What Parents Know Matters: Parental Knowledge at Birth Predicts Caregiving Behaviors at 9 Months Christy Y. Y. Leung, PhD, and Dana L. Suskind, MD Objective To examine the mediating role of socioeconomically disadvantaged parents’ knowledge of early cogni- tive and language development at the first postpartum visit in the relation between education and caregiving behav- iors at 9 months. Study design Parental knowledge was assessed at the 1-week newborn visit (n = 468); anticipatory guidance received and desired at 1-month (n = 212) and 6-month (n = 191) visits were reported; and caregiving behaviors toward infants during a teaching task were observed at 9-month visit (n = 173). Results We found substantial variation in knowledge and caregiving behaviors. Parents who had more knowledge of infant development at 1 week were more likely to respond to cues (r = 0.18; P < .05) and foster social-emotional (r = 0.17; P < .05) and cognitive growth (r = 0.20; P < .05) at 9 months. Importantly, the indirect effect of education on cognitive growth fostering at 9 months through knowledge at 1 week was significant, controlling for primary lan- guage and number of other children in the home (infancy: b = 0.06; B = 0.07; SE = 0.04; 95% CI, 0.007-0.165; early childhood: b = 0.04; B = 0.06; SE = 0.03; 95% CI, 0.008-0.152). Open-ended responses indicated that anticipatory guidance in the first 6 months focused on infant physical growth; however, parents did not request additional antic- ipatory guidance from their pediatricians. Conclusions This study sheds light on the importance of promoting parental knowledge about cognitive and lan- guage development to foster parental cognitive stimulations and language inputs during the first year of life. This study highlights the important role of anticipatory guidance on cognitive and language development during the earliest well-child visits and the need to better understand parental baseline knowledge to tailor anticipatory guidance to the family strengths and needs. (J Pediatr 2019;-:1-9). See editorial, p  and related article, p  E arly social and language experiences represent an important social determinant of health. 1 Enhancing parental knowl- edge and input during the newborn stage of rapid brain growth is an important approach in ameliorating the impact of socioeconomic status (SES) on children’s long-term development. 2-6 Pediatric health care providers are ideally posi- tioned within well-child visits to inform parents of low SES about early cognitive and language development and strategies for enriching their children’s early environments. 7 Additionally, pediatricians are often the primary source of guidance on childrearing and developmental milestones for parents of low SES. 8 Parental knowledge of child development varies considerably within socioeconomically disadvantaged populations. 9,10 Qualitative research with families of low SES showed veteran parents attributed their knowledge to previous parenting expe- riences, whereas first-time parents reported lacking familiarity with developmental milestones. 10 Mothers of multiple children were determined to be more supportive than mothers of singletons in fostering their young children’s development. 11 Yet, dif- ferences in knowledge and caregiving behaviors between first-time and veteran parents have never been quantitatively tested among families of low SES. Notably, anticipatory guidance and evidence-based programs are often implemented using a one-size-fits-all approach without considering the heterogeneity among parents from low SES backgrounds. 12,13 Pediatric practitioners have limited re- sources to clinically assess parental baseline knowledge and caregiving behaviors. This limitation minimizes the personalization of anticipatory guidance provided about infant cognitive growth and language learning. Thus, the first aim of this study was to examine knowledge about cognitive and language development as well as care- giving behaviors among socioeconomically disadvantaged parents of newborn; differences between first-time and veteran parents were also explored. From the TMW Center for Early Learning + Public Health, University of Chicago, Chicago, IL. Supported by the W.K. Kellogg Foundation and the Pritzker-Traubert Family Foundation. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. ª2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jpeds.2019.12.021 NCAST Nursing Child Assessment Satellite Training SES Socioeconomic status 1 ORIGINAL ARTICLES