Enhancing Pediatric Primary Care Literacy Promotion with Early-Letter Name Knowledge

Literacy is an important social determinant of health [1-3]. The science of reading, a vast interdisciplinary body of research spanning five decades from across the world, should inform our understanding about how reading develops, including ways to prevent and intervene when reading difficulties persist. One influential framework from this research is the Simple View of Reading: decoding times language comprehension equals reading comprehension [4]. Children with strong oral language skills but weak decoding abilities will not be able to read proficiently. Conversely, children who can decode words but have limited vocabulary and language comprehension will likely have difficulties reading.

In 2024 the American Pediatric Association (AAP) updated their policy statement titled, “Literacy Promotion: An Essential Component of Primary Care Pediatric Practice.” In this statement the AAP highlights the importance of unique opportunities physicians and advanced care providers have to encourage parents and caregivers to engage in shared reading, or reading aloud, of books or stories with their children beginning at infancy and at least through kindergarten. With the goal of literacy promotion, multiple large-scale programs exist to place books in the homes of children aged 0-5 years [1]. (See the AAP’s full statement for examples.)

Early prevention is important because research shows that at the beginning of formal education, some children are more equipped for early literacy instruction and quickly make gains [5]. Even as early as preschool (ages 3 to 5) discrepancies in pre-reading skills emerge and are often linked to differences in children’s language environment and resources [6, 7].

While we wholeheartedly agree that reading aloud is very important for children’s language development, we argue that there are additional predictors of later reading success that are important for pediatricians to attend to. Recently a systematic review found that merely delivering books to parents is not enough to improve children’s outcomes, that effective early literacy interventions include code-based activities focusing on how the written alphabetic system works and that parental training in skills like dialogic reading is necessary to generate benefits from reading aloud [8]. Among the code-based activities, we would specifically stress the importance of alphabetic knowledge. Alphabetic knowledge consists of knowing the name, form, and common sound(s) for the letters in the alphabet [9]. It is closely related to an important literacy concept called the alphabetic principle. Alphabetic principle is the understanding that language is made up of sounds and that letters represent those sounds in a systemic way in speech and in print [10].

One of the strongest predictors of later reading achievement and overall literacy development is letter-name knowledge [11-14]. Letter-name knowledge is the ability to identify and name upper and lower case letters of the alphabet, and it is a foundational literacy skill. It makes sense, if children do not understand the printed symbols, they cannot read words and gain meaning from print.

Overarchingly, educational research supports the importance of letter-name knowledge. For instance, the more letters a child knows, the less likely the child will have difficulty reading [15,16]. Additionally, letter-sound knowledge in the first year of reading instruction is a predictor of word-reading and reading growth across that year [17] as well as a predictor of decoding and comprehension in the following years [18,19].

Perhaps the educational study that would be of most relevance to pediatricians is Piasta and colleagues’ 2012 longitudinal study that identified the exact baseline prior to kindergarten entry to minimize the risk of later literacy difficulties: 18 upper case letters and 15 lower case letters. They investigated the diagnostic efficiency of letter-naming benchmarks using a database of 371 children who attended publicly funded preschools. The children were assessed on letter-naming at the end of preschool and also literacy achievement with three standardized measures at the end of first grade. Diagnostic indices were used to examine letternaming benchmarks and risk for later literacy difficulties. Head Start standards were revised to align with their findings [20].

Arguably, leaning into the evidence in educational research, pediatric physicians and advanced care providers can encourage parents and caregivers to understand the importance of lettername knowledge in addition to reading aloud to their children. Pediatricians may share the goal of learning 18 upper case letters and 15 lower case letters to prepare for kindergarten and to ameliorate reading difficulties [20]. Pediatricians can provide ways parents and caregivers can engage with children and letters in play-based ways. Some no cost examples include telling stories incorporating a letter or making a game of finding things on a walk or in a store that start with a certain letter. Some low-cost options include having children practicing writing letters in shaving cream or making letters with play dough or pipe cleaners. Other low-cost toys for letter play include magnetic letters, letter puzzles, Alphabots, foam letters for the bathtub or water table, or ABC books such as The Very Hungry Caterpillar’s ABCs by Eric Carle or Chicka Chicka Boom Boom by Bill Martin Jr. and John Archambault.

Pediatricians can quickly assess letter-name knowledge. Assessing a child’s ability to recognize and name letters helps determine whether children are developing the foundational skills necessary for beginning reading instruction in kindergarten. One way to assess letter-name knowledge is to ask questions of preschoolers (ages 3 to 5) in a well-visit: Can you find a letter you know? What letter does your name start with? Do you know what letter this is? A pediatrician may also consider administering the Quick Letter Name Knowledge Assessment (Q-LNK), a researchbased letter-name knowledge assessment designed specifically for screening that can be administered in less than one minute [21].

We strongly agree that literacy promotion is an essential component of primary care in pediatric practice, and we encourage pediatricians and advanced care providers to continue to encourage parents and caregivers to engage in shared reading or reading aloud with their children. At the same time, we highlight additional evidence regarding decoding skills, including a specific strong predictor of later reading achievement: letter-name knowledge. We encourage pediatricians and advanced care providers to also promote evidence on letter-name knowledge during well-visits with children through assessment and in play-based ways.

The Hoekelman Center is grateful for the ongoing support from GOALS (Greater Opportunity After Literacy Support). Any opinions expressed in this article are those of the authors and do not represent their employers or funders.

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