Announcing COMBO National

By attaching real-time relational research to an unprecedented social disruption, COMBO opened the door to a once-in-a-generation opportunity: a truly comprehensive look at the science of early relationships. In exclusive partnership with Reach Out and Read, the “COMBO National” pilot is expanding across the country to build the evidence base for the growing field of Early Relational Health.

The COMBO Initiative: A Crucial Study of Early Childhood Relationships

For years, the American Academy of Pediatrics (AAP) has guided pediatric clinicians toward a relational lens on child health, urgently calling for strategies to support positive parent/caregiver-child interactions. “The AAP’s stance is critical,” stresses Dr. Dani Dumitriu, a Columbia pediatrician and neuroscientist, inaugural director of the Center for Early Relational Health, and Principal Investigator of its key COMBO Initiative. “We know that children’s development is deeply impacted by their close relationships, which protect against all kinds of insults during childhood. So promoting early relational health (ERH) has tremendous potential to impact lifelong resiliency and health outcomes.”

 Yet the Center for Early Relational Health’s 2022 fieldwide meta-analysis, which looked specifically at dyadic interventions (involving both parent/caregiver and child), led to a startling discovery: currently, there is not sufficient data for any existing dyadic ERH intervention that would support its implementation into pediatric clinical care, to improve health or development outcomes.

 Why have no scalable relational tools emerged to promote better health outcomes, despite the AAP’s longstanding call for them?

 Science has historically focused on individuals,” Dani says. “But relationships involve two people. So while we’re confident that human connection is both protective and healing, we’re missing a crucial puzzle piece: a precise, scientific understanding of the mechanisms underneath relationships—what actually gets communicated between our bodies and brains when we’re interacting with each other. Without that science, we can’t develop actionable tools. So while the AAP’s stance is crucial, the fact is: as pediatricians, we simply do not yet have a way to do what the AAP wants us to do.”—Dani Dumitriu, PhD, MD, Director Center for Early Relational Health at Columbia

There is an urgent need to re-examine how we look at relational health—broadly, but especially during early childhood, when it has the potential to affect a child’s (and in many ways, a family’s) lifelong development. COMBO set out to do just that, becoming a world-leading study of mother-infant and mother-child health.

And now, COMBO has entered a groundbreaking new phase: in exclusive partnership with Reach Out and Read, a national network of pediatric clinicians, this foundational study is expanding across the country. Unlike other existing studies, COMBO National strives to enroll as many of a child’s caregivers as possible, to build the most comprehensive understanding of the full space of early relationships.

“We know that positive interactions between parents or caregivers and young children support healthy growth and development,” says Nikki Shearman, PhD, Chief of Research and Innovation at Reach Out and Read. “Together, we’re trying to learn more about why these early interactions make such a difference, so that families can do what they most want to do — help their young children thrive.”

Our “COMBO National” pilot, which launched in April 2025 across six states, is currently enrolling through Reach Out and Read’s clinical network. Our aim is to generate the most comprehensive data on how early relational experiences shape both individual and social resiliency, and impact long-term health outcomes.

How Did COMBO Become a Cornerstone Study of ERH?

When Dani launched COMBO in the spring of 2020, at the epicenter of the pandemic, she started looking at moms and babies through a relational lens right away, because the childbearing year is such a critical time for maternal health and child development. “Based on the AAP’s stance, we expected these relationships to buffer any developmental effects of the virus,” Dani says. “But actually, what we started seeing during the pandemic were effects of disruptions in the relationships themselves.” So COMBO’s 200+ doctors, scientists, and students (at Columbia and beyond) worked together to develop cutting-edge methods of understanding the science of early relationships.

 In its first 5 years, COMBO grew to include an unparalleled 2,000+ mother-baby pairs, becoming one of the world’s largest studies to follow the development of babies born since 2020, from the womb through (hopefully) adulthood. Their research was some of the first to find answers to families’ and clinicians’ questions, and meaningfully influenced national and global policies to support early health and development—including reversing precautionary pandemic separation policies in hospitals, reuniting millions of moms and babies.

 Thankfully, being exposed to Covid in the womb doesn’t seem to be impacting population-wide developmental outcomes for these kids, at least so far. “But we are seeing impacts on child development from things like moms’ stress levels,” Dani says. “This has been a hard time for families. Kids are still experiencing disruptions, including social ones; it’s critical we continue to look at those to promote child and family well being.”

Because COMBO has looked at pandemic data through a relational lens from the beginning, they have crucial data on parent-child relationships going all the way back to the start of this major social disruption. And that positioned COMBO to become the first to study the wide spectrum of early childhood relationships from every angle.

COMBO’s National Expansion

As the size and scope of the initiative grew, the Center for Early Relational Health (which houses COMBO) developed an exclusive partnership with Reach Out and Read, whose nationwide network of pediatric clinicians is committed to promoting parent/caregiver-child relationships during well-child visits. This partnership marks the start of COMBO National: bringing COMBO’s foundational study of parent/caregiver-child health into a clinical network that serves nearly 5 million families across America. Nikki, who leads the implementation research arm of COMBO National (while Dani leads the clinical research arm) says, "Our dream is to offer pediatric clinicians feasible, evidence-based interventions that support a family’s early relational health, and make a bigger difference for every family and every child.”

A child’s relationships are core to their ability to develop long-lasting social resiliency and health. While other studies have looked at individual, one-way relationship models (like attachment, which is child-to-parent, or bonding, which is parent-to-child), COMBO National is the first study pilot to look at all known components of early relationships (including emotional connection, which goes both ways), and how each component maps onto future outcomes in health and development.

Meanwhile, the Center for Early Relational Health is actively working toward generating new ERH constructs—for example, by integrating in-depth parent interviews with cutting-edge machine learning—to develop novel ways of understanding relationships from all angles. This innovative work will continue to inform, and be informed by, COMBO National’s collaborative work with families and clinicians.

Further, COMBO National is an expansion from focusing solely on the mother-baby dyad (pair) to involving many kinds of caregivers in families all across the country. Ultimately planning to follow an unparalleled 5,000+ families (from infancy and early childhood), this unprecedented study will rapidly gather essential longitudinal ERH data at a scale not yet seen in dyadic research.

Finally, while existing studies of dyadic ERH interventions tend to focus on specific at-risk populations, COMBO National focuses on a broad sampling of American families. Building this comprehensive evidence base is a crucial step toward developing interventions that every family can benefit from, and embedding ERH into universal pediatric care.

COMBO National’s Field-Leading Approach to Early Relational Health

Crucially, the Center for Early Relational Health and Reach Out and Read co-designed this phase of the study in equal partnership with parents and pediatric clinicians across the country. “We know that the lived experience of parents/caregivers is not always considered in the development of medical care, and that has led to a lot of families not getting the care they need,” Dani says. “Listening to the families and doctors who will actually use the research is an essential step in building interventions that make a real difference.”

By conducting the largest, most rigorous long-term study of the science of early childhood relationships, COMBO National seeks to begin to answer the AAP’s call, toward building a world where pediatric clinicians have access to truly-evidence-based interventions—developed for and with the families they serve—for those critical early years.

The Harvard Study of Adult Development has given us nearly a century of actionable information on what makes a good life. So far, their data (and many others’) have shown irrefutable evidence that relationships are key to both health and well-being. COMBO National will be the first longitudinal study to illuminate the childhood origins of those healthy adult relationships—how they form, how they grow, and how they help families thrive lifelong.