Baby Steps Clinic

Department of Pediatrics

Moving Forward One Step at a Time

The Baby Steps Clinic is for families who have a child exposed to substances before birth, which can influence growth, development, learning, and behavior. We know families want the best for their child, and the Baby Steps Clinic can help by offering support, assessment, and interventions. The clinic is here to help every child reach his or her full potential and to support families as they support their child’s development. The Baby Steps Clinic is also recognized as a Promising Practice   by the American Academy of Pediatrics. In May 2023 Dr. Dianna Puhr, Medical Director for Baby Steps, spoke on Improving Care for Children & Families Affected by Substance Use for the ETSU Child and Family Health Institute Collaborative Series.

Baby Steps Interprofessional Team:

  • Care coordinator
    • The care coordinator follows your family from pregnancy through early childhood helping to track progress, schedule appointments, serve as the point person for questions, make referrals to other services, and help you navigate aspects of your child's medical, developmental, and emotional needs.
  • Tennessee Early Intervention Specialist
    • The Tennessee Early Intervention Specialist (TEIS) will talk you through various free services available to you to help your child reach optimal development. A plan will be developed between you and the TEIS to fit your needs and best support your family. 
  • Audiologist
    • The audiologist will use age-appropriate objective tests like tympanometry, otoacoustic emissions (OAE) and/or auditory brainstem responses (ABR) to assess your child's entire auditory system from the eardrum to the auditory brain. The audiologist will also ask about your child's listening behavior at home.
  • Speech-language pathologist
    • The speech-language pathologist (SLP) will play with your baby, talk with you, and use age-appropriate tests during your visit. SLPs help babies develop their listening, sound-making, talking, social, play, and feeding skills.
  • Occupational therapist
    • The occupational therapist (OT) will assess your child’s sensory, social, play, and daily living skills by watching your child. The OT will ask how your child sleeps, eats, plays, and learns at home, in child care, or at school.
  • Physical therapist
    • The physical therapist (PT) will observe how your child moves while playing and look for muscle stiffness. The PT will help you to support your child in learning to move, calming himself or herself, and playing to get stronger with better balance
  • Registered dietitian
    • The registered dietitian (RD) will evaluate your baby’s growth and nutrition. The RD will assess your child's nutritional needs and make suggestions for healthy growth
  • Behavioral health consultant
    • The Behavioral Health Consultant (BHC) will assess and monitor your child's behavioral, emotional, and developmental needs. They can help with many common behavioral issues that occur in young children. 
  • Board-certified pediatrician
    • The pediatrician on the team will answer your questions, address medical needs, and make any referrals that may be needed. 
  • Logic Model

    Baby Steps Program Expansion (Tennessee Opioid Abatement Grant) 

    1. Inputs (Resources) 

    • Tennessee Opioid Abatement Council 3-year grant funding
    • ETSU Department of Pediatrics interdisciplinary team
    • Dedicated staff:
      • Full-time Care Coordinator
      • Behavioral Health Consultant (Dr. Kristen Riem)
    • Clinical site: Elizabethton Nave Center (weekly full-day clinic)
    • THRIVE-1000 protocol and feeding/growth monitoring tools
    • Community partnerships (STRONG ACC, TEIS, TIPQC, recovery organizations)
    • Baby Steps Manual (program replication resource)

    2. Activities (What the Program Does) 

    • Provide interdisciplinary clinic services: 
      • Pediatric care
      • Behavioral health services
      • Developmental screening and referrals 
      • Nutrition and feeding support 
    • Deliver intensive care coordination: 
      • Transportation, housing, food support linkage 
      • Appointment reminders and outreach 
      • Warm hand-offs to community services 
    • Implement THRIVE-1000 protocol: 
      • Weekly multidisciplinary case huddles
      • Early feeding intervention and growth monitoring 
    • Integrate behavioral health: 
      • On-site consultation and assessments (ADHD, autism)
      • School coordination and follow-up care 
    • Facilitate recovery support engagement: 
      • Bimonthly family-centered events
      • Peer/community connection activities
    • Conduct education and dissemination: 
      • Provider training and internal education
      • Conference presentations (regional, national, international)
      • TIPQC participation and quality improvement 

    3. Outputs (Direct Products of Activities) 

    • 383 individuals served
    • 282 clinic visits (269 individual, 13 group)
    • Weekly clinic sessions established
    • Care coordination contacts and resource referrals completed 
    • Behavioral health consultations and assessments conducted 
    • THRIVE-1000 protocol implemented with regular case reviews 
    • Recovery support events held (e.g., 50–114 attendees per event) 
    • Provider trainings and conference presentations delivered 
    • Baby Steps Manual developed 

    4. Short-Term Outcomes (0–12 Months) 

    • Increased access to coordinated, multidisciplinary care 
    • Improved appointment adherence and reduced no-show rates 
    • Increased early identification of developmental delays 
    • 90% of infants with suspected delay referred within one month 
    • Improved caregiver engagement in services and recovery supports 
    • Increased provider knowledge and confidence in referral processes 
    • High provider-reported acceptability and appropriateness of the model 

    5. Intermediate Outcomes (1–3 Years) 

    • Improved developmental outcomes for opioid-exposed infants 
    • Reduced growth faltering through early feeding intervention 
    • Increased utilization of early intervention and specialty services 
    • Improved caregiver stability (housing, food, transportation access) 
    • Strengthened integration of pediatric and behavioral health care 
    • Increased family social connectedness and reduced isolation 
    • Sustained cross-system collaboration among healthcare and recovery partners 

    6. Long-Term Impact (3+ Years) 

    • Improved health and developmental trajectories for substance-exposed infants 
    • Reduced long-term effects of prenatal opioid exposure 
    • Strengthened family recovery and stability 
    • Reduced healthcare system fragmentation 
    • Scalable, replicable model for integrated maternal–infant recovery care across Tennessee 
  • Selected References

    1.      Conradt E, Flannery T, Aschner JL, et al. Prenatal opioid exposure: neurodevelopmental consequences and future research priorities. Pediatrics. 2019;144(3):e20190128. doi:10.1542/peds.2019-0128

    2.      Patrick SW, Schumacher RE, Horbar JD, et al. Improving care for neonatal abstinence syndrome. Pediatrics.2016;137(5):e20153835. doi:10.1542/peds.2015-3835

    3.      Yeoh SL, Eastwood J, Wright IM, et al. Cognitive and motor outcomes of children with prenatal opioid exposure: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(7):e197025.

    4.      Bada HS, Langer J, Twomey J, et al. Importance of stability of early living arrangements on behavior outcomes of children with and without prenatal drug exposure. J Dev Behav Pediatr. 2008;29(3):173-182. doi:10.1097/DBP.0b013e3181644a79

    5.      Fill MA, Miller AM, Wilkinson RH, et al. Educational disabilities among children born with neonatal abstinence syndrome. Pediatrics. 2018;142(3):e20180562. doi:10.1542/peds.2018-0562

    6.      Marcellus L, Badry D. Infants, children, and youth in foster care with prenatal substance exposure: a synthesis of two scoping reviews. Int J Dev Disabil. Published online 2023. doi:10.1080/20473869.2021.1945890

    7.      Rubin DM, O’Reilly AL, Luan X, Localio AR. The impact of placement stability on behavioral well-being for children in foster care. Pediatrics. 2007;119(2):336-344. doi:10.1542/peds.2006-1995

    8.      Peacock-Chambers E, Leyenaar JK, Foss S, et al. Early intervention referral and enrollment among infants with neonatal abstinence syndrome. J Dev Behav Pediatr. 2019;40(6):441-450. doi:10.1097/DBP.0000000000000679

    9.      Behnke M, Smith VC; Committee on Substance Abuse; Committee on Fetus and Newborn. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics. 2013;131(3):e1009-e1024. doi:10.1542/peds.2012-3931

    10.  Council on Children with Disabilities; Medical Home Implementation Project Advisory Committee. Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451-e1460. doi:10.1542/peds.2014-0318

    11.  Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis. JAMA Pediatr. 2015;169(10):929-937. doi:10.1001/jamapediatrics.2015.1141

    12.  Kolko DJ, Perrin E. The integration of behavioral health interventions in children’s health care: services, science, and suggestions. J Clin Child Adolesc Psychol. 2014;43(2):216-228.

    13.  Antonelli RC, McAllister JW, Popp J. Making care coordination a critical component of the pediatric health system: a multidisciplinary framework. The Commonwealth Fund; 2009.

    14.  Loomis AM, Musson Rose D, Mitchell J. Closing gaps in care: effects of CARE training on early childhood provider trauma-informed attitudes and collaboration. J Child Fam Stud. 2024;33(3):924-938.

    15.  Paley B, Delja J, Gorospe C, et al. A family school readiness intervention for children with prenatal alcohol exposure and involvement with the child welfare system. Child Welfare. 2023;101(3):157-190.

    16.  Lloyd MH, Akin BA, Brook J. Parental drug use and permanency for young children in foster care: a competing risks analysis of reunification, guardianship, and adoption. Child Youth Serv Rev. 2017;77:177-187.

  • Team-member Publications and Presentations

    Peer-Reviewed Manuscripts 

    BOOK CHAPTER:

    McCarthy D, Boynewicz K. Chapter 9: Neonatal Opioid Withdrawal Syndrome (NOWS): The impact on the movement system and the role of the physical therapist. In: Louw Neonatal Opioid Withdrawal Syndrome (NOWS): Speech-Language Pathologists and Interprofessional Care. 1st ed. Routledge; New York, NY. Jan. 2026:188-212. 

    RESEARCH FUNDING:

    Early Intervention for the Caregiver–Infant Dyad with Neonatal Abstinence Syndrome: A Case Series  
    Role: Principal Investigator  
    Sponsor: Academy of Pediatric Physical Therapy  
    Amount: $9,480  
    Completed: Feb 2025 

    Presentations in Professional Meetings

    SCIENTIFIC ABSTRACT (poster):

    Boynewicz K, Chroust A. Adams O, Dennis, S. Marlin V. Ochoa, V, Smith, R, Johnson M. Gross Motor Surveillance, and Referrals among infants with and without Prenatal Substance Exposure. Abstracts of the APTA Academy of Pediatric Physical Therapy Poster Presentations at the Combined Sections Meeting. Pediatric Physical Therapy 37(1):p 124-164, January 2025. | DOI: 10.1097/PEP.0000000000001175 CSM 2025

    Boynewicz K, Chroust A. Practitioners’ Perceptions of Families with Prenatal Substance Exposure. Poster presented at: Division for Early Childhood of the Council for Exceptional Children 40th International Conference on Young Children with Disabilities and their Families; September 2024; New Orleans, LA. 

    Boynewicz K, Chroust A. Early Intervention for the Caregiver-Infant Dyad with Neonatal Abstinence Syndrome: A Case Series. International Congress infant Studies Glasgow, Scotland July 9-11, 2024.

    Boynewicz K, Hale, K, Chroust A. Knowledge and Attitudes of Early Interventionists Surrounding Drugs and Drug Problems. International Congress infant Studies Glasgow, Scotland July 9-11, 2024.

    Chroust, A, Boynewicz K, Johnson M. Multilevel Modeling of Infant Growth Trajectories Across the First Years of Life in Infants with Different Prenatal Substance Exposures. International Congress infant Studies Glasgow, Scotland July 9-11, 2024.   

    Chroust, A, Blasco, P, Ludwig, N, Boynewicz, K, Isbell, C, Johnson, M, Cimino, C, Rich-Wimmer, N, Ng, R, Lieb, R, Stolpe, L. (2024). Clinical feasibility pilot of the NIH Infant and Toddler Toolbox. International Congress of Infant Studies. Glasgow, Scotland. July 9-11, 2024.  

     Invited Presentations (Professional Meetings) 

    INTERNATIONAL  
     
    Poster: The Baby Steps Clinic: An Interprofessional Approach to Improving Care for Families Impacted by Prenatal Substance Exposure   
    Advancing Comprehensive Early Childhood Intervention Conference  
    (Johnson, M., Isbell, C., Puhr, D., Boggs, T., and Boynewicz, K.)  
    International Society of Early Intervention  
    Lisbon, Portugal  
    September 4, 2025  
      
    Influence of the Sensory and Motor Systems on Caregivers and Infants born with Neonatal Abstinence Syndrome and Developmental Trajectory for Infants born with Prenatal Substance Exposure.    
    Advancing Comprehensive Early Childhood Intervention Conference  
    (Boynewicz, K., Isbell, C., Johnson, M., Puhr, D., and Boggs, T.)  
    International Society of Early Intervention  
    Lisbon, Portugal  
    September 4, 2025  
      
    Feeding Disorders in Prenatally Substance Exposed Infants: A Family-Centered and Trauma-Informed Approach​  
    (Isbell, C., Johnson, ME., and Boggs, T.)  
    International Pediatric Feeding Disorder Conference 2025  
    Arizona State University  
    Phoenix, Arizona  
    February 20, 2025   
      
    Poster: Clinical Feasibility Pilot of the NIH Baby Toolbox (NBT)  
    (Chroust, A., Johnson, ME., Isbell, C., and Boynewicz, K.)  
    International Congress of Infant Studies  
    Glasgow, Scotland  
    July 9, 2024 

    NATIONAL  
      
    Early Intervention Approaches for Infants and Toddlers with Prenatal Drug Exposure  
    National Association for the Education of Young Children 2025 Conference  
    Orlando, FL  
    November 19, 2025  
      
    Poster: Nutrition Implications and Optimal Interventions for Infants and Toddlers with Prenatal Substance Exposure in an Outpatient, Interprofessional Developmental Clinic  
    (Johnson M, PhD RDN, Chroust A, PhD, and Isbell, C, PhD OTR/L)  
    2025 Food & Nutrition Conference & Expo™ (FNCE®)   
    Nashville, TN  
    October 14, 2025  
     
    Prenatal Drug Exposure and Implications for the Early Interventionist.
    Conference Proceedings of the Division for Early Childhood of the Council for Exceptional Children 40th International Conference on Young Children with Disabilities and their Families; 
     September 2024;  
    New Orleans, LA 
      
    Poster: Feeding Challenges in Substance-Exposed Infants and Young Children: Insights from the Baby Steps Clinic  
    (Puhr, D, MD,  Isbell, C, PhD OTR/L, Schetzina, K, MD, and Chroust, A, PhD)  
    2025 American Academy of Pediatrics (AAP) National Conference & Exhibits  
    Denver, CO  
    September 27, 2025  
      
    Poster: Feeding of Prenatally Substance-Exposed Infants: A Family-Centered and Trauma-Informed Approach  
    American Occupational Therapy Association Annual Inspire Conference 2025  
    Philadelphia, PA  
    April 3, 2025  
      
    Poster: Interprofessional Approach to Feeding in Prenatally Substance-Exposed Infants and Toddlers  
    American Occupational Therapy Association Annual Inspire Conference 2024  
    Orlando, FL  
    March 21, 2024  

  • Feeding Education Materials 0-6 Months

     Nutrition: 

    • 0-6 months is a time where your baby will be growing a lot, so frequent feedings are needed to keep them full and happy. Recommended feeding times are: 
      • Birth-2 months: 2 to 4 ounces every 3 to 4 hours (6-8 times per day) 
      • 2-4 months: 3 to 6 ounces every 4 to 6 hours (4-6 times per day) 
      • 4-6 months: 6 to 8 ounces every 4 to 6 hours (4-6 times per day)
    • If you have concerns about the formula you are using, speak with your pediatrician before switching. 
    • Some spit up is normal. If your baby has a lot of spit up, or seems to be in pain during or after feeding, talk with your pediatrician. 
    • For the first 6 months of life (of until solid foods are introduced) you should only feed your baby breastmilk or formula. Do not give your baby water, cow's milk, or any other beverage. 
    • Until your child turns 1, they should not have honey. 

    How to Know Your Baby is Hungry: 

    • Bringing hands to their mouth. 
    • Turning head towards bottle. 
    • Puckering, smacking, or licking lips. 
    • Opening and closing of the mouth. 
    • Clenching their hands. 
    • Becoming more alert or active. 
    • Sucking on things such as hands or clothes. 

    Signs to Watch for That Your Baby is Stressed When Feeding: 

    • Sudden stiffness in their body. 
    • Nose flaring/brow raising. 
    • Drool or milk escaping from their mouth while eating. 
    • Short and fast breaths that are weak. 
    • Gulping or gurgling sounds coming from their throat. 
    • Coughing/choking. 
    • Uncontrolled sucking on nipple. 
    • A lack of rhythm with your baby's sucking and swallowing when feeding. 
    • Follow your baby's cues. If they stop sucking, the feeder should tilt the bottle to slow the flow of milk. When your baby begins to suck again, tilt the bottle back towards the baby for milk to enter the nipple to allow them to have control of their feeding time. 

    Positioning: 

    • "Kangaroo care" Skin-to-skin contact where parent holds baby against bare skin. This encourages bonding with baby before/after feeding and helps emotional and physical development. 
    • Use blankets, towels, or pillows (U pillow or regular) to prop up the back of your arm during feeding to help keep your arm from getting tired and allow for a more secure hold of baby. 
    • Holding your baby semi-upright during feeding can help. It allows for better swallowing and breathing. 
    • Holding your baby upright for 20-30 minutes after feeding may help reduce the large spit ups. 
    • Do not prop the bottle for feeding. 

    Tips to Support Your Baby's Feeding: 

    • Give breaks when you notice your baby seems tired or stops sucking. 
    • Do not twist the nipple in and out of the mouth to increase flow. 
    • Feed the baby on a consistent schedule. See nutrition section.

    How to Know Your Baby is Done Eating: 

    • You should feed on your baby's cues. 
    • If your baby is showing signs of discomfort, then they are done eating. 

    Helpful Tips: 

    • Keep lights dim and the room quiet. 
    • Try to limit quick or startling movements to keep your baby comfortable. 
    • Use pacifier before feedings. (This may also assist in readiness for bottle feedings.) 
    • Slow rocking at 1 rock per second while feeding. 
    • Be comfortable while feeding. 
    • Limit phone and technology use during feeding. 
    • If your baby is sleepy during feeding, gently use a cool washcloth to wake them. 
  • Feeding Education Materials 6-12 Months

     Nutrition: 

    • Continue breastmilk or formula until 12 months of age to support growth and development 
      • Babies 6-12 months of age should have 28-32 ounces of breastmilk or formula per day. 
    • Start one solid food at a time. Give each new food for 3-4 days. If baby gets a rash, vomiting, or wheezing, stop that food and see a doctor. 
    • Introduce a variety of foods including meats, cereal, veggies, fruit, yogurt, eggs, and fish. 
    • It is important to add iron and zinc rich foods after your baby is 6 months, especially if you are breastfeeding. 
      • These include iron fortified infant cereals (oatmeal/rice) and meats. 
    • Suggest trying veggies next, then fruits. 
    • Remember your baby's tummy is still growing, so give small amounts of food at each feed. 
    • Avoid juice for the first year. Use juice only if baby is constipated. If constipated, then a small amount of prune, pear, or apple may help. 
    • No cow's milk or honey the first year. 

    How to Know Your Baby is Ready for Solid Foods: 

    • Your baby is interested in watching you or others eat. 
    • Your baby is able to sit up, grab, gesture, and want to touch other foods that are not their milk. 

    How to Start Solid Food: 

    • Start with a soft or thin mashed food like a stage 1-baby food or cereal. 
    • Place the food in front of them on the spoon or on their high chair tray and let them explore this new food or texture. 
    • Let your baby get messy and explore or eat their food with their hands. 
    • Sit with your baby at mealtime. Your baby learns how to eat by watching you. 
    • Once your baby is easily eating thin and mashed foods, you may give thicker foods or small pieces of soft or meltable foods they can pick up and feed themselves. 
    • Do not force any foods or react negatively! Show encouragement and be positive. Follow your baby's cues when they are ready to begin and stop eating. 

    Where to Feed: 

    • High Chair Feeding: 
      • If you notice your baby seems to lean or cannot sit on the floor without falling over, they may need more support in their high chair! 
      • Try putting a rolled up towel behind the baby's back or on either side of the baby for support. 
    • Adult's Lap: 
      • Sit the baby on an adult's lap. 
      • Position baby's back snuggly against your body. 
      • Always keep one arm around their waist. 
    • Other Tips: 
      • Prop/sit baby up for at least 30 minutes after they are finished eating to help prevent spitting up. 
      • Sit directly in front of your child when feeding them. 
      • Try to avoid feeding in areas that have a lot of noise and distractions like the TV. 

    Exploring New Foods: 

    • Let your child touch and explore their foods before trying them. 
    • Playing with food will allow your child to learn about different foods. 
    • Your child may need to see a new food 10-20 times before wanting to eat it. 

    Helpful Tips: 

    • Eating with your child during meal time can help them learn routines and strengthen their independence. 
    • Talk with your baby and limit distractions from your phones and screens.
    • Be patient and do not force feed your baby if uncomfortable. 
    • A little gagging can be a normal response to new foods. Do not react negatively. 
    • Praise what your child can do! 
    • Have fun and enjoy mealtimes together. 
  • How To Care For Your New Baby

    YOUR BABY MAY BE FUSSY AND UNTIL YOU ARE ABLE TO GET TO BABY STEPS, HERE ARE SOME THINGS THAT MAY HELP YOU AT HOME:

    KEEP THE ENVIRONMENT CALM

    • Speak in a calm, soothing voice
    • Dim the lights and keep it a little quiet (turn down the TV or music)
    • Hold your baby close to your body, especially for feeding
    • Limit screen use (phone, TV) with your baby

    TRY SOOTHING ACTIVITIES

    • Gently rock or bounce your baby with slow, steady movements
    • Lightly rub your baby’s back, chest, or tummy
    • Give your baby a warm bath and apply lotion afterward to help them relax
    • Start a bedtime routine; try to put your baby to bed at the same time each night, and read or sing to your baby before putting them down

    KNOW YOUR BABY’S FEEDING CUES:

    Your baby may:

    • Move hands to their mouth
    • Rooting (move head from side to side with mouth open)
    • Stick out tongue and make mouth movements 

    How do you know your baby is getting enough to eat?

    • 6-8 wet diapers each day Feeding Guide:
    • Gains a little weight every day
    • Helpful tip:
      A little spit up is okay. Check with your doctor before you change the formula.
      *Only feed your baby breastmilk or formula for the first  6 months.

    PRACTICING SAFE SLEEP IS VERY IMPORTANT!

    • It is safest for babies to sleep alone
    • Babies should sleep on their backs on a firm, flat mattress without any toys, blankets, or pillows.