mergent literacy has been described as "a developmental continuum [involving] skills, knowledge and attitudes that are precursors to reading and writing." 1(p848) Reading difficulties stem from deficits in any of these domains and take root early, with many children beginning kindergarten unprepared to learn to read 2 (typical skill emergence is summarized in Figure 1). These children are disproportionately from households with low socioeconomic status (SES) and minority race and/or ethnicity. 3,4 In total, 65% of fourth-grade students in the US scored lower than proficient in reading in a 2019 assessment. 5 Low reading proficiency is associated with adverse outcomes that accelerate over time. These outcomes include behavior and conduct issues, withdrawal from school, and low vocational potential and poverty, with an estimated annual cost of more than $350 billion in the US and more than $1.2 trillion worldwide. 6 Dyslexia is defined as persistent difficulty learning to read accurately or fluently despite adequate exposure to written language and normal nonverbal intelligence, with a substantial genetic component and an estimated prevalence of 5% to 17%. 7 Other reading difficulties occur in the context of medical and environmental risk factors, including premature birth, 8 chronic medical conditions, 9 English as a second language, 10 excessive screen-based media exposure, 11,12 and an understimulating home literacy environment, which, while variable, can be defined as the resources, motivation, and/or stimulation required to learn to read. [13][14][15] Dyslexia is traditionally characterized as having a phonological basis, while environmentally based reading difficulties are IMPORTANCE Literacy has been described as an important social determinant of health. Its components emerge in infancy and are dependent on genetic, medical, and environmental factors. The American Academy of Pediatrics advocates a substantial role for pediatricians in literacy promotion, developmental surveillance, and school readiness to promote cognitive, relational, and brain development. Many children, especially those from minority and underserved households, enter kindergarten unprepared to learn to read and subsequently have difficulty in school.OBSERVATIONS Emergent literacy is a developmental process beginning in infancy. Component skills are supported by brain regions that must be adequately stimulated and integrated to form a functional reading network. Trajectories are associated with genetic, medical, and environmental factors, notably the home literacy environment, which is defined as resources, motivation, and stimulation that encourage the literacy development process. Eco-biodevelopmental models are advocated by the American Academy of Pediatrics, and these models offer insights into the neurobiological processes associated with environmental factors and the ways in which these processes may be addressed to improve outcomes. Emergent literacy is well suited for such a model, particularly because the mechanisms underlying...