy changes.

Access to Prenatal Care

Infants born to women who receive late or no prenatal care are twice as likely to have low birth weights as infants born to women with prenatal care in the first trimester. According to the KIDS COUNT Data Center, 6% of U.S. births are from women who receive late or no prenatal care.⁷ Timely prenatal care reduces unhealthy behaviors, such as using alcohol and tobacco, by providing treatment and services for expectant mothers and their babies.

Perinatal quality collaboratives are state or multi-state networks of teams working to improve infant and maternal health through evidence-informed clinical best practices. North Carolina’s Perinatal Quality Collaborative is a public-private partnership to support expecting mothers and improve birth outcomes. Alaska’s Perinatal Advisory Committee includes partners from city, state and tribal health departments; hospitals and community health centers; military health care; media; the legislature and business. In 2019, New Mexico introduced legislation to create a statewide perinatal collaborative.

Improving Prenatal Care

Prenatal care for pregnant women generally includes physical exams, laboratory screening tests, nutrition counseling and mental health services. Yet, approximately one quarter of U.S. women are unable to access the recommended number of prenatal visits, in part because of disparities in insurance and a shortage of maternity care providers. States, hospitals and nonprofit organizations can improve access to prenatal care in a variety of ways and through various payment or program models. For example, some states allow for “presumptive eligibility,” which automatically enrolls low-income pregnant women in Medicaid so they are eligible for prenatal services.

Medical practices in at least 46 states have adopted the Centering Pregnancy model. This model, thus far implemented as hospital-based pilot programs, brings together expectant mothers for a series of enhanced prenatal visits. In addition to medical care, participating women receive guidance about nutrition, breastfeeding, labor and delivery. The program also builds community and peer support. Where implemented, Centering Pregnancy can decrease the rate of preterm and low-weight births, reducing costly admissions to neonatal intensive care units. One study estimated more than 4-to-1 return on investment for every dollar spent on Centering Pregnancy.

Breastfeeding Needs and Supports

Mothers’ ability to care for and form an attachment with their infants affects children’s long-term social, emotional, physical and cognitive development. Breastfeeding builds maternal sensitivity, which helps mothers understand and respond to infant cues. It also improves infant health and reduces health care costs by lowering the occurrences of infections, asthma, allergies, diabetes, childhood obesity and sudden unexpected infant death syndrome. The American Academy of Pediatrics recommends that infants be exclusively breastfed for at least six months, followed by breastfeeding in combination with complementary foods for at least 12 months. Nearly half of babies born in the United States are breastfed for their first six months, and the rate continues to increase as people become more aware of the health and bonding benefits of breastfeeding. As of 2018, all 50 states, the District of Columbia, Puerto Rico and the Virgin Islands have laws that protect the right of women to breastfeed in any public or private location. At least six states—California, Illinois, Minnesota, Missouri, Mississippi and Vermont—and Puerto Rico have implemented or encouraged the development of breastfeeding awareness campaigns.

Access to lactation consultation and supplies help mothers bond with their babies. The Affordable Care Act requires private health insurance plans to provide coverage for specified women’s preventive health services with no cost sharing (i.e., copayment, coinsurance or deductible). Breastfeeding support, supplies and lactation counseling are approved preventive services. As of April 2018, 18 states have enacted laws or regulations requiring hospital policies and practices to encourage and support breastfeeding initiation and continuation. This is sometimes referred to as breastfeeding-supportive or “baby-friendly” hospital policies. At least three states—Georgia, Oregon and Rhode Island—have enacted legislation to license lactation consultants. In 2019, several states considered legislation to establish licensure requirements for lactation consultants to receive reimbursement for their services.

The federal Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides supplemental food, nutrition education, health care referrals and breastfeeding support to low-income pregnant and postpartum women, infants and children up to age 5. Breastfeeding promotion and support are core components of the nutrition services offered through WIC. WIC staff are trained to provide support, such as breastfeeding peer counselors and lactation consultants, and breastfeeding aids such as breast pumps. Data suggests WIC has been successful in promoting and supporting breastfeeding as breastfeeding rates among WIC participants are steadily increasing. In 2018, Washington, D.C. enacted the Birth-to-Three for All DC Amendment Act, which establishes a pediatric primary care demonstration program, strengthens lactation support services and requires a feasibility study for co-locating clinics participating in WIC with select primary care providers.

Public Awareness of Healthy Pregnancies

Campaigns to raise awareness of the importance of healthy pregnancies and how to achieve optimal health outcomes for mothers and babies serve a variety of functions, including educating the general population, educating specific populations and building support for policy changes. The Ohio Department of Health launched a public awareness campaign in 2016 to encourage young women and families to engage in family planning and prenatal care to improve overall birth outcomes and reduce racial and ethnic disparities in health. Maternal depression before, during or after pregnancy is widespread in the United States and can have lasting negative effects on new mothers and their young children. Colorado and several other states have responded with various strategies, including creating public awareness campaigns about maternal depression.

Three Early Steps

• Ask your state maternal and child health director about opportunities to better support healthy development through your state’s prenatal care
• Find out more about your state’s rate of breastfeeding.
• Gather information about the percentage of well-child visits in your state.

Five Questions to Ask

• What percentage of women in my state have access to prenatal care?
• What percentage of women in my state breastfeed for at least six months?
• Which hospitals in my state are “baby friendly?”
• What percentage of babies in my state receive well-child visits?
• How many pregnant and postpartum women and infants participate in WIC services in my state?

• Voluntary home visiting and other forms of parent training and education.
• Family economic supports.
• Streamlined access to services and resources.

Research underscores the importance of strong, stable and positive relationships between parents and other caregivers and the infants and toddlers in their care. While parents are their children’s first and best teacher, all parents need help now and then, and many don’t have adequate support through family and friends. Providing guidance and support for families with infants and toddlers leads to better social and emotional outcomes.

Poor socioeconomic status is closely linked to negative indicators of child and maternal well-being, including low birth weight, which correlates to negative health issues throughout life. This is not good news for the 1-in-5 infants and toddlers living in poverty in 2017 or for the 50% of new families living below, at or near poverty thresholds.

Reducing prolonged economic stress is one of three principles for improving outcomes for families and their children, according to the Center on the Developing Child at Harvard University. Economic supports such as Temporary Assistance to Needy Families (TANF), Medicaid and child care assistance help parents of infants and toddlers work or attend job-training programs. The Earned Income Tax Credit (EITC), Supplemental Nutrition Assistance Program (SNAP) and other two-generation approaches can simultaneously address the needs of parents and children to improve outcomes for the whole family. States are expanding on these federal programs and creating their own unique initiatives. In addition, some states are trying to ensure parents are aware of services and resources through mobile apps, child care centers, medical offices, job sites, businesses and religious establishments.

Eligibilty for these services is determined by the federal poverty threshold—a family’s measure of need, determined mostly by family size and composition. All family members have the same poverty threshold. If a family’s income is below the threshold, they are considered to live “in poverty.” According to the Congressional Research Service, 39.7 million people in the United States (12.3% of the population) live in poverty and another 49.3 million live within 200% of poverty thresholds.

Training and Education to Equip Parents

Parents want help supporting their child’s social and emotional development. Parent training and support through home visiting, mobile apps or educational tools can help. South Dakota’s Bright Start Initiative is a comprehensive family engagement and early childhood initiative that provides home visitation, newborn hearing and early intervention screenings, immunizations, online information resources, parent and infant welcome boxes, and responsive parenting seminars. The Read to Grow program in Connecticut is a literacy program that aims to get books into the hands of families with infants and toddlers. It provides free books to families, beginning with the birth of their child.

Voluntary home visiting is a parent-support and prevention strategy used to help pregnant women and new parents meet the social-emotional, cognitive and health needs of their young children. Cost-benefit analyses show that high-quality home visiting programs offer returns on investment ranging from $1.75 to $5.70 for every dollar spent on child protection, K-12 special education, grade retention and criminal justice expenses. Program lengths vary, with some targeting the first year of a child’s life. Some programs, such as Parents as Teachers or Nurse-Family Partnership are targeted to families meeting certain criteria. Others are universally available within defined geographic areas. Family Connects is a communitywide universal nurse home visiting program for parents of newborns. It is based on the Family Connects Durham model piloted in Durham County, N.C. Family Connects operates in five states.

Home visiting is an increasingly common strategy for promoting infant and child health, fostering healthy social-emotional development and school readiness, and preventing child abuse and neglect. Across the country, high-quality home visiting programs offer vital support to mothers, and in some cases fathers, as they handle challenges of parenting babies and young children. Most publicly funded home visiting programs require or emphasize use of evidence-based models, of which at least 18 are federally recognized, with even more showing promising results. 

Family Economic Supports

Federal programs, such as SNAP, WIC and the EITC, support the well-being of infants and toddlers and their families. EITC, for example, is a tax credit policy the federal government, 29 states, the District of Columbia, Guam, Puerto Rico and some municipalities have implemented to support the financial stability of low-income working families, especially those with children. EITCs reduce income tax liability for qualifying taxpayers in an amount determined mostly by their income level, marital status and number of dependent children. State EITC policies are mostly modeled after the federal credit, but they vary somewhat on eligibility standards, methods for calculating the credit amount and refundability.

The federal EITC is the largest and most successful anti-poverty means-tested program and research has shown it benefits the health and well-being of mothers, infants and children.¹⁹ State EITCs provide an additional benefit to the federal credit. For example, in 2017, 1.4 million families in California shared a total of $325 million in state credits, bolstering the $6.8 billion they received in federal credits.

EITCs can free up family resources for child care expenses by decreasing the amount of taxes owed. Research finds that single mothers, especially those with low wages, are more likely to be employed and experience an increase in earnings when they receive a credit. Low-income mothers receiving a credit are more capable of paying for child care and, thus, are more apt to be employed.

SNAP is a federal nutrition program for the approximately 40% of poor families that may be experiencing food insecurity. According to the American Academy of Pediatrics, good nutrition in the first 1,000 days between a woman’s pregnancy and her child’s second birthday lays the groundwork for success later in life. The Government Accountability Office finds that families with young children miss out on benefits they are eligible for due to varied and complex requirements between federal programs. For example, states could reduce barriers to WIC by combining WIC applications with other social programs, such as TANF, SNAP or Medicaid.

Early Head Start Provides Comprehensive Supports for Infants and Toddlers

Early Head Start is a federal program focused on the early education experiences of low-income babies and toddlers. Early Head Start programs, which can be center- or home-based, offer an array of child and family development services, including health and developmental screenings; nutritious food; parenting resources and support; and access to health, mental health and social services. Minnesota, Missouri and Oregon supplement with state funding. Early Head Start-Child Care Partnerships are collaborations between Early Head Start and local infant and toddler child care programs. These partnerships increase access, enhance services and provide opportunities to raise program quality at both child care centers and Early Head Start programs.

Funding Strategies

Prenatal-to-three strategies often involve a complex mix of federal, state, local and private-sector funding, and because state legislatures make fiscal decisions regarding their state budgets, legislators play a critical role in determining funding approaches for prenatal-to-three programs. A 2018 report from the Center for the Study of Social Policy examined public-sector spending for pregnant women, infants and toddlers and funding strategies for improving health and developmental trajectories for infants and toddlers. The report found that current funding investments provide an insufficient base of support for vulnerable families with young children.

Funding streams that support healthy beginnings, family supports and early learning, development and care include:

• Federal Funding – Maternal and Child Health (Title V), Maternal, Infant and Early Childhood Home Visiting (MIECHV), Medicaid, Early Head Start, Child Care and Development Block Grant (CCDBG).
• State Funding – Maintenance of Effort (MOE), state match, general fund, dedicated funds, set-aside.
• Other Funding – Public-private partnerships, local tax earmarks, philanthropic.

How can states make these federal and state dollars work better? Consider the following funding strategies:

• Blending funds combines funding sources for one purpose. For example, Early Head Start and CCDBG can be blended to support early care for infants and toddlers.
• Braiding funds coordinates multiple sources of funding to support the total service cost. Braided funding often leads to coordinating eligibility requirements or co-location of services.
• Public-private partnerships are partnerships between government agencies and businesses, philanthropies or other nonprofit organizations with common goals.

Home Visiting Funding

According to NCSL’s fiscal year 2019 early care and education budget actions report, states use a variety of sources to pay for home visiting programs: state general funds, federal Maternal, Infant and Early Childhood Home Visiting program (MIECHV), Title V Maternal and Child Health (MCH) Block Grant, tobacco settlements and taxes, TANF, Medicaid, federal child welfare funds, federal Project Launch and private funds. Twenty-six states reported investing state or dedicated funds in home visiting programs. Despite federal and state funding, home visiting programs reach only a small fraction of those who could benefit from them.

MIECHV is the primary source of federal funding for home visiting. Since 2010, Congress has invested billions of dollars through MIECHV to help states begin and expand evidence-based home visiting. For states, tribes and territories, current funding provides $400 million per year through federal fiscal year 2022. Funds can be used for evidence-based programs, innovation, statewide needs assessments, training and technical assistance, and evaluation.

In 2016, the Virginia General Assembly directed a review by the Joint Legislative Audit and Review Commission of early childhood development programs in the state. The review found that Virginia’s voluntary home visiting programs are generally effective, but funding for home visiting is unstable and “hinders the ability of the programs to operate consistently and strategically over time.

Streamlined Access to Services and Resources

Programs and services for infants and toddlers and their families span a multitude of providers, agencies, levels of government and funding streams. And while the needs of families and young children often are complex and interrelated, most programs (e.g., child care assistance, early intervention, health and mental health services, home visiting and nutrition) are siloed. Bureaucratic and burdensome requirements often stand in the way of families accessing the services they need and are eligible to receive. Coordinated communication, enrollment, outreach and service delivery in places that parents and families naturally visit increase the chances that families will reap the intended benefits of programs.

A 2016 Urban Institute report examined state policies in six states to streamline access to Medicaid, SNAP and child care assistance. States implementing universal enrollment or categorical eligibility offer an opportunity for state agencies to break down siloes, which sometimes require state legislative and administrative rule changes. Three states—Colorado, Idaho and North Carolina—passed legislation to align eligibility rules for child care assistance programs and SNAP. These states also examined the use of technology to help low-income families get and keep services for which they are eligible.

Many states are beginning to break down bureaucratic siloes and improve service delivery by adopting a two-generation approach, also known as intergenerational, multi-generational or whole-family strategies. This approach simultaneously addresses the needs of parents and children to improve outcomes for the whole family. Two-generation approaches draw from findings that the well-being of parents is crucial to their young children’s social and emotional, physical and economic well-being. At the same time, parents’ ability to succeed in school and the workplace is substantially affected by how well their children are doing.

Oklahoma and Colorado offer examples of two-generation strategies at work. CAP-Tulsa, the community action agency in Tulsa, Okla., provides education and job training opportunities to parents while, at the same time, providing high-quality early childhood education programs for their children, newborns through 4-years-olds. In 2017, Colorado Governor John Hickenlooper created a two-generation program coordinator position within the governor’s office to help state agencies develop and implement programs, policy and goals. Colorado’s Department of Human Services also uses a two-generation approach to guide its delivery of TANF services and child support programs.

Connecting Families to Resources

Help Me Grow connects at-risk children with early childhood health services to improve health outcomes and control health care costs. The program was started 1997 by a Connecticut physician and later funded by the state legislature in 2002. Since then, 27 states have replicated it. Through state-specific approaches, Help Me Grow helps health care and child care professionals identify developmental and behavioral issues in children and direct their parents to local resources and services through a call center. The initiative has connected thousands of families to parent education, programs for children with developmental disabilities, mental health services and other resources. It also has saved states millions of dollars in sometimes unnecessary medical services. The Help Me Grow system in South Carolina has access to primary care physicians, and Delaware’s Help Me Grow is augmenting home visiting services and developmental screening referrals to promote optimal child development.

More than 20 states are funding Reach Out and Read, an evidence-based nonprofit organization of medical providers who promote early literacy and school readiness through their pediatric offices. Focusing mostly on low-income families, children between 6 months and 5 years of age receive a new book to take home as part of their well-child visits. At each visit, pediatricians and other medical providers support healthy child and parent interactions and talk to parents about the importance of reading to their children and advise parents on how to engage with their children when reading.

Three Early Steps

• Use the IRS’s resources to understand benefits provided by the federal EITC in your state. You can participate in EITC awareness efforts by using the IRS’s outreach toolkit.
• Learn more about home visiting in your state through the National Home Visiting Resource Center and NCSL.
• Ride along on a home visit or talk to someone who has. Watch this video from the Urban Institute of a home visit.

Five Questions to Ask

• What are the most pressing unmet needs of families with infants and toddlers in my state?
• Does my state have the capacity to collect data and measure home visiting program outcomes?
• How can my state use state or federal funding to serve more eligible infants and toddlers and their families with evidenced-based home visiting services?
• To what extent are agencies and programs in my state working together to remove enrollment barriers and support the needs of whole families beginning from the prenatal period?
• Does my state have its own EITC? Find out at NCSL’s Tax Credits for Working Families: Earned Income Tax Credit webpage.

• High-quality early care and learning system for infants and toddlers.
• Early care and education professionals that serve infants and toddlers.
• Developmental screenings and interventions.

Infants and toddlers need safe, stimulating and nurturing environments and positive relationships with caregivers to support healthy brain development and to lay the foundation for lifelong learning and overall well-being. Parents of infants and toddlers often struggle to access high-quality child care due to limited availability and high cost. Research on low-quality care shows it can harm a child’s cognitive and social development.²⁸ Meanwhile, a inadequate supply of early care providers and educators earn extremely low wages and must navigate confusing and duplicative preparation standards. Some states are elevating the early care and education workforce through new compensation strategies and by incentivizing or requiring higher levels of preparation. 

Developmental screenings and referrals conducted by health care providers also support early learning and healthy development in infants and toddlers. Routine screenings to monitor growth and development result in early identification of developmental issues and increase the likelihood interventions will be successful. A growing number of states provide, through statute and administrative rule, guidelines for physicians to follow as they administer social, behavioral and developmental screenings. To ensure referrals result in appropriate interventions, some states are also acting to ensure availability of programs and services to address developmental concerns. In 2013, Oregon enacted legislation that required the coordination of a voluntary statewide standardized screening and referral effort for families with children from birth to age 3.

High-Quality Early Care and Learning Systems for Infants and Toddlers

Infants and toddlers are cared for and supported by professionals in a variety of settings. Building a high-quality early care and learning system that efficiently and effectively serves very young children and their families requires collaboration between public agencies, across levels of government, within and among communities and private-sector stakeholders.

Recent changes to the federal Child Care and Development Block Grant (CCDBG) increase the minimum amount states must spend on high-quality infant and toddler care and other activities. At least 31 states have infant and toddler standards within their QRIS. Georgia’s public and private partnership, which includes the state agency on early learning and other stakeholders, raised $14 million in private and corporate funds to support monetary incentives for child care providers to earn a QRIS rating.

Some states have developed operating and governance structures to improve the delivery and accountability of programs to better serve young children and their families. A subset has adopted or is considering adopting two-generation strategies to promote government efficiency while achieving better outcomes for families and their children. Strategies include improving coordination of programs with memoranda of understanding, consolidating programs within a single existing agency (e.g., office of child development) and creating a new department or agency (e.g., department of early learning). Washington state’s Birth to 3 Plan, which was submitted to the Washington State Legislature in 2010, outlines policy recommendations to improve services for infants, toddlers and their families. The plan calls for regional coalitions and infant-and-toddler steering committees to coordinate efforts for children birth through age 3 in regions around the state.³² In 2017, the Washington Legislature passed HB 1661, which consolidated early childhood and child welfare programs and services, to focus on the development and well-being of children. The new entity emphasizes prevention, early childhood development, early intervention and supporting parents.

Colorado’s Early Childhood Framework, created by the state’s Early Childhood Leadership Commission, outlines strategies to create a system focused on increasing access, quality and equity. The Early Childhood Colorado framework emphasizes infant-toddler needs for local and state early childhood systems. In 2012, Minnesota created a Prenatal-to-Age-Three Framework establishing desired outcomes and indicators in health, education, well-being and systems for children prenatal through 3 years and their families and communities. Minnesota’s PN-3 Policy Initiative is raising awareness about prenatal-to-three issues “to ensure our youngest citizens are both meeting important developmental benchmarks and are ready for kindergarten.

Data

Access to data is vital to states’ efforts to provide high-quality programs and services and improve outcomes for young children and their families; however, states often report issues with data sharing between departments and programs. To improve policy and funding decisions, many states are developing coordinated data systems to better understand when and how families access early childhood services, to assess program effectiveness and to inform continuous quality improvement efforts. For example, Wisconsin’s Early Childhood Integrated Data System creates links between the Department of Public Instruction, Department of Health Services and Department of Children and Families. Vermont Insights, a web-based early childhood data hub, tracks prenatal care, birth weight, developmental screenings, high-quality early childhood experiences and other data specific to infants and toddlers. The hub is a resource for policymakers to understand the well-being of young children and their families in the state.

Early Care and Education Professionals That Serve Infants and Toddlers

High-quality early learning for infants and toddlers requires high-quality early care and education professionals. Worker compensation, caregiver turnover and the diversity of settings for infant and toddler care contribute to the challenges of developing a qualified workforce. Despite the well-established importance of a consistent caregiver and the positive relationships between young children and their caregivers, early care and education professionals often earn poverty-level wages and must contend with varying training and educational requirements as they enter or seek advancment in the field.

States are trying to address the challenges of preparing, retaining and compensating a high-quality early care and education workforce. Thirty-one states offer an infant-toddler credential, and at least 23 states have infant-toddler specialist networks to support practitioners working in child care centers; family child care homes; or family, friend and neighbor care settings and Early Head Start. For credentialing, the higher education system, including community colleges, is another policy engagement lever that states can use to impact the quality and supply of infant and toddler care.

California’s Child Care Initiative Project is a public-private partnership that provides high-quality training for licensed family child care providers on environmental health in child care settings, social and emotional competence in young children, and the unique aspects of caring for infants and toddlers. The Family Infant Toddler Studies track of New Mexico’s early childhood professional development system includes coursework specifically for students working toward an infant-toddler certification or a degree.

Developmental Screenings and Interventions

Identification of risk factors associated with well-being early in a child’s life is critical because the earlier interventions occur, the more likely they are to improve their developmental path for children. Millions of children receive health coverage through their state’s Medicaid or Children’s Health Insurance Program (CHIP). Well-child visits and developmental screenings provided through these programs can save states money by reimbursing providers for identifying and treating health and developmental issues early rather than waiting for more costly conditions to arise. States are required to provide children enrolled in Medicaid with the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which includes comprehensive preventive, dental, mental health, developmental and specialty services. In addition, state Medicaid agencies may allow a maternal depression screening to be claimed as a service for the child as part of the EPSDT benefit.

The Bright Futures guidelines, developed by the American Academy of Pediatrics, is a blueprint for physicians to follow when administering social, behavioral and developmental screenings. The Affordable Care Act requires private health insurance plans to cover Bright Futures screenings and services, and many state Medicaid agencies also incorporate these guidelines and schedules into children’s preventive services. Illinois amended state Medicaid policies and implemented a QRIS to help ensure the needs of infants and toddlers are identified and addressed early.

Three Early Steps

• Read Child Care Aware’s child care fact sheets to better understand the state of infant and toddler care in your state.
• Find out more about the workforce caring for infants and toddlers in your state and which policies are in place to support a qualified early learning workforce.
• Learn whether your state allows Medicaid and CHIP-eligible infants and toddlers to receive the developmental screenings recommended by the American Academy of Pediatricians.

Five Questions to Ask

• What child care eligibility requirements best meet the needs of the low-income parents with infants in my state?
• Does my state have a birth-to-three plan or emphasize infants and toddlers in system-level work?
• Does my state offer incentives for infant and toddler caregivers to continue their education and training?
• What percent of infants and toddlers in my state have access to developmental screenings, and are there enough programs available to serve those who need developmental support services?
• What public agencies, academic institutions or other entities in my state collect social and economic data on infants and toddlers and their families?

Early experiences lay the foundation for a child’s development with implications for success in school and later in life. NCSL worked with legislators and legislative staff to design this guidebook to help state legislators identify policy pathways for improving outcomes for infants and toddlers. Ultimately, these efforts can be expected to increase school readiness, reduce crime, build a workforce pipeline and improve health outcomes.

Additional Resources

Contact NCSL to learn more about the infant and toddler data and prenatal-to-three programs and initiatives in your state. Other resources include:

• The National Collaborative for Infants and Toddlers (NCIT) Online Solution Center has information on state infant and toddler policies and practices from around the country. It provides reports, online tools to help craft data-informed policies and opportunities to connect with early childhood leaders nationwide.
• The first-of-its-kind State of Babies Yearbook provides a snapshot of how babies are faring nationally and in individual states. The yearbook, which was produced by Child Trends and Zero To Three, looks across nearly 60 indicators and policies.
• For legislative inspiration and examples, visit NCSL’s Maternal and Child Health Legislative Database or Early Care and Education Legislative Database.

NCSL formed the Prenatal-to-Three Legislative Advisory Group in 2018. The group was charged with three objectives:

• Create a neutral, bipartisan forum for dialogue around prenatal-to-three policy issues.
• Enhance the leadership capabilities of participating state legislators by increasing their knowledge of prenatal-to-three policy issues.
• Inform a broader legislative audience on prenatal-to-three policy issues through a legislative framework.

The bipartisan advisory group included eight legislators and two legislative staff from Alabama, Colorado, North Carolina, New Mexico, New York, South Dakota, Oregon, South Carolina, South Dakota, Virginia and the District of Columbia. Members participated in two face-to-face meetings, consulted researchers and other experts, and deliberated on an array of topics, including early brain development, maternal and infant health, developmental screenings, early childhood data and systems, funding mechanisms and the return on investment of early childhood programs. Ultimately, the group developed a legislative framework that identifies three focal areas for prenatal-to-three policy options, actions and strategies: 

• Healthy Beginnings
• Family Supports
• Early Learning, Development and Care

Advisory Group Members

Senator Thomas Alexander, R-S.C.

Representative Terri Collins, R-Ala.

Representative Tom Holmes, R-S.D.

Representative Craig Horn, R-N.C.

Representative Susan Lontine, D-Colo.

Senator Beth Martinez Humenik, R-Colo.

Representative Carla Piluso, D-Ore.

Assemblymember Michaelle Solages, D-N.Y.

Councilmember Robert White, D-D.C.

Maria Garnett, Virginia Joint Legislative Audit and Review Commission

Kelly Klundt, New Mexico Legislative Finance Committee

Experts Consulted

Jill Cannon, senior policy researcher, RAND Corporation

Sarah Daily, senior research scientist, Child Trends

Kay Johnson, president, Johnson Group Consulting

Edward Maynard, M.D., American Academy of Pediatrics, Colorado Chapter

Jennifer Stedron, executive director, Early Milestones Colorado

Sarah Watamura, associate professor, Child Health and Development Lab, University of Denver

NCSL Staff

Wade Fickler, group director, Children and Families Program

Tahra Johnson, program director, Health Program

Alison May, policy associate, Children and Families Program

Jennifer Palmer, policy associate, Children and Families Program

Julie Poppe, program manager, Children and Families Program

Matthew Weyer, senior policy specialist, Education Program

Margaret Wile, senior policy specialist, Health Program

Rich Williams, program manager, Children and Families Program

Amber Bellazaire, policy associate, Health Program        

Meghan McCann, senior policy specialist, Children and Families Program