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1 PART I The Field of Pediatrics Since the late 19th century, pediatrics has been the only discipline dedi- cated to all aspects of the care and well-being of infants, children, and adolescents, including their health—their physical, mental, social, and psychologic growth and development—and their ability to achieve full potential as adults. The importance of scientific inquiry and research discovery in pediatrics and related subspecialties was cemented by the creation of the National Institute for Child Health and Development (NICHD) in 1962. As the earliest pediatricians focused on social and environmental issues that affected health (e.g., housing, sanitation, and poverty), so too are today’s pediatricians (e.g., racism, poverty, and other socioenvironmental influences). In 1959 the United Nations (UN) issued the Declaration of the Rights of the Child, articulating the universal presumption that children have fundamental needs and rights. However, the United States is the only UN member that has not yet ratified these rights. The pediatrician’s purpose is to advance the well-being of children, and thus pediatricians must be concerned with specific organ systems, genetics, and biologic processes and also with environmental, psycho- social, cultural, and political influences, all of which affect the health and well-being of children and their families. Pediatricians must be advocates for the individual child, their families, and communities because children cannot advocate wholly for themselves. Pediatricians must serve as advocates of all children irrespective of culture, religion, gender/gender identity, sexual orientation, race or ethnicity, ability, place of birth, or geographic boundaries. The more politically, econom- ically, or socially disenfranchised a population is, the greater the need for advocacy for its children and for those who support children. Youth are often the most vulnerable persons in society, and thus their needs require special attention. As boundaries between nations blur through advances in media, transportation, technology, communication, and economics, a global, rather than a national or local, perspective for the field of pediatrics becomes both a reality and a necessity. The interconnectedness of health issues across the world has achieved widespread recognition in the wake of new and emerging ill- nesses, such as COVID-19, Zika, Ebola, and severe acute respiratory syndrome (SARS), as well as familiar and persistent illnesses, such as malaria, tuberculosis, HIV/AIDS, and vaccine-preventable illness. Additionally,
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health issues transcend communicable disease and are influenced by global events, such as war, ethnic wars, mass shootings, bioterrorism, the burning of the Amazon rainforest, and the growing severity of wildfires, storms, drought, and hurricanes brought about by climate change to very specific events, such as the earthquake in Haiti in 2010; the displacement of families during the Syrian refugee crisis in 2016–2018; the White supremacist attack on a mosque in Christchurch, New Zealand, livestreamed in 2019; and George Floyd’s and Breonna Taylor’s murders in 2020. VITAL STATISTICS ABOUT CHILDREN’S HEALTH GLOBALLY From 1990 to 2020, the world population grew at an annual rate of 1% per year, down from 1.3% during the prior 20 years, to reach a popula- tion of nearly 8 billion people. The population growth rate continues to decline. The Pew Research Center projects the population to reach 10.9 billion people in 2100 with a growth rate of less than 0.1% at that time because of the fall in fertility rates. Africa is the only continental region that is predicted to continue to have strong population growth, as the 20 countries with the highest birthrates currently are all located in Africa. By 2100, the countries of India, China, and Nigeria are estimated to be the largest. In 2019, the average birthrate in the world was 17.9 births per 1,000 population, with a range from 46/1,000 in Niger to 6.0/1,000 in Monaco. The most populous countries—China (18.5% of the world population), India (17.7%), and the United States (4.3%)—have birth- rates of 11, 18, and 11 per 1,000 population, respectively, which were all trending down from previous years. Worldwide, there are roughly 2.5 billion youth under 19 years old, which accounts for approximately one third (32%) of the world’s population. The African region boasts the largest share of youth under 15 at 40% compared with 26% globally. Despite global interconnectedness, the health of children and youth varies widely between and within regions and nations, depending on several interrelated factors. These include (1) economic conditions, (2) educational, social, and cultural considerations, (3) health and social welfare infrastructure, (4) climate and geography, (5) agricultural resources and practices, which account for nutritional resources, (6)
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stage of industrialization and urbanization, (7) gene frequencies for certain disorders, (8) the ecology of infectious agents and their hosts, (9) social stability, and (10) political focus and stability. Although genetics, biology, and access to affordable and quality healthcare are important determinants, social and structural influences on health outcomes—the physical environment, political and economic condi- tions, and social, cultural, and behavioral considerations—play as great a role, if not greater. To ensure that the needs of children and adults worldwide were not obscured by local needs, in 2000 the international community estab- lished eight Millennium Development Goals (MDGs) slated to be achieved by 2015. Although all eight MDGs affect child well-being, MDG 4 was exclusively focused on children: to reduce the under-5 mortality rate (U5MR) by two thirds between 1990 and 2015. It was estimated that poor nutrition contributed to more than one third of the deaths worldwide in children <5 years old, so many of the efforts to reach this goal centered on increasing household food security. There has been significant progress toward this goal; the worldwide U5MR decreased by 60% between 1990 and 2021, from 93 deaths per 1,000 live births in 1990 to 38 in 2021. However, the World Health Orga- nization (WHO) cites that between 5.2 and 5.4 million children died worldwide from preventable or treatable causes. Infants younger than 28 days account for over half the deaths, followed by children age 1-11 months, and then by children age 1-4 years old. Children in sub- Saharan Africa are 9 times more likely to die before age 5 than children in the developed areas of the world (see Fig. 3.1). School children (ages 5-9 years old) also experienced a large decline in mortality since the year 1990 related to lower prevalence of infectious diseases. The infant mortality rate globally (2023) is 27.4 deaths per 1,000 live births, with female infants having a lower rate than male infants. The child death rates in the first year of life were highest in Afghani- stan (106.8), Somalia (88.0), and Central African Republic (84.2) per 1,000 live births. In the least developed countries, as classified by the UN, this rate was 45 per 1,000, and the rate was 4 per 1,000 for high- income countries.
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The causes of infant and under-5 mortality differ greatly between developed and developing nations. The leading causes of under-5 mortality are preterm birth and birth-related asphyxia/ trauma, pneumonia, diarrhea, and malaria (Fig. 1.1). As compared with higher-resourced countries, more children less than 5 years old in lower-resourced countries die from non–birth-related causes (see Fig. 3.4). In developing countries, over half of the deaths in children less than 5 years old resulted from infectious and parasitic diseases, including diarrheal disease (10% of deaths) and pneumonia (15%). Neonatal Chapter 1 Overview of Pediatrics Lee M. Pachter and Nia J. Heard-Garris Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 2 Part I u The Field of Pediatrics causes contributed 12%, congenital defects 9%, and malaria, AIDS, and measles accounted for the other causes of death. In the United States, pneumonia and influenza accounted for only 2% of under-5 deaths, with only negligible contributions from diarrheal diseases and malaria (Table 1.1). Although unintentional injuries in developing countries are a proportionately less important cause of mortality than in devel- oped countries, the absolute rates and contributions of these injuries to morbidity are substantially greater. In the United States, the top causes of unintentional injury include unintentional suffocation, drowning, motor vehicle collision, and fire. Other causes accounted for <5% of total mortality within this age-group (Tables 1.2). Violence is a sig- nificant contributor to injury-related mortality in all child age-groups (Tables 1.2 and 1.3). Globally (2023), the life expectancy at birth is 73.2 years old, with females at 76 years and males at 70.8 years. THE CHANGING PEDIATRIC WORLD A profound improvement in child health within industrialized nations occurred in the 20th century with the introduction of vaccines, anti- biotic agents, improved hygienic practices, and attention to scientific clinical practice. Efforts to control infectious diseases were comple- mented by better understanding of the role of nutrition in prevent-
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ing illness and maintaining health. In the United States, Canada, and parts of Europe, new and continuing discoveries in these areas led to establishment of publicly funded well-child clinics for low-income families. Although the timing of infectious disease control was uneven around the globe, this focus on control was accompanied by significant decreases in morbidity and mortality in all countries. Later in the 20th century, with improved control of infectious diseases through more effective prevention and treatment (including the eradica- tion of polio in the Western hemisphere), pediatric medicine in indus- trialized nations increasingly turned its attention to a broad spectrum of noninfectious acute and chronic conditions. These included potentially lethal conditions in addition to temporarily or permanently disabling conditions. Advances occurred in the diagnosis, care, and treatment of leukemia and other neoplasms, cystic fibrosis, sickle cell disease, diseases of the newborn infant, congenital heart disease, genetic defects, rheu- matic diseases, renal diseases, and metabolic and endocrine disorders. Until the 1970s and early 1980s, children affected with sickle cell disease often died within the first 3 years of life, often from overwhelm- ing sepsis caused by encapsulated bacteria. In the 1980s a multicenter study showed that early initiation of penicillin prophylaxis led to an 84% risk reduction for pneumococcal sepsis. Life expectancy for those with sickle cell disease increased when penicillin prophylaxis was initi- ated early in life. The use of prophylactic penicillin became the stan- dard of care, increasing the importance of early detection of sickle cell disease (which led to expanding universal newborn screening) and paving the way for advances in the chronic management of the disease, including transfusion therapy, radiographic screening for silent cere- bral infarctions, hydroxyurea as a disease-modifying therapy, and now, gene-altering therapies. The success of penicillin prophylaxis likely led to a more rapid rate of innovation in the diagnosis and management of the disease as a result of increased life expectancy. Today 95% of indi- viduals born with sickle cell disease will live to their 18th birthday, and most will survive until their fifth decade. Similarly, the treatment of acute lymphoblastic leukemia (ALL), the most common pediatric malignancy, has also shown amazing 1.39 8.14 0.58 1.69 2
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.40 4.86 14.94 17.82 12.41 6.47 9.79 8.76 4.55 6.21 HIV/AIDS Diarrheal diseases Tetanus Measles Meningitis/encephalitis Malaria Acute lower respiratory infections Prematurity Birth asphyxia and birth trauma Sepsis and other infectious conditions Other communicable, perinatal and nutritional conditions Congential anomalies Other noncommunicable diseases Injuries Fig. 1.1 Global causes of death under the age of 5 years. Table 1.1 Ten Leading Causes of Death by Age Group, United States – 2018 10 leading causes of death by age group, United States – 2018 Rank <1 1–4 5–9 Age groups 10–14 15–24 1 Congenital anomalies 4,473 Unintentional injury 1,226 Unintentional injury 734 Unintentional injury 692 Unintentional injury 12,044 2 Short gestation 3,679 Congenital anomalies 384 Malignant neoplasms 393 Suicide 596 Suicide 6,211 3 Maternal pregnancy comp. 1,358 Homicide 353 Congenital anomalies 201 Malignant neoplasms 450 Homicide 4,607 4 SIDS 1,334 Malignant neoplasms 326 Homicide 121 Congenital anomalies 172 Malignant neoplasms 1,371 5 Unintentional injury 1,168 Influenza and pneumonia 122 Influenza and pneumonia 71 Homicide 168 Heart disease 905 6 Placenta cord membranes 724 Heart disease 115 Chronic lower respiratory disease 68 Heart disease 101 Congenital anomalies 354 7 Bacterial sepsis 579 Perinatal period 62 Heart disease 68 Chronic lower respiratory disease 64 Diabetes mellitus 246 8 Circulatory system disease 428 Septicemia 54 Cerebro- vascular 34 Cerebro- vascular 54 Influenza and pneumonia 200 9 Respiratory distress 390 Chronic lower respiratory disease 50 Septicemia 34 Influenza and pneumonia 51 Chronic lower respiratory disease 165 10 Neonatal hemorrhage 375 Cerebro- vascular 43 Benign neoplasms 19 Benign neoplasms 30 Complicated pregnancy 151 Courtesy Centers for Disease Control and Prevention, https://www.cdc.gov/injury/wisqa rs/pdf/leading_causes_of_death_by_age_group_2018-508.pdf. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal
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use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 1 u Overview of Pediatrics 3 advances. Five-year survival rates have increased from <10% in the 1960s to >90% in 2023. Cystic fibrosis has shown improvements in survival as well. In the 1960s, most children with cystic fibrosis did not live to school age. With advances in pulmonary and nutritional therapies, as well as earlier initiation of these therapies secondary to earlier identification through newborn screening, a child born with cystic fibrosis in 2010 has a projected life expectancy of 39-56 years. These major advances in the management of chronic diseases of childhood were accomplished when significant improvement occurred in the prevention and treatment of acute infectious diseases, at least in industrial countries. This allowed human and economic resources to shift toward addressing chronic disease. However, infec- tious diseases continue to cause significant morbidity and mortality throughout the world. In the fall of 2021, the WHO recommended the use of the RTS,S/AS01 malaria vaccine for children in areas of moderate and high levels of transmission of Plasmodium falciparum, which is the most prevalent cause of malaria in Africa. This historic declaration holds great promise for improving children’s health, as more than 250,000 African children under 5 die from malaria each year. The coronavirus disease 2019 (COVID-19) pandemic has proved to be an unremitting global health challenge that has not only affected health but also changed and influenced the socioeconomic lives of people throughout the world. THE NEW NORMAL: PANDEMICS Since COVID-19 was first reported and identified in Wuhan, China, in 2019, it has radically and fundamentally affected both the public health and global health landscapes (see Chapters 311 and 449.1). The identifica- tion of COVID-19 and development of a vaccine unfolded over the course of 1 year, which was a testament to the importance and critical need for scientific research and rapid clinical implementation. We learned that children could present with or without symptoms and were important factors in community-based viral transmission. Whereas many children experienced minor illnesses, others expe- rienced more severe illnesses, which were related to underlying chronic conditions, such as asthma or the use of medical devices for children with special healthcare needs, and around 1% of children would go on to develop multiinflammatory syndrome (MIS-C). This condition could
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be lethal, but most children who received timely care improved. As of spring 2023, there were over 766 million cases and nearly 6.9 million deaths from COVID-19, and the United States had the highest number of cases and deaths throughout the world. Chil- dren in the United States accounted for 6 million COVID-19–posi- tive cases, with 0.1–2.0% of children hospitalized and 0.03% leading to child deaths. Although children were less affected by COVID-19–related illnesses than their adult counterparts, they experienced significant mental health and psychosocial challenges, grief, and loss. Over 1.5 billion Table 1.2 Ten Leading Causes of Injury Deaths by Age Group Highlighting Unintentional Injury Deaths, United States – 2018 10 leading causes of injury deaths by age group highlighting unintentional injury deaths, United States – 2018 Rank <1 1–4 5–9 Age groups 10–14 15–24 1 Unintentional suffocation 977 Unintentional drowning 443 Unintentional MV traffic 341 Homicide unspecified 152 Homicide firearm 57 Unintentional drowning 86 Unintentional drowning 39 Unintentional drowning 431 Undetermined suffocation 45 Suicide suffocation 361 Unintentional MV traffic 6,308 Unintentional MV traffic 360 Unintentional poisoning 4,245 Homicide firearm 4,107 Suicide firearm 2,995 Suicide suffocation 2,237 Suicide poisoning 454 Unintentional MV traffic 292 Homicide unspecified 125 Unintentional MV traffic 80 Homicide other spec., classifiable 68 Unintentional fire/burn 123 Unintentional drowning 130 Unintentional suffocation 112 Unintentional pedestrian, other 70 Unintentional other land transport 20 Homicide suffocation 30 Homicide other spec., classifiable 66 Homicide unspecified 17 Unintentional suffocation 43 Undetermined unspecified 30 Homicide firearm 54 Adverse effects 16 Unintentional other land transport 37 Homicide cut/pierce 256 Unintentional natural/ environment 22 Unintentional natural/ environment 38 Unintentional pedestrian, other 15 Unintentional poisoning 23 Undetermined poisoning 224 Two tied 18 Unintentional firearm 30 Homicide other spec., NECN 14 Suicide poisoning 20 Suicide fall 205 Unintentional suffocation 30 Suicide firearm 202 Homicide firearm 134 Unintentional fire/burn 99 Unintentional fire/burn 52 2 3 4 5 6 7 8 9 10 Courtesy Centers for Disease Control and Prevention, https://www.cdc.gov/injury/
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wisqa rs/pdf/leading_causes_of_injury_deaths_highlighting_unintentional_2018-508.pdf. Table 1.3 Ten Leading Causes of Injury Deaths by Age Group Highlighting Violence-Related Injury Deaths, United States – 2018 10 leading causes of injury deaths by age group highlighting violence-related injury deaths, United States – 2018 Rank <1 1–4 5–9 Age groups 10–14 15–24 1 2 3 4 5 6 7 8 9 10 Unintentional suffocation 977 Homicide unspecified 125 Unintentional MV traffic 80 Homicide other spec., classifiable 68 Undetermined suffocation 45 Unintentional drowning 39 Homicide suffocation 30 Undetermined unspecified 30 Unintentional natural/ environment 22 Two tied 18 Unintentional drowning 443 Unintentional MV traffic 292 Homicide unspecified 152 Unintentional fire/burn 123 Unintentional suffocation 112 Unintentional pedestrian, other 70 Homicide other spec., classifiable 66 Homicide firearm 54 Unintentional natural/ environment 38 Unintentional firearm 30 Unintentional MV traffic 341 Unintentional drowning 130 Unintentional fire/burn 99 Homicide firearm 57 Unintentional suffocation 30 Unintentional other land transport 20 Homicide unspecified 17 Adverse effects 16 Unintentional pedestrian, other 15 Homicide other spec., N 14 NEC Suicide suffocation 361 Unintentional MV traffic 360 Suicide firearm 202 Homicide firearm 134 Unintentional drowning 86 Unintentional fire/burn 52 Unintentional suffocation 43 Unintentional other land transport 37 Unintentional poisoning 23 Suicide poisoning 20 Unintentional MV traffic 6,308 Unintentional poisoning 4,245 Homicide firearm 4,107 Suicide firearm 2,995 Suicide suffocation 2,237 Suicide poisoning 454 Unintentional drowning 431 Homicide cut/pierce 256 Undetermined poisoning 224 Suicide fall 205 Courtesy Centers for Disease Control and Prevention, https://www.cdc.gov/injury/wisqa rs/pdf/leading_causes_of_injury_deaths_highlighting_violence_2018-508.pdf. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 4 Part I u The Field of Pediatrics children living through the
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pandemic faced unprecedented learning challenges because of widespread school closures and dependence on electronic devices and stable internet connections and widening edu- cational disparities, especially for those in poverty, children of frontline workers and single parents, and those already marginalized. Addition- ally, children who received nutritional support in school or received in-school or in-home services to support their learning and/or devel- opmental needs (e.g., speech therapy, specialized teaching, or other ancillary therapies) also faced disruptions. These disruptions and stress contributed to an increase in mental and emotional health burdens, such as depression, anxiety, isolation, and fear; however, these burdens were unable to be matched with a sufficient number of mental health- care professionals to provide needed care. The pandemic also disproportionately affected poor families and fam- ilies of color in other ways. Children in these families faced increased risk of economic hardship and instability, loss of caregivers, and other challenges. Additionally, concerns about all children’s safety and welfare continued and were highlighted, as noncustodial adults had less access and exposure to children who may have experienced physical, sexual, or emotional abuse. Finally, children with special healthcare needs expe- rienced insurmountable challenges throughout the pandemic, such as not receiving essential medicines, medical supplies, and nursing or home healthcare services because of supply chain disruptions and staff- ing shortages. So although children largely were spared from the illness severity, there were undoubtedly victims of the sequelae that the pan- demic brought forth. Now, in partnership with parents, communities, schools, and governments, pediatricians will need to continue to advo- cate for and support children to mitigate COVID-19’s effects on children. THE NEW MORBIDITIES Given the advances in public health in decreasing morbidity and mor- tality in infectious diseases (immunization, hygiene, antibiotics), along with technologic advances in clinical care that improved survival for many chronic illnesses, attention was given to what was described in the 1980s and 1990s as the “new morbidities”—behavioral, develop- mental, psychosocial conditions, and societal inequities, which have been shown to be increasingly associated with suboptimal health out- comes and quality of life. The prevention, early detection, and manage- ment of these types of child health problems should be a central focus of the field of pediatrics and require an expansion in the knowledge base regarding (1) physical
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and environmental factors affecting behav- ior, (2) normal child behavior and development, (3) health behaviors as they pertain to child health, and (4) mild, moderate, and severe behav- ioral and developmental disorders. Accomplishing this would require reconceptualizing professional training, improving clinical communi- cation and interviewing skills, expanding mental health resources for children, and shifting time allocation during child health supervision visits to address these concerns. In 2001 this issue was revisited and reemphasized the need to address environmental and social aspects in addition to developmental and behavioral issues (Table 1.4). This included violence, firearms, substance use, food insecurity, and school problems, as well as poverty, unhoused (homelessness), single-parent families, divorce, social media, incarceration, and childcare. Although at first glance this list seems daunting and beyond the scope of what pediatricians typically address (i.e., physical health and development), many of these behavioral, environmental, and psychosocial prob- lems (which all fall under what was termed the “social determinants of health” but are better characterized as the “social and structural influences on health”) account for a large proportion of variance in health outcomes in children and youth. The role of pediatrics and the boundaries of clinical practice needed to change in order to address these salient contributors to child health and well-being. Newer mod- els of clinical care that rely on close collaboration and coordination with other professionals committed to child welfare (e.g., social work- ers, psychologists, mental health providers, educators) were developed. As this model expanded, so did the role of the family, in particular the child’s caregiver, from a passive recipient of professional services to a more equitable and inclusive partner in identifying the issues that needed to be addressed, as well as helping decide which therapeutic options had the “best fit” with the child, the family, and the condition. The framing of salient child health issues under the “new morbid- ity” concept acknowledges that the influences on health are hetero- geneous but interconnected. Biology, genetics, healthcare, behaviors, social conditions, and environmental influences should not be viewed as mutually exclusive determinants; they exert their influ- ences through complex interactions on multiple levels. For example, epigenetic changes that result from specific social and environmental conditions illustrate the influence of context on gene expression. Studies have demonstrated that
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while each of these interrelated influ- ences are important for optimal health, development, and well-being, the greatest contributions to health outcomes occur in the behavioral, social, and environmental domains—the social and structural influences on health. From 40% to 70% of the relative variation in certain health outcomes are caused by social and economic conditions, health behav- iors, and environmental factors, as well as structural inequality in the healthcare domain. Whereas traditional medical education and clinical practice emphasized the biologic and genetic determinants of health, the recognition of the new morbidities as a focus of child healthcare provi- sion reinforced the need to address social and structural influences as a key component of pediatric care, training, and research. The “New” New Morbidities The new morbidities concept brought into perspective the importance of addressing the social determinants of health, as well as the increasing Table 1.4 A Development History of the New Morbidities in Child Health* THE NEW MORBIDITIES (1982–1993) THE NEW MORBIDITIES REVISITED (2001) THE “NEW “NEW MORBIDITIES (2010 TO PRESENT) Behavioral disorders/mental health School problems Adverse childhood experiences (ACEs) Family crisis Mood and anxiety disorders Toxic stress Abuse and neglect Adolescent suicide/homicide Allostatic load Long-term disease Firearms in home Chronic illnesses of lifestyle (e.g., obesity, type 2 diabetes, hypertension) Substance abuse School violence Behavioral conditions (autism, ADHD, depression, anxiety) School difficulties Drug and alcohol abuse Food insecurity HIV Oral health Effects of media Witnessing community/interpersonal violence Poverty Peer victimization/bullying Homelessness Discrimination Single-parent families Effects of divorce Struggle of working parents Child care quality and policy *Each column adds further categories and refinements to prior columns. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 1 u Overview of Pediatrics 5 prevalence and salience of chronic physical and behavioral health con- ditions in pediatric healthcare. Since then, advances in epidemiology, physiology, and epigenetics have expanded the scope of inquiry into the effects of a broad range of health influences and provided more sophisticated explanatory models for the mechanisms that explain their effects (see Table
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1.4). Racism Although racism is known as “America’s Original Sin,” racism and racial discrimination is a worldwide problem (see Chapter 2.1). Racism can occur at the systemic/structural, interpersonal, and internal/psychologic levels. Structural racism is the hierarchical grouping of people based on physical attributes, including skin color, which assigns value to those groups and then allocates certain resources, privileges, and power to the dominant or in-group. Structural racism built on White supremacy and hegemony has been a persistent and plaguing problem for over 400 years. It is racism and racist ideology that have created and perpetuated pediatric health disparities by race (see Chapters 2 and 2.1). In the after- math of the state-sanctioned violence against Black people, there are calls for the end of racism, police actions, and White supremacy ideol- ogy throughout the world. The field of pediatrics did not go untouched in these discussions, and numerous articles were presented about how to dismantle structural racism and equip pediatricians with the tools to do so. Importantly, pediatricians have been called to examine areas in which racism and harm are perpetuated through healthcare, through policies, practices, beliefs, and ideals. Racism along with adverse childhood expe- riences are some of the pressing challenges for the modern-day pediatri- cian in promoting equitable health access and outcomes. The issue of racism is even more relevant by understanding that of the ∼73,000,000 children in the United States, ∼50% are non-White, non-Hispanic (∼26% Hispanic, ∼14% Black, 5% Asian, ∼5% other), 20% speak a language other than English at home, and ∼25% are immi- grants or children of immigrants. Adverse Childhood Experiences Adverse childhood experiences (ACEs) are stressful events experi- enced during childhood that can have profound health consequences both in childhood and throughout the life course into adulthood. ACEs were initially defined as abuse (physical, emotional, sexual), neglect (physical and emotional), and household challenges/family dysfunction (parental spousal abuse, mental illness in household, household substance abuse, incarceration of household member, parental separation or divorce). Retrospective studies have shown a graded dose-response effect of ACEs on future adult health of those who experience the adverse event in childhood. For example, more childhood adversity is associated with significantly increased risk
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in later life of ischemic heart disease, chronic obstructive pulmonary disease, liver disease, depression, obesity, and cancer. People who suffer ≥6 ACEs die almost 20 years earlier than those who had not experienced ACEs. Although the original conceptualization of ACEs included family- level psychosocial trauma, recent attempts have been made to expand the concept to include “macro” level stressors, such as those encoun- tered in the neighborhood and community (Table 1.5). These include witnessing violence in the community, poverty, bullying and peer victimization, peer isolation, living in unsafe neighborhoods, low neighborhood social capital, living in foster care, and experiencing dis- crimination or racism. ACEs and other psychosocial traumas may influence health through a number of mechanisms. ACEs are associated with adoption of risky behaviors such as substance use and early initiation of sexual activity, which in turn may increase the risk of chronic diseases such as lung cancer, liver disease, obesity, human papillomavirus (HPV) infection and cervical cancer, chronic lung disease, and premature mortality. Childhood trauma can also disrupt neurodevelopment during critical stages of brain development and contribute to social, emotional, and cognitive impairment. Finally, ACEs can result in toxic stress and lead to the dysregulation of normal physiologic processes (see Toxic Stress and Allostatic Load later). The documentation of cumulative ACE “scores” has value from a population-based epidemiologic perspective but has limited clinical utility. An ACE score gives no information regarding specific adver- sities and traumas, nor information regarding which interventions may be required. Although ACE screening may not be the optimal approach to incorporating a trauma lens into individual clinical care, a discussion around ACEs can help the clinician to begin collabora- tive communication with patients and families on the importance of psychosocial stress and adversity in health and well-being in childhood and throughout the life course. Furthermore, it becomes important to understand that individuals are not merely a sum of their traumas. Although the recognition of the importance of ACEs and trauma-informed care has resulted in the reframing of the question “what’s wrong with you” to “what’s happened to you,” this needs to be seen as a transition step toward the goal of healing-centered care, which includes an emphasis not only on adver- sity but also on assets (
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Fig. 1.2). Those assets may be external (e.g., family, community, peers, mentors) or internal (e.g., resilience, posi- tive coping strategies, locus of control). In a healing-centered model of care, the evolution of the question “what’s wrong with you” to “what happened to you” gets further refined to include “what’s right or posi- tive about you.” Toxic Stress and Allostatic Load The effects of stress are moderated by the intensity of the stress, the bio- logic response to the stress, and the social and physical environment in which the stress is experienced. Toxic stress occurs when a child expe- riences stressful events that are chronic, intense, or prolonged and are inadequately buffered by the child’s social support system (most impor- tantly, parents and adult caregivers). Toxic psychosocial stress influ- ences physical health by producing allostatic load, or pathophysiologic dysregulation of normal regulatory systems. Allostatic load is the “wear and tear” that the body and its regulatory mechanisms experience in response to chronic, unbuffered stress. The systems that can be affected through allostatic load include the neuroendocrine, cardiovascular, immune, and metabolic systems. Dysregulation of stress hormones in the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal- medullary (SAM) systems, inflammatory cytokines, hormones (e.g., insulin), immune factors (e.g., fibrinogen, C-reactive protein), and Table 1.5 Adverse Childhood Experiences CATEGORY ITEMS Abuse and neglect Physical abuse* Physical neglect* Emotional abuse* Emotional neglect* Sexual abuse* Family dysfunction Intimate partner violence* Substance use in household* Mental illness in household* Parental separation or divorce* Family member incarcerated* Parental discord Community-level adversity Witnessing community violence Neighborhood safety Lack of neighborhood connectedness/ trust Experiencing discrimination Others Being bullied/peer victimization Living in foster care Social isolation Low socioeconomic status/poverty *Items included in original Kaiser ACE study. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use
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only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 6 Part I u The Field of Pediatrics cardiovascular biomarkers (e.g., blood pressure) can occur from chronic stress and result in pathophysiologic conditions associated with chronic diseases. Chronic stress can also have effects at the genetic level. Stud- ies of cellular aging have shown that chronic stress decreases telomere length, a determinant of aging on the cellular level. Epigenetic changes, including differential immune system DNA methylation, may occur after child abuse and posttraumatic stress disorder (PTSD) potentially contributing to inflammatory and immune dysregulation.* Pediatrics, developmental psychology, basic sciences, and public health have contributed significant advances to the study of the behav- ioral, developmental, and social influences on child health. The influ- ence of psychosocial stress brought about by environmental challenges, although always acknowledged as important, has taken on a new level of salience as epidemiologists have linked its occurrence to significant morbidities throughout the life course and as basic and clinical neuro- science has provided a multilevel framework for understanding how behavioral and psychosocial issues “get under the skin” to cause physi- ologic dysfunction and dysregulation. Such a framework can also be seen as a mechanism underlying health disparities (see Chapter 2). Ecobiodevelopmental Framework An ecobiodevelopmental framework has been proposed to integrate the overlapping influences of environmental (ecologic), biologic, and devel- opmental factors into a model of health and illness. This model posits that ecology (or the social and physical environment) affects biology through physiologic disruptions and adaptations secondary to allostatic load mechanisms. The environment also influences development through life course science, which includes the effects of toxic exposures and child- hood adversity on learning, cognitive, behavioral, and physical health throughout the life course. Stress-induced biologic responses to adversity may negatively affect development and biologic health. Biology influences development though brain maturation and neuroplasticity, which in turn are also affected by inputs from the social and physical environment. The ecobiodevelopmental framework is consistent with the biopsychosocial model while adding a longitudinal life course developmental dimension. CHRONIC ILLNESS AND CHILDREN WITH SPECIAL HEALTHCARE NEEDS The care of children with chronic conditions has become an increasingly larger part of clinical pediatrics for both the pediatric subspecialist and the general pediatrician. Children and
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youth with special healthcare needs (CSHCN) are defined by the U.S. Maternal and Child Health Bureau as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” According to the 2018–2019 National Survey of Children’s Health (NSCH), >14.1 million, or 19% of U.S. children, have a special health need. The 2009–2010 National Survey of Children with Special Health Care Needs (NS-CSHCN) reports that almost one quarter (23%) of U.S. households with children have a child with a special need. The conditions these children have are extremely heterogeneous, as shown in Table 1.6. Most of these children need specialty care in addition to primary care. In the United States, 0.4–0.7% of children fall into the category of “highest medical complexity”; these children account for 15–33% of all healthcare spending for children. Children with medical complexity account for >70% of hospital readmissions. Nine of 10 CSHCN have functional difficulties in the sensory, cogni- tive, movement, emotional, or behavioral domains (Table 1.7). More than 65% (7.2 million) of CSHCN have conditions that affect their daily activities, and >2.3 million families experience financial difficul- ties because of their children’s special health needs. The fact that 25% of family members of CSHCN cut back work hours or stop working because of their child’s special needs highlights the social and eco- nomic impact of child chronic illness at both the individual and the national economic level. Pediatricians are typically the “point persons” in the professional care of these children and provide data and expert opinion to procure needed services and resources to the child in the clinic, home, schools, and com- munity. Such demands require an efficient model of chronic care. SYSTEMS OF CARE Population Health Approach Because pediatric practice is increasingly spent working with patients and families who have chronic issues and conditions, new approaches to healthcare services delivery have been proposed. Whereas tradi- tional practice models concentrate efforts toward the preventive and therapeutic needs of those patients who present for care, a popula- tion health approach to care refocuses efforts to emphasize the need to address health from a community
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- or population-level perspective, with emphasis on identifying and addressing the needs of individuals and families who do not seek regular care or whose care is episodic and suboptimal from a prevention or management standpoint. Effec- tiveness of such a system improves with greater collaboration between healthcare providers and payers (insurance companies) to identify gaps in care, with data surveillance systems and electronic health records (EHRs) and with an expanded cadre of healthcare personnel such as care coordinators, nurse practitioners, physician assistants, social workers, health navigators, and community health workers. Health- care reimbursement modifications, such as incorporating value-based External • Family • Peers/friends • Other adults • Community • Neighborhood • Social capital Assets / Adversity → Outcomes Internal • Resilience • Coping style • Locus of control • Spirituality • Epigenetics Fig. 1.2 Healing-centered care. Well-being and outcomes are a func- tion of an individual’s assets and adversities. Table 1.6 Children with Special Healthcare Needs (CSHCN)* HEALTH CONDITIONS Attention-deficit/hyperactivity disorder Depression Anxiety problems Behavioral or conduct problems Autism spectrum disorder Developmental delay Intellectual disability Communication disorder Asthma Diabetes Epilepsy or seizure disorder Migraines or frequent headaches Head injury, traumatic brain injury Heart problems, including congenital heart disease Blood problems, including anemia or sickle cell disease Cystic fibrosis Cerebral palsy Muscular dystrophy Down syndrome Arthritis or joint problems Allergies *List is not comprehensive and does not include all conditions that CSHCN may have. Adapted from Child and Adolescent Health Measurement Initiative. “2009/10 NS-CSHCN: Health Conditions and Functional Difficulties.” Data Resource Center, supported by Cooperative Agreement 1-U59-MC06980-01 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). Maternal and Child Health Bureau (MCHB). 2012. Available at www.childhealthdata.org. Revised 01/27/2012. *Editor Note: Community members and some healthcare workers refer to this disorder as “hood disease.” Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only
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. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 1 u Overview of Pediatrics 7 and quality-of-care–based models, if implemented correctly, may fur- ther advance a population health approach to care. Medical Home The concept of the patient and family–centered medical home (PFCMH) approach to providing care is defined as a medical home that provides care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effec- tive. Patients and family members are key active participants, working with clinicians to identify priorities for and approaches to care (shared decision-making; see Chapter 18). A key aspect of the PFCMH is care coordination. Care coordination “addresses interrelated medi- cal, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes.” A care coordina- tor is the “point person” on the team who prospectively identifies the patient’s and family’s needs, concerns, and priorities for the healthcare visit, gathers pertinent information (lab results, consultations, educa- tional plans, screening/testing results), communicates with subspecial- ists, and relays all important information to the clinical team before the patient/family visit. After a healthcare visit, the care coordinator works with the family to address any ongoing concerns, directs efforts to schedule follow-up appointments and referrals, and communicates information to all necessary parties. The care coordinator typically is not a physician. The intended result of care coordination is an efficient and comprehensive interaction between the pediatric team and the family, between primary care and specialty care, between ambulatory and inpatient care teams, and between the pediatric care team and the community-based supports on which the patient and family depend. Provision of care consistent with the elements of a medical home has been associated with more accurate and early diagnosis, fewer emer- gency department visits and inpatient hospitalizations, lower costs, fewer unmet needs, lower out-of-pocket medical costs, less impact on parental employment, fewer school absences, and better patient satis- faction. According to the 2016 NSCH, 43% of U.S. CSHCN and 50% of U.S. children without a SHCN received coordinated, comprehensive care within a medical home. Medical and Health Neighborhood Although the medical home concept relates to practice transforma- tion specific to primary care, a
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broadening of this concept has been proposed along two separate dimensions. The medical neighborhood expands the medical home concept and refers to coordinated and effi- cient integration between primary care pediatricians and the subspe- cialists, including integrated EHRs, efficient coordinated appointment scheduling, and enhanced communication. Such a system has the potential to provide a less stressful patient and family experience and could also lead to cost reduction and a decrease in medical errors. Another expansion and modification of the medical home is the health neighborhood concept. The health neighborhood is based on the recognition of the importance of coordination with community-based and nonmedical providers to address comprehensively and efficiently the social and structural influences on health. Health neighborhoods include the healthcare providers (consistent with the medical home and neighborhood) but also involve services such as early intervention pro- grams, the education system, childcare, community-based behavioral and mental health services, legal services, nutritional support services, and other clinical and community-based services that the patient and family need to access. The health neighborhood team helps families identify the needs of the patient, assists with referrals to appropriate agencies outside the healthcare system, and coordinates care. Some nonmedical services may be co-located at the medical office. Medical-legal partnerships (MLPs) are collaborations between the healthcare and legal systems and embed legal aid personnel in the medical clinic. These lawyers and legal paraprofessionals can provide direct ser- vices to patients and families who have legal issues that may be affecting the child’s health (e.g., housing code violations, utility shutoff, food insecu- rity, immigration issues, educational accommodations, guardianship). In addition to providing direct services, MLPs train healthcare personnel in the legal, social, and structural influences on health and work with physi- cians and others to advocate for policy change. Other nonmedical health neighborhood services that could be co-located in the medical center include supplemental nutrition assistance programs, parenting programs, behavioral health services, and family financial counseling. Many, if not most, other services are located in the community. The health neighborhood model links families to these services and provides efficient ongoing coordination and communication. Com- munity health workers or health navigators are paraprofessional team members who are community and culturally informed and serve as a coordinating link between the family, the medical home, and needed community services. Community health workers and health navigators can also provide patient and family education. Expanded care models such as
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these have the potential to achieve what the Institute for Healthcare Improvement calls the “quadruple aim” for healthcare: focusing on care (improving the patient experience with healthcare, quality care, and satisfaction), health (improving the health of populations, including emphasis on equity), provider satisfaction (“joy in work”), and cost (reducing per-capita healthcare costs) (Fig. 1.3). Visit Elsevier eBooks+ at eBooks.Health.Elsevier.com for Bibliography. Table 1.7 Functional Difficulties in Children with Special Healthcare Needs (CSHCN)* Experiencing difficulty with… Breathing or respiratory problem Swallowing, digesting food, or metabolism Blood circulation Repeated or chronic physical pain, including headaches Seeing even when wearing glasses or contact lenses Hearing even when using a hearing aid or other device Taking care of self, such as eating, dressing, or bathing Coordination or moving around Using his or her hands Learning, understanding, or paying attention Speaking, communicating, or being understood Feeling anxious or depressed Behavior problems such as acting out, fighting, bullying, or arguing Making and keeping friends *List is not comprehensive and does not include all functional difficulties that CSHCN may have. From Child and Adolescent Health Measurement Initiative. “2009/10 NS-CSHCN: Health Conditions and Functional Difficulties.” Data Resource Center, supported by Cooperative Agreement 1-U59-MC06980-01 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). 2012. Available at www.childhealthdata.org. Revised 01/27/2012. Health: Improving the health of populations (including equity) Cost: Reducing per capita healthcare costs Satisfaction: Joy in work for providers Care: Improving the patient care experience Fig. 1.3 The quadruple aim for healthcare. (Data from Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573–576.) Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved
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. 8 Part I u The Field of Pediatrics Health and illness are not distributed equally among all members in most societies. Differences exist in historical roots, risk factors, preva- lence and incidence, manifestations, severity, and outcome of health con- ditions, as well as in the availability and quality of healthcare. When these differences are modifiable and avoidable, they are referred to as dispari- ties or inequities. The U.S. Department of Health and Human Services (DHHS) Healthy People 2030 report defines health disparity as “a partic- ular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disabil- ity; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” The U.S. Centers for Disease Control and Prevention (CDC) define health disparities as “preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups, and communities.” Healthy People 2030 defines health equity as “the attain- ment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” Health and healthcare disparities occur because of unequal distribution of resources that are inherent in societies that exhibit social stratification, which occurs in social systems that rank and categorize people into a hierarchy of unequal status and power. ROOT HISTORICAL CAUSES OF STRUCTURAL DETERMINANTS OF HEALTH AND HEALTH DISPARITIES Figure 2.1 displays a categorization of the multiple determinants of health and well-being. Applying this categorization to health dis- parities, conceptualizations of the root causes of health disparities emphasize the most modifiable determinants of health: the physical and social environment, psychology and health behaviors, socioeco- nomic position and status, and access to and quality of healthcare (and the policies that place marginalized groups at greater risk based on these determinants). Differential access to these resources results in differences in material resources (e.g., money, education
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, health- care) or psychosocial factors (e.g., locus of control, adaptive or risky behaviors, stress, social connectedness) that may contribute to dif- ferences in health status. This section will explore several historical social and structural root contributors to health disparities (see also Chapter 2.1). Federal Policies and Economic Outcomes Redlining (1933–1960) A federally backed homeowner mortgage banking system, the Home- owners Loan Corporation (HOLC), was created in the 1930s and graded neighborhoods on credit risk for investment and mortgage lending into four color-coded levels that were outlined on city maps. The four color- coded levels were based primarily on racial and ethnic demographics rather than economic factors, with the 2 most desirable codes being for more affluent White neighborhoods. Neighborhoods defined as “Defi- nitely Declining” were marked in yellow and were older neighborhoods with mixed ethnic makeup, including lower-income White residents and European immigrant residents, but no Black residents. Residents in these communities were allowed to get homeowner mortgages, but there was less overall economic development. Neighborhoods defined as “Hazard- ous” were marked in red (hence the term redlined communities) and were where Blacks lived, including affluent Blacks. Residents in these neigh- borhoods were denied homeowner mortgages and were systematically disinvested by local, state, and federal government policies. The Federal Housing Authority (FHA), created in 1934 to be the government entity that would federally secure homeowner mortgages, created underwriting manuals for banks with rules regarding lending practices that included denying loans to Black applicants and devaluat- ing properties in redlined neighborhoods. Therefore from the 1930s to 1960s, 98% of FHA homeowner mortgage loans were given to White Americans. This led to decades of residential housing segregation. Redlining was officially outlawed by the Fair Housing Act of 1968; however, the impact of redlining continues. Urban Renewal (1949–1974) After World War II, city officials and city planners across the United States described urban areas as “slums,” full of poor people and in blight. At the same time, the Great Migration (1916–1970) changed the racial makeup for northern cities, when millions of rural southern Black farm workers, domestic workers, laborers, and their families left the harsh Jim Crow segregated conditions of the South and migrated to northern cities seeking a better life and improved economic conditions and opportunities. The leaders in northern destination cities
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sought to control and contain these southern Black Americans. The federal government passed the Housing Act of 1949 to provide funding to cit- ies across the country to clear and redevelop the slums (called “slum clearance”). City leaders and planners used the funds to revitalize their downtown areas to woo suburban Whites for shopping and entertain- ment and simultaneously target redlined communities to demolish old buildings and houses and move poor Black and brown residents into public housing facilities (called “housing projects”). In 1956, the Eisen- hower administration passed the Federal-Aid Highway Act of 1956 that created the national interstate system. Redlined communities were targeted for placement of these interstate highways that displaced Black and brown residents into segregated housing projects. All of these fed- eral policies led to the following consequences affecting public health: • Residential housing segregation: Fifty-plus years of discriminatory homeowner lending practices, real estate practices, and economic disinvestment have led to hypersegregation of neighborhoods and resources. Black and Latinx residents are more likely to live in neigh- borhoods where the majority of residents have incomes below the federal poverty level, which is referred to as concentrated poverty. Residents living in formerly redlined neighborhoods have poorer Chapter 2 Child Health Disparities Lee M. Pachter and Adiaha I.A.Spinks-Franklin Behavior Social Medical Genetic Biology Environment Fig. 2.1 Determinants of health. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 2 u Child Health Disparities 9 health outcomes, including higher rates of asthma, cancer, heart disease, and premature birth and shorter life expectancies. They are at higher risk of being exposed to environmental toxins, including lead, mold, exhaust pollutants and greenhouse gases, that all con- tribute to poor health. Residential housing segregation has other significant health consequences for Black and Latinx American chil- dren, including living in food deserts (having few grocery stores in neighborhoods), digital deserts (lack of access to reliable high-speed internet), having fewer green spaces, and few pharmacies. • Economic disparities, racial wealth gap, and concentrated poverty: Federal policies during the 1930s and 1940s created the foundation for racial wealth gaps.
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The Social Security Administration and the Service- men’s Readjustment Act of 1944 (the GI Bill) were established to cre- ate a middle class. The Social Security system was created to provide income to older adults. However, farmworkers and domestic workers were not included among the professionals that would pay into the So- cial Security system. These occupations employed predominantly Black laborers, who did not benefit from the initial Social Security policy. The GI Bill provided former World War II military soldiers with low-interest home, farm, and business loans; funds to pay for higher education; and unemployment assistance. White and Japanese American soldiers were granted the financial benefits from the GI Bill to buy homes and attend college. However, millions of Black soldiers were denied the GI Bill. First American (i.e., Indigenous Nations peoples) WWII veterans used the GI Bill to pay for a college education, but could not use the GI Bill to buy homes on reservations because reservation land was excluded from the GI Bill. Mexican American soldiers did not have full access to the benefits of the GI Bill for homeownership, but some were able to benefit from job training. Therefore millions of Black, Indigenous Nations peoples, and Mexican American WWII veterans did not re- ceive all the financial and educational benefits of the GI Bill. White Americans have accumulated 10 times the wealth of Black Americans, which has transgenerational implications. Discriminatory hiring and firing practices place minoritized workers at higher risk of chronic un- deremployment and unemployment. Additionally, there is an ongoing racial and gendered racial pay gap between White American men and women and men and women who are Black, Asian American, Latinx American, and Indigenous Nations peoples. In 2021, for every dollar a White American man made, Asian American women made 85 cents, Black women made 63 cents, Indigenous Nations women made 60 cents, and Latina American women made 57 cents. • School segregation and educational underfunding: Public schools are funded by property taxes. In hypersegregated communities with concentrated poverty, schools are underfunded, with a 2019 study reporting a $23 billion funding gap between school districts with predominantly White students and school districts with predomi- nantly Black, Latinx, and Indigenous Nations students. This fund- ing gap leads to schools with less qualified teachers, less rigorous curricula, and fewer extracurricular activities. Black, Latinx, and Indigenous Nations students have overpolicing and harsher school punishment practices, as discussed further in Chapter 2.1. Schools
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are not teaching BIPOC students self-discipline; they are over- punishing and criminalizing these students. • Environmental injustice: There are racial disparities in who suffers the health consequences of climate change. Residential housing segrega- tion and environmental policies have contributed to unequal exposure to environmental toxins. White Americans produce the majority of greenhouse gas emissions but experience less of the negative health ef- fects of such emissions such as asthma, other chronic lung disease, can- cer, and cardiovascular disease. Black and Latinx American children in hypersegregated neighborhoods are also more likely to be exposed to lead poisoning compared with their White American counterparts. Lead exposure increases the risk of health problems, including anemia, attention regulation problems, and learning problems. Increased expo- sure to mold and other major asthma triggers contributes to disparities in asthma outcomes among children of color and poor children. Resi- dential housing segregation also places communities of color at risk for poor water quality and the health consequences. Figure 2.2 illustrates the complex relations among multileveled fac- tors and health outcomes. Historical social stratification factors, such as socioeconomic status (SES), race, and gender, have profound influ- ences on environmental resources available to individuals and groups, including neighborhood factors (e.g., safety, environmental toxins, grocery stores, transportation, healthy spaces), social connectedness and support, work opportunities, and family environment. Much of the differential access to these resources results from historical discrimina- tion on a systematic, institutional, and interpersonal level (see Chapter 2.1). Discriminatory policies place historically subordinated groups at greater risk of poorer health outcomes and psychologic function- ing, including sense of control over one’s life, expectations, resiliency, negative affect, and perceptions of and response to discrimination. Environmental and psychologic context then have influence over more proximal determinants of health, including health-promoting or risk- promoting behaviors; access to and quality of healthcare and health education; exposure to pathogens, toxins, and carcinogens; patho- physiologic responses to stress; and the resources available to support optimal child development. Psychosocial Stress and Allostatic Load An understanding of allostatic load helps explain how psychosocial stress influences disease, health outcomes, and health disparities (Fig. 2.3 and Chapter 1). Allostasis refers to the normal physiologic changes that occur when individuals experience a stressful event, including acti- vation of the
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stress-response systems, changes in levels of inflamma- tory and immune mediators, cardiovascular reactivity, and metabolic and hormone activation. These are normal and adaptive responses to Social Stratification Mechanism Race/ethnicity Environment • Physical • Social Behaviors • Health promoting • Risk taking Support for child development • Parents • Childcare • Schools Stress & adversity • Allostatic load Health care • Access • Quality Exposure to toxins, pollutants, pathogens, carcinogens Disparities in child health & development SES, social class Residence pattern (e.g., urban/ rural) Context Psychology Differential Access/Exposure Fig. 2.2 Child health disparities. SES, Socioeconomic status. (Data from Adler NE, Stewart J. Health disparities across the lifespan: Meaning, meth- ods, and mechanisms. Ann NY Acad Sci. 2010;1186[1]:5–23.) Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 10 Part I u The Field of Pediatrics stress and result in physiologic stability in the face of an external chal- lenge. After an acute external stress or challenge, these systems revert to normal baseline states. However, when the stressor becomes chronic and unbuffered by social supports, dysregulation of these systems may occur, resulting in pathophysiologic alterations to these responses, such as hyperactiva- tion of the allostatic systems, or burnout. Over time this dysregulation contributes to increased risk of disease and dysfunction. This patho- physiologic response is called allostatic load. Allostatic load may contribute to increased incidence of chronic dis- eases such as cardiovascular disease, stroke, diabetes, obesity, asthma, and depression. It is notable that these specific chronic diseases have increased prevalence in racial and ethnic minority groups because of long-standing historical and current discrimination and oppression that have contributed to increased psychologic distress that in turn con- tributes to allostatic load and the resultant disparities in these chronic diseases. Many of these conditions are noted to occur in adulthood, demonstrating the life course consequences of chronic psychosocial stress and adversity that begins in childhood. Figure 2.3 shows a model through which racism as a toxic psychosocial stressor “
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gets under the skin” to cause physiologic dysregulation (allostatic load), which over time leads to chronic illnesses that are known to have higher preva- lence in minoritized populations (health disparities). The allostatic load model provides a pathophysiologic mechanism through which negative structural and social determinants of health contribute to health disparities. It complements other mechanisms noted in Figure 2.2, such as differential access to healthcare; increase in health risk behaviors; and increased exposure to pathogens, toxins, and other unhealthy agents. The Healthy Immigrant Paradox The Healthy Immigrant Paradox refers to the epidemiologic finding that first-generation immigrants have better health than native-born coun- terparts regardless of age, sex, economic status, or ethnic category, but their health status declines and converges with the native-born popula- tion over time. Studies in the United States and Europe have found that most immigrants have better physical and psychologic health status than native-born people of similar ethnicity in their receiving country. There are a variety of possible explanations for this health difference, including self-selection bias among people who emigrate: being younger, more educated, and physically healthier than those in the country of origin who do not emigrate. In addition, immigrants may bring healthier cultural beliefs and practices that may contribute to better health out- comes. However, the health status of immigrant populations declines in the decades after initial migration because of a variety of complex socio- political and economic reasons, including denial of access to healthcare services (e.g., laws that prohibit immigrants from having access to preventive health services), having jobs with unsafe work conditions, adopting poorer health habits, and the psychologic stress of adapting to a new society (i.e., acculturation stress) (see Fig. 12.1). The Healthy Immigrant Paradox is not universal and has been called into question by some. Many studies of the Healthy Immigrant Para- dox use self-report of health status, which may be prone to bias. Not all first-generation immigrants demonstrate better health than their U.S.-born counterparts. Immigrant health status can be influenced by country-of-origin factors (e.g., war, famine), health beliefs (e.g., perceiving obesity to be a sign of wealth rather than of poor health), and racialized immigration policies in the receiving country that favor immigrants from some countries over others. Many studies of the Healthy Immigrant Paradox do
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not include temporary immigrant workers who often do not have the same access to resources as do longer-term immigrants. Approximately 18.4 million, or 25% of children in the United States under age 12 years, have at least one immigrant parent. Children of immigrant parents have better health and academic outcomes com- pared with their U.S.-born counterparts. For example, Latinx and Asian children who are born to immigrant parents (second generation) and those brought to the United States as children (1.5 generation) have better study habits and better academic outcomes compared with third-generation U.S.-born Latinx and Asian American counterparts. Behavioral health outcomes also vary among immigrant children and their U.S.-born counterparts, where third-generation and subsequent generation children engage in more risky health behaviors. DISPARITIES IN CHILD HEALTH AND HEALTHCARE Tables 2.1 and 2.2 display some of the known disparities in child health and healthcare. Many health disparities may occur as a result of historical oppression and marginalization of people with policies targeting groups Processing of the social environment RACISM structural institutional interpersonal internalized Physiological dis-stress Psychological dis-stress Racial identity/ Socialization Perceived social status Coping responses/ resources Chronic maladaptation Conceptual model for how racism increases disease risk and health disparities Physiologic dysregulation (allostatic load) HPA dysregulation (cortisol) SMA dysregulation (CV reactivity; arterial elasticity) Altered inflammation (IL-6; CRP) Health disparities ↑ Morbidity/ Mortality (e.g.,CVD, diabetes, obesity, depression, asthma) Hormonal regulation Altered immunity Epigenetic alteration Fig. 2.3 Mechanism through which racism leads to health disparities. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 2 u Child Health Disparities 11 Table 2.1 Child Health Disparities HEALTH INDICATOR RACE/ETHNICITY FAMILY INCOME RESIDENCE Child health status fair or poor Black and Hispanic > White and Asian Poor > Not Poor Children with special healthcare needs (CSHCN) Black > White > Hispanic Poor > Not Poor One or more chronic health
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conditions Black > White > Hispanic > Asian Poor > Not Poor Asthma Mainland Puerto Rican > Black > White and Mexican American Poor > Not Poor Urban > Rural Obesity Hispanic and Black > White and Asian Poor > Not Poor Rural > Urban Infant mortality Black > Hispanic > White Poor > Not Poor Low birthweight (<2,500 g) Black > White, Hispanic, American Indian/ Native Alaskan, Asian/Pacific Islander Mainland Puerto Rican > Mexican American Poor > Not Poor Preterm birth (<37 wk) Black > American Indian/Native Alaskan, Hispanic, White, Asian/Pacific Islander Mainland Puerto Rican > Mexican American Poor > Not Poor Seizure disorder, epilepsy Black > White, Hispanic Poor > Not Poor Bone, joint, or muscle problem White > Black, Hispanic Poor > Not Poor Ever breastfed White, Hispanic, Asian > Black Not Poor > Poor Urban > Rural No physical activity in the past week Hispanic > Black, Asian > White Poor > Not Poor Hearing problem Poor > Not Poor Vision problem Poor > Not Poor Oral health problems (including caries and untreated caries) Hispanic > Black > White, Asian Poor > Not Poor Rural > Urban Attention-deficit/hyperactivity disorder (ADHD) White, Black > Hispanic Poor > Not Poor Rural > Urban Have ADHD but not taking medication Hispanic, Black > White Anxiety problems White > Black, Hispanic Poor > Not Poor Depression Poor > Not Poor Rural > Urban Behavior or conduct problem (ODD, conduct disorder) Black > White, Hispanic Poor > Not Poor Autism spectrum disorder White > Black > Hispanic Poor > Not Poor Learning disability Black > White, Hispanic Poor > Not Poor Rural > Urban Developmental delay Black > White > Hispanic, Asian Poor > Not Poor Risk of developmental delay by parental concern Hispanic > Black and White Poor > Not Poor Speech or language problems Poor > Not Poor Adolescent suicide attempts (consider, attempt, needed medical attention for an attempt) Girls: Hispanic > Black and White Boys: Hispanic and Black > White Adolescent suicide rate Girls: American Indian > White, Asian/Pacific Islander, Hispanic, Black Boys: American Indian and White > Hispanic, Black, Asian/Pacific Islander Child maltreatment (reported) Black, American Indian/Alaskan Native, Multiracial > White, Hispanic, Asian, Pacific Islander Poor > Not Poor Flourishing Asian American > White > Other Non- Hispanic > Black >Hispanic Not Poor > Poor AIDS (adolescents
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) Black > Hispanic > White AIDS, Acquired immunodeficiency syndrome; ODD, oppositional defiant disorder. Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 12 Part I u The Field of Pediatrics that are deemed to be socially, politically, geographically, and economi- cally inferior. As a result of these targeted policies, we tend to see health disparities of people based upon racial/ethnic group, socioeconomic status (often operationalized through family income, sometimes using insurance status as a proxy), and residency patterns, such as urban and rural locale. Other stratification factors, such as ability/disability status, may also contribute to health and healthcare inequality Child Health Disparities Asthma Disparities in asthma prevalence are seen by racial/ethnic group and SES. According to the CDC’s 2019 National Health Interview Survey (NHIS) data, the national mean prevalence of asthma among chil- dren (<18 years old) was 7.0%. Compared with the mean, the children with the highest prevalence of asthma were Black (18.0%), Indigenous Nation/Alaskan Native (17.8%), and Hispanic (12.5%). Asthma preva- lence for Asian American children was 8.2%. There are also significant regional and SES differences in asthma prevalence, with children who live below the federal poverty level having a 14.5% prevalence. Exposure to environmental pollutants is one factor explaining these disparities in asthma prevalence. Although non-Hispanic White Ameri- cans consume the most goods and services that produce greenhouse gases (e.g., fine particulate matter), Black and Hispanic Americans have higher exposure to greenhouse gases that are associated with poor health outcomes, including asthma. Residential hypersegregation results in higher exposure to air pollution and other respiratory toxins for Black and Hispanic Americans, increasing their risk of asthma. In addition, evidence shows a correlation between exposure to traffic pollutants and having fewer local pharmacies and healthcare providers. This “triple jeopardy” is more common with Black and Hispanic children. Obesity In 2018, the National Center for Health Statistics found that 19.3% of all U.S. children and adolescents (ages 6-17 years) have obesity (Fig. 2.4). Obesity prevalence was highest among
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Hispanic children (25.6%) and non-Hispanic Black children (24.2%). The prevalence of obesity was 16.1% among non-Hispanic White children and 8.7% among non-Hispanic Asian children. The obesity prevalence among Indigenous Nation/Alaskan Native adolescents is 11.0% and among Native Hawaiian/Pacific Islanders is 26.7%. There are complex inter- plays between social, environmental, and behavioral influences on health that contribute to obesity disparities in the United States. Studies have found that obesity prevalence is higher in communities with high rates of poverty and communities with a majority Black population because of lack of access to grocery stores and farmers markets (food deserts), overabundance of fast-food restaurants, less access to parks and outdoor recreation areas, food marketing targeting, and higher healthy food prices. In addition, dietary patterns, access to nutri- tious foods, and differing cultural norms regarding body habitus may account for some of these differences. Pregnancy Outcomes, Preterm Birth, and Infant Mortality The highest rates of infant mortality are seen in non-Hispanic Black infants (Figs. 2.5 and 2.6). According to data from the CDC, the overall Table 2.2 Child Healthcare Disparities HEALTHCARE INDICATOR RACE/ETHNICITY FAMILY INCOME RESIDENCE Did not receive any type of medical care in past 12 mo Hispanic, Black, Asian > White Poor > Not Poor Rural > Urban No well-child checkup or preventive visit in past 12 mo Hispanic > White and Black Poor > Not Poor Rural > Urban Delay in medical care Hispanic > Black > White Poor > Not Poor Unmet need in healthcare due to cost Black > Hispanic > White > Asian Poor > Not Poor No coordinated, comprehensive, or ongoing care in a medical home Hispanic > Black and Asian > White Poor > Not Poor Rural > Urban Problem accessing specialist care when needed Hispanic and Black > White Poor > Not Poor No preventative dental care visit in past 12 mo Hispanic and Asian > Black > White Poor > Not Poor Rural > Urban No vision screening in past 2 yr Hispanic and Asian > Black and White Poor > Not Poor Did not receive needed mental health treatment or counseling in past 12 mo Black and Hispanic > White Poor > Not Poor Not receiving a physician recommendation for HPV vaccination among 13- to 17-yr-old girls Black and Hispanic > White Immunization rates: adolescent HPV vaccine Girls: white > Black and
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Hispanic Boys: Black and Hispanic > White HPV, Human papillomavirus. 100 50 40 30 20 10 0 Percent 1999– 2002 2003– 2006 2007– 2010 Total White, non-Hispanic Asian, non-Hispanic Mexican American Black, non-Hispanic 2011– 2014 2015– 2018 Fig. 2.4 Percentage of children ages 6-17 with obesity by race and Hispanic origin, selected years 1999–2002 through 2015–2018. (From National Center for Health Statistics. National Health and Nutrition Ex- amination Survey. https://www.childstats.gov/americaschildren/surveys 2.asp#nhnes.) Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 2 u Child Health Disparities 13 infant mortality rate was 5.7 infants per 1,000 live births. For Black infants, the mortality rate was 10.8 infants per 1,000 live births. The top 5 causes of mortality (in order of frequency) among Black infants were low birthweight, congenital malformations, maternal complications, sudden infant death syndrome (SIDS), and unintended injuries. Black American infant mortality remains high compared with other popula- tions, regardless of maternal education, insurance status, maternal age, and income. Chronic experiences with structural, institutional, and interper- sonal racism contribute to elevated biomarkers for stress and allostatic load, which is referred to as weathering—the accumulative effect of adversity on the health of individuals (see Chapter 2.1). Weathering of Black women has been associated with a risk of preterm birth and infant mortality. When examining the life-course perspective, studies suggest that early life exposure to adversity, including systemic racism, increases the risk of poor birth outcomes (see Chapter 2.1). Having a racially concordant physician significantly reduces the risk of infant mortality by 39% among Black newborns. Infant mortality rates among Indigenous Nation/Alaskan Native pop- ulations was 8.2 infants per 1,000 live births, with the leading causes of infant death (in order of frequency) being low birthweight, congenital malformations, and maternal complications. Asian American infants had the lowest infant mortality rates, at 3.8 infants per 1,000 live
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births, with the leading causes of death (in order of frequency) being congeni- tal malformations, low birthweight, maternal complications, and unin- tended injuries. The Asian American population was not disaggregated by country of origin, so granular details regarding this heterogenous American population were not available. Overall Hispanic infant mor- tality was 4.9 infants per 1,000 live births, but mortality rates varied sig- nificantly based upon country of origin from 3.8 to 5.6 per 1,000 live births. Leading causes of death among all Hispanic infants (in order of frequency) were congenital malformations, low birthweight, maternal complications, SIDS, and unintended injuries. The White American infant mortality rate was 4.6 infants per 1,000 live births, with the lead- ing causes of infant mortality (in order of frequency) being congenital malformations, low birthweight, SIDS, unintended injuries, and mater- nal complications (see Chapters 114 and 114.1). Infant mortality among the Native Hawaiian/Pacific Islander pop- ulation was 9.4 infants per 1,000 live births overall. Infant mortality rates varied in the Native Hawaiian/Pacific Islander population when the data were disaggregated by country of origin from 10.1 to 22.5 per 1,000 live births. In 2017, the World Health Organization (WHO), UNICEF, and United Nations (UN) highlighted some of the social and environmental risk factors for such high infant mortality among Pacific Islanders, which include prematurity, birth complications, and severe infections (specifically, pneumonia and diarrheal illnesses). Infant mortality among Native Hawaiians was 9.4 infants per 1,000 live births, and the leading causes of infant mortality were preterm birth and low birthweight, sudden unexplained infant death, congenital anomalies, infection, and injury. Many of the causes of infant mortality disparities can be mitigated through public policy, public health measures, and healthcare inter- ventions that specifically target populations at highest risk, such as increased access to quality prenatal care, reducing air pollution expo- sure, and improving physician training to reduce implicit bias and improve communication skills. Oral Health Significant differences exist in oral health status and in preventive oral healthcare according to race/ethnicity, SES, and residency locale. The 2019–2020 National Survey of Children’s Health (NSCH) found the prevalence of oral health problems among children (ages 1-17
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years) to be 17.7% for Hispanic Americans, 16.2% for Black Americans, 15.8% for Asian Americans, 12.1% for White Americans, and 13.2% for other non-Hispanic Americans. The prevalence of oral health problems in this 2019-2020 NSCH were found to be highest among children who live in households with incomes below the federal poverty level (20.3%) compared with children who live in households making >400% of the federal poverty level (8.7%). 1983 1985 0 5 10 15 20 25 Infant deaths per 1,000 live births 1990 1995 2000 2014 2010 Black, NH AIAN, NH Total Hispanic White, NH API, NH Fig. 2.5 Death rates among infants by race and Hispanic origin of mother, 1983–1991 and 1995–2014. AIAN, American Indian or Alaska Native; API, Asian or Pacific Islander; NH, non-Hispanic. (From National Center for Health Statistics. National Vital Statistics System. https://w ww.childstats.gov/americaschildren/health_fig.asp#health2. Accessed July 2018.) Total White, non-Hispanic Black, non-Hispanic American Indian or Alaska Native, non-Hispanic Asian or Pacific Islander, non-Hispanic 0 5 10 15 100 Percent 1990 2005 2015 Fig. 2.6 Percentage of infants born with low birthweight by race and Hispanic origin of mother, 1990, 2005, and 2015. (From National Cent- er for Health Statistics. National Vital Statistics System. https://www.c hildstats.gov/americaschildren/health_fig.asp#health1b. Accessed July 2018.) Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 14 Part I u The Field of Pediatrics Data from the CDC demonstrated that overall prevalence of dental caries decreased for children age 6-11 years: from 21% in the 1994– 2004 NHANES survey to 17% in the 2011–2016 survey. The children in the survey who did not show improvements in the prevalence of den- tal caries were younger children (ages 6-8 years), poor children (both near-poor and children living below the federal poverty level), and non-Hispanic Black children
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. Preventive oral healthcare may improve rates of caries and treat caries before further impairment ensues. Data from the 2014 Medical Expenditure Panel Survey revealed that being poor and lacking health insurance were the main reasons for not receiving preventive dental care. Hearing Care No data suggest that the prevalence of hearing loss (either congenital or acquired) is different among racial/ethnic or SES categories, but fol- low-up care after diagnosis of a hearing problem has been shown to be poorer in certain groups. Delays in diagnosis and treatment of hearing loss are found among children who lack health insurance, live farther away from diagnostic health centers, are poor, live in areas with spe- cialists’ shortages, live in rural areas, and have primary care providers with limited experience in caring for children with hearing loss. Much of this disparity is reduced when families have access to specialists. Vision Problems The parent-reported 2019–2020 NSCH found that vision problems were reported in 3.1% of Hispanic children, 1.2% of White children, 2.1% of Black children, 1.0% of Asian children, and 1.6% of children in other racial categories. Vision problems were more commonly reported among children who lived in households with an income that was less than the federal poverty level (3.4%) compared with children living in households with an income greater than 400% of the federal poverty level (0.8%). Vision problems were more commonly reported among children who did not have a medical home (2.6%) compared with children with a medical home (1.0%). Reports of vision problems in children also varied by insurance coverage type, with 0.9% of chil- dren with private health insurance, 3.0% of children with public health insurance, 3.0% of children with both public and private health insur- ance, and 4.1% among uninsured children. Immunization Disparities in immunization rates had been noted with household income status, insurance status, and residential location. In response to these socioeconomic disparities and to higher rates of measles cases in the 1980s, a number of interventions were initiated, including the cre- ation of the Vaccines for Children program (VFC), which eliminated the financial barrier to immunization by providing free immunizations to at-risk groups (Medicaid-eligible, uninsured, Indigenous Nation/ Alaskan Native, or underinsured and vaccinated at a federally quali- fied health center or rural health clinic).
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Although vaccination rates have improved, the 2018–2020 CDC National Immunization Survey— Child study found income, geographic, and racial disparities in infant vaccination rates. Vaccination rates were lower among infants living in households with an income below the federal poverty level and infants who lacked health insurance. Vaccination rates varied widely by state and region of the United States. Although rates of initial primary vaccine series demonstrate no or decreasing disparities, other vaccination rates do show differences. Black and Hispanic adolescent females have lower human papillomavi- rus (HPV) vaccination rates than do Whites. Reasons for this disparity include parental concerns about safety and providers not recommend- ing the vaccine. Of interest, Black and Hispanic male adolescents have higher rates of HPV vaccine coverage than do Whites. Adolescent Suicide In 2019, the CDC Youth Behavior Risk Surveillance System of 9th-12th graders reported suicide attempts by racial category, sex, and sexual ori- entation. The highest rate of suicide attempts was among Indigenous Nations/Alaskan Native teens (25.5%), followed by Native Hawaiian/ Pacific Islanders (18.4%), multiracial teens (12.9%), Blacks (11.8%), Latinx Americans (8.9%), White Americans (7.9%), and Asian Ameri- cans (7.7%). Suicide attempts were higher among adolescent females (11.0%) than among adolescent males (6.6%). Suicide attempts vary when stratified by sexual orientation status, with the highest prevalence among bisexual teens (24.5%), followed by gay male teens (19.5%) and heterosexual teens (6.4%). Risk factors for suicide ideations and attempts include sexual assault, being bullied, substance abuse, depression, and experiences with interpersonal racial discrimination (see Chapter 40). Child Maltreatment In 2014, reports of child abuse and neglect were higher in Black (15.3 per 1,000 children), Indigenous Nation/Alaskan Native (13.4/1,000), and multiracial (10.6/1,000) children, compared with Hispanic (8.8/1,000), Pacific Islander (8.6/1,000), White (8.4/1,000), and Asian (1.7/1,000) chil- dren. Poverty, measured at the family and at the community level, is also a significant risk factor for maltreatment. Counties with high poverty con- centration had >3 times the rate of child abuse deaths than counties with the lowest concentration
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of poverty. Additionally, it is the “criminaliza- tion” of poverty that increases the risk of poor people being reported for abuse and neglect compared to their more affluent counterparts. However, despite the fact that Black children are overrepresented in the child wel- fare system in the United States, race itself should not be a marker for child abuse or neglect. Studies have found that Black parents are overreported for child abuse and maltreatment compared with White parents who engage in the same behavior because of historical systemic racism and implicit racial bias among those who report and caseworkers. Latinx children’s represen- tation in the child welfare system varies by state and region, where they are overrepresented in some states, but underrepresented in other states. Indigenous Nation/Alaskan Native youth are underrepresented in the child welfare system in most states, but Alaska is the state with the highest overrepresentation of Indigenous children reported to the child welfare system. White American children are not overrepresented in the child welfare system and are often underrepresented. Behavioral Health Disparities Attention-Deficit/Hyperactivity Disorder (ADHD) The 2019–2020 NSCH found the overall prevalence of ADHD among children age 3-17 years to be 8.9%. White and Black children are more often diagnosed with ADHD (10.2% and 10.5%, respectively) than are Hispanic children (6.9%), Asian American children (2.7%), and chil- dren of other non-Hispanic groups (8.5%). Other studies have shown that both Black and Hispanic children have lower odds of having an ADHD diagnosis than White children. Children reared in homes with a household income below the federal poverty level are diagnosed more often (10.9%) than those at or above the federal poverty level (8.3%). Children with two or more adverse childhood experiences (ACEs) are almost 3 times as likely to be diagnosed with ADHD (17.1%) compared with children with no ACEs (5.8%). Children without a medical home are more likely to be diagnosed with ADHD (9.7%) compared with children who have a medical home (8.0%). Children diagnosed with ADHD have different treatment expe- riences. After being diagnosed with ADHD, White children, when compared with Black and Hispanic children, were more likely to be diagnosed with a coexisting anxiety disorder. Within the first year of treatment for ADHD, White children were most likely to be treated with medication or behavior therapy and
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Asian American children were the least likely to receive any type of treatment for ADHD. Depression and Anxiety Disorders According to the 2020 National Survey of Drug Use and Health, from 2004 to 2019, the reported prevalence of major depression episodes increased among all U.S. adolescents. In 2019, those with the high- est reported prevalence of a major depression episode were 16- to 17-year-olds (20.2%), adolescent girls (23.0%), adolescents of two or more races (20.9%), and teens living in households with incomes above the federal poverty level (16.1%). When stratifying by racial group, a major depression episode was found in 17.3% of Hispanic teens, 15.9% of White teens, 15.1% of Asian American teens, 12.2% of Indigenous Nation/Alaska Native teens, and Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 2 u Child Health Disparities 15 11.4% of Black teens. Differences in reported rates of depression based upon racial group may be the result of differences in the manifestation of depression symptoms, clinician treatment bias, and limited access to adequate mental healthcare. Autism Spectrum Disorder (ASD) Compared with White children, Black and Hispanic children are less likely to be diagnosed with ASD, and when diagnosed, are typically diag- nosed at a later age and with more severe symptoms. Nonetheless, Blacks and Hispanics are typically diagnosed at a later age and with more severe symptoms. Disparities in diagnosis and timing of diagnosis are concern- ing given that early diagnosis provides access to therapeutic services that are most effective when initiated early. Reasons for these disparities may include differences in cultural behavioral norms, stigma, differences in parental knowledge of typical and atypical child development, poorer access to quality healthcare, and differences in the quality of provider- patient communication along with trust in providers. Recent CDC data suggest that racial and ethnic disparities in ASD diagnosis are decreasing. Behavioral or Conduct Problems According to the 2011–2012 NSCH, Black children age 2-17 years have higher rates of oppositional defiant disorder (ODD) or conduct disorder than do White and Hispanic children. Evidence suggests that the overdiagnosis of Black children with these disorders is linked to the pervasive criminalization and
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adultification of Black child behavior. Adults often view Black children as older, less innocent, and in less need of protection than same-age peers of other racial groups. In fact, studies have found that physicians with negative implicit racial bias are more likely to overpathologize Black child behavior and overdiagnose Black children with ODD, conduct disorder, and ADHD. The patholo- gizing of Black child behavior can have severe consequences, including excessive school punishment, school expulsion, and early contact with the legal system. Developmental Delay The 2019–2020 NSCH found that Black children age 3-17 years had higher reported rates of developmental delay (7.4%) than Hispanic chil- dren (5.3%), White children (5.4%), and other non-Hispanic children (5.4%). Children living in households with incomes below the federal poverty level were more likely to be diagnosed with a developmental delay (8.7%) than children living in households with an income at 400% of the federal poverty level (3.6%). Children experiencing two or more ACEs have a higher prevalence of developmental delay than do children with no ACEs (10.8% vs 3.8%). ACEs increase the child’s allostatic load and impede neurologic development, thus placing them at increased risk of developmental delays. Evidence also suggests that physicians with negative implicit racial biases are less likely to ask Black parents and parents who speak English less fluently about their concerns regard- ing developmental delays and are less likely to refer the children to early intervention, and these children are less likely to receive appropriate developmental evaluations by early intervention providers. Flourishing In the 2019–2020 NSCH, parents reported rates of flourishing, which is overall good mental health in their children and teens. Flourishing was measured by three behaviors: learning, resilience, and self-regulation. Overall, 63.3% of parents reported their child met all three flourish- ing criteria. Females (66.8%) were reported as having higher flourish- ing than males (59.9%). The highest level of flourishing was reported among Asian American youth (73.0%), followed by White (64.8%), other non-Hispanic children (62.1%), Black (61.8%), and Hispanic (59.7%). Flourishing rates were lowest among youth who live in house- holds with incomes lower than the federal poverty level (55.6%) and highest among youth living in families with incomes higher than 400% of
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the federal poverty level (70.0%). Child Healthcare Disparities In almost all areas, Black, Hispanic, and Indigenous Nation/Alaskan Native children have been identified as having worse access to needed healthcare, including receipt of any type of medical care within the past 12 months, well-child or preventive visits, delay in care, having an unmet need because of healthcare cost, lack of care in a medical home, problems accessing specialist care when needed, lack of pre- ventive dental care, vision screening, mental health counseling, and recommendations for adolescent immunizations (see Table 2.2). In addition, many of these healthcare indicators are found to be worse for children living in poverty and for those living in a rural area. Dispari- ties in access to and quality of healthcare among children of color and poor children are linked to long-standing structural barriers, systemic racist policies and practices, environmental policies, social and struc- tural determinants of health, and healthcare provider negative implicit racial biases that influence healthcare delivery and patient-physician communication and relationships. APPROACHES TO ERADICATING DISPARITIES: INTERVENTIONS An example of a successful intervention that closed the disparity gap is the implementation of the VFC program, which significantly decreased the disparity in immunization rates noted among racial/ethnic groups and poor/underinsured children. This is an example of a public health policy approach to intervention. Interventions need to occur at the clinical level as well. The almost- universal use of electronic health records (EHRs) provides a unique opportunity for collecting vital clinical and demographic data that can be helpful in identifying disparities and monitoring the success of interventions. All EHR platforms should use a standardized approach to gathering information on patient race/ethnicity, SES, primary lan- guage preferences, and health literacy. The Institute of Medicine’s 2009 report Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement provides best practices information about capturing these data in the health record. The advancing science of clinical quality improvement can also provide a framework for identifying clinical strategies to reduce dis- parities in care. Use of PDSA (Plan-Do-Study-Act) cycles targeting specific clinical issues where health disparities exist can result in prac- tice transformation and help reduce differential outcomes. Another practice-level intervention that has the potential to reduce disparities in care and outcomes is the medical home model, provid- ing care that is accessible
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, family centered, continuous, comprehensive, compassionate, coordinated, and culturally effective. The use of care coordinators and using community-based health navigators are effec- tive tools in helping to break down the multiple social and health sys- tem barriers that contribute to disparities. Community engagement is an essential requirement for lessening health and healthcare inequities. Health systems, practices, provid- ers, public health, researchers, and payers need to include community voice and representation in all aspects of quality improvement, data interpretation, program design and development, and dissemination. To do less would be “working on people” instead of “working with peo- ple.” To use a phrase from the disability advocacy community: “Nothing about us without us.” Many potential interventions seem appropriate and demonstrate efficacy under ideal circumstances. However, if the intervention does not address the concerns of the end users—patients and communities—or fit the social or cultural context, it will likely be ineffective in the “real world.” Only by involving the community from the beginning, including defining the issues and problems, can the like- lihood of success be optimized. At the provider level, there are opportunities for training in implicit bias and communication skills, as discussed in Chapter 2.1. Shared decision-making has been found to improve physician-patient rela- tionships and health outcomes. Another strategy to address cognitive biases in physician clinical decision-making is to identify heuristic and other cognitive errors (see Tables 5.3-5.5) and use the diagnos- tic time-out (see Table 5.6) when a diagnosis does not fit the clinical presentation. Population health strategies have the advantage of address- ing the determinants of disparities at both the clinic and commu- nity levels. Techniques such as hotspotting, cold-casing (finding Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 16 Part I u The Field of Pediatrics patients and families lost to follow-up and not receiving care), and geocoding; collaborating with communities and community-based organizations; and periodic community health needs assessments identify the structural, systemic, environmental, and social factors that
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contribute to disparities and help guide interventions that are tailored to the local setting. Health disparities are a consequence of social and structural deter- minants of health that often have developed based on historically rac- ist policies and other practices and traditions that led to the social stratification mechanisms inherent in many modern societies. Health disparities mirror other societal disparities in education, policing, employment opportunities, and living conditions. While society grap- ples with the broader issues contributing to disparities, healthcare and public health can work to understand the multiple causes of these dis- parities and develop interventions that address the structural, clinical, and social root causes of these inequities. Visit Elsevier eBooks+ at eBooks.Health.Elsevier.com for Bibliography. 2.1 Racism and Child Health Mary T. Bassett, Zinzi D. Bailey, and Aletha Maybank RACISM AS A SOCIAL DETERMINANT OF HEALTH AND HEALTH INEQUITIES An emerging body of evidence supports the role of racism in a range of adverse physical, behavioral, developmental, and mental health out- comes. Racial/ethnic inequity in health outcomes in the United States is long-standing, apparent from the first collection of vital statistics in the colonial period. However, the extensive data that document racial disparities have not settled the question of why groups of people, par- ticularly of African and Indigenous Nations peoples ancestry, face increased odds of shorter lives and poorer health (see Tables 2.1, 2.2, and 2.3). The role of societal factors is well recognized in determining population health, but often omits racism among social determinants of health. This oversight occurs in the face of a long history of racial and ethnic subjugation in the United States that has been justified both explicitly and implicitly by racism. From the early 18th century, colonial America established racial categories that enshrined White supremacy, conferring rights specifically on White men, while deny- ing these rights to others. This “racial” designation was social and not based on genetics. Similar, perhaps less explicit, discrimination has continued through the centuries and remains a primary contributor to racial/ethnic inequities in children’s health. Current lifelong exposure to interpersonal, structural, and institutional racial discrimination and subordination has a significant impact on Black health outcomes. For generations, racial/ethnic disparities have been documented beginning at birth and extending across life. In 2018, life expectancy at birth for Blacks was almost 4 years shorter than life expectancy of non-Hispanic Whites
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, influenced heavily by disparities starting at birth (Table 2.3). The infant mortality rate (IMR), arguably the most important measure of national health, has shown a persistent Black- White gap despite a substantial decline in U.S. IMR for all racial/eth- nic groups (see Fig. 2.5). NCHS data in 2022 showed a double-digit IMR only among non-Hispanic Blacks, with 10.38 deaths per 1,000 live births, compared to 4.4/1,000 for non-Hispanic Whites. A troubling stagnation in IMR, with no recent decline, is found among Alaska Natives and Indigenous Nations peoples. The 2022 IMR among non- Hispanic Indigenous Nation peoples or Alaskan Native individuals, 7.68 deaths/1,000 live births, has remained essentially unchanged for almost 2 decades. Exposures that affect infant survival occur before birth. Much of the maternal and child health literature emphasizes a higher preva- lence of maternal obesity, diabetes, and substance/alcohol use before conception among Black women as individualized risk factors leading to disparities in birth outcomes (Chapter 114.1). A California study of maternal obesity found that 22.3% of pregnant Black women and 20.3% of Latina women had a body mass index (BMI) of 30-40, com- pared with 14.9% of White and 5.6% of Asian women. BMI >40 was more than twice as prevalent in Black (5.7%) than in White (2.6%) women. Further, in a nationally representative study of over 7 million singleton live births from the 2016 and 2017 U.S. National Vital Sta- tistics System, although maternal prepregnancy obesity was associated with the risk of preterm birth in the general population, risk varied by maternal age and race/ethnicity. Maternal obesity among non- Hispanic Black women was inversely associated with risk of preterm birth among those younger than 30 years, but positively associated among those age 30 and older. Similar relationships were shown for non-Hispanic White and Hispanic women. Although individual risk factors such as obesity contribute to differences in birth and health out- comes, individual risk factors alone do not sufficiently explain these differences. Further, a focus on individual risk factors may contribute to a narrative that places blame on the individual without acknowledg- ing the structural and social conditions of patients’ lives influencing the prevalence of these risk factors. Proximal factors
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such as maternal obesity do not capture the root causes of early childhood health inequi- ties, social determinants of health, which present intervention points for achieving health equity. Achieving health equity requires examining equity in outcomes and also equity in process. Causes and interventions to address health ineq- uities can be conceptualized as occurring upstream, downstream, or somewhere in between (Fig. 2.7). Downstream determinants occur on individual levels, including individual biology and specific risk factors and behaviors. In Figure 2.7, measures of health and health inequities, like life expectancy, IMR, maternal obesity, and maternal age, are at the far right and are considered downstream factors. Clinical inter- ventions focused on downstream factors may help individuals, but do not address factors upstream that drive inequities in population health outcomes. These upstream factors include the physical, social, work, and service environments in which people are born, grow, live, work, and age that lead to downstream outcomes. If a child lives in public housing that is systematically underresourced to eliminate common pests, that child is more likely to encounter asthma triggers, experience asthma attacks, and require emergency department care or hospitalization. Interven- tions could include remediating one apartment or home or increasing access to insurance; however, this is not getting at systematic mecha- nisms by which public housing becomes a social determinant of health. Moreover, these interventions do not address the reasons that families need public housing in the first place or why these living conditions are more prevalent among certain communities compared with others. The distribution of these living conditions is patterned by institu- tional inequities in the public and private sectors and in our laws and regulations, which represent a wider set of forces and systems shap- ing the conditions of daily life. Social inequities, like racism, sexism, classism, heterosexism, and ableism, represent upstream social deter- minants of health that affect access to resources and healthy living con- ditions and are inequitably distributed across preexisting hierarchies of power. Resource allocation for public housing and the absence of universal access to a living wage might drive the living conditions within public housing. Focusing solely on downstream results of larger inequitable structures seldom yields sustainable change and ignores the roots of health inequities while tending to blame individuals structur- ally constrained by centuries of inequitable systems. Prenatal maternal exposures to pesticides, lead, and other envi- ronmental toxins vary by race
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. This inequitable distribution is largely driven by racist policies and practices affecting exposures to small- and large-scale environmental hazards (see Chapter 2). The effects of per- sistent racism are stressful and toxic to the body, with the experience of discrimination across leading to biologic changes that persist the life span, especially for pregnant women and their children. Thus racism is an essential social determinant of racial/ethnic inequities in mater- nal and child health. Racism can increase cortisol levels and lead to a cascade of effects, including impaired cell function, altered fat metabo- lism, increased blood glucose and blood pressure, and decreased bone formation (see Chapter 1 and Fig. 2.3). This can affect a growing fetus, Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Chapter 2 u Child Health Disparities 17 Table 2.3 New Social and Health Inequities in the United States TOTAL WHITE NON- HISPANIC ASIAN* HISPANIC OR LATINO BLACK NON- HISPANIC† NATIVE AMERICAN OR ALASKA NATIVE Wealth: median household assets (2019) $118,200 $187,300 $206,400 $31,700 $14,100 NR Poverty: proportion living below poverty level, all ages (2019) 12.3% 9.0% 9.7% 17.2% 21.2% 24.2% Poverty: proportion living below poverty level, children <18 yr (2019) 16.0% 10.0% 9.0% for Asians only; 18.0% for Pacific Islanders 23.0% 30.0% 30.0% Unemployment rate (2021) 5.2% 4.6% 4.7% 6.2% 8.4% NR Incarceration: male inmates per 100,000 (2010) 733 450 115 for Asians only; 1,017 for Native Hawaiians and other Pacific Islanders 831 2,306 1,291 Proportion with no health insurance, age <65 yr (2018) 11.0% 7.8% 7.4% 20.1% 12.1% 28.6% Infant mortality per 1,000 live births (2018
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) 5.7 4.6 3.9 for Asians only; 9.4 for Native Hawaiian and other Pacific Islander 4.9 10.8 8.2 Preterm Birth: proportion of singleton births before 37 wk gestation (2018) 8.2% 7.2% 7.1% 8.4% 11.9% 10.2% Maternal mortality, deaths per 100,000 live births (2018) 17.4 14.9 NR 11.8 37.3 NR Proportion of children <18 yr reporting current asthma (2018) 7.5% 5.6% 3.6% 8.0% 14.3% NR Self-assessed health status (age-adjusted): proportion with fair or poor health (2018) 9.0% 7.6% 8.2% 12.3% 13.5% 18.6% Potential life lost: person-years per 100,000 before age 75 yr (2016) 7,431.7 7,021.0 3,176.8 4,926.0 10,505.2 7,360.2 Proportion reporting serious psychologic distress‡ in past 30 days, age ≥18 yr, age-adjusted (2015–2016) 3.6% 3.7% 2.1% 3.7% 3.6% 9.2% Life expectancy at birth (2018), yr 78.7 78.6 NR 81.8 74.7 NR Diabetes-related mortality: age-adjusted mortality per 100,000 (2018) 21.4 18.9 15.4 for Asians only; 48.1 for Native Hawaiians and other Pacific Islander 24.6 39.3 32.1 Mortality related to heart disease: age-adjusted mortality per 100,000 (2018) 163.6 168.1 82.0 for Asian alone; 161.4 for Native Hawaiian and other Pacific Islander 112.3 212.0 109.6 *Economic data and data on self-reported health and psychologic distress are for Asians only; all other health data reported combine Asians and Pacific Islanders, unless otherwise noted. †Wealth, poverty, and potential life lost before age 75 yr are reported for the Black population only; all other data are for the Black non-Hispanic population. ‡Serious psychologic distress in the past 30 days among adults 18 yr and older is measured using the Kessler 6 scale (range: 0-
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24; serious psychologic distress ≥13). NR, Not reported. Sources: Wealth data taken from the U.S. Census; poverty data for adults taken from the Kaiser Family Foundation, and poverty data for children taken from the National Center for Education Statistics; unemployment data taken from the U.S. Bureau of Labor Statistics; incarceration data taken from the Prison Policy Initiative using U.S. Census Bureau data; data on uninsured individuals, infant mortality, self-assessed health status, potential life lost, serious psychologic distress, current asthma, preterm birth, life expectancy, diabetes-related mortality, and mortality related to heart disease taken from the National Center for Health Statistics. leading to increased infant cortisol levels, lower birthweight (LBW), and prematurity. In New York City, White women had lower rates of adverse birth outcomes: 1.3% had preeclampsia, less than half the rate for Black women (2.9%). Although infant deaths occur more frequently among low-income groups of all races/ethnicities, these birth outcome disparities by race/ethnicity are found also in Blacks with higher SES. College- educated Black women are more likely than White high school–edu- cated women to have a LBW infant, a principal risk factor for infant death. Another study examined California birth certificates of preg- nant Arab American women after the September 11, 2001, terrorist attacks and found that those who experienced discrimination imme- diately after the 9/11 attacks had a higher relative risk of giving birth to an LBW infant in the following 6 months than seen in births before this date. A similar association between exposures to discrimination- based violence and Latina mothers giving birth to LBW infants was found after the largest federal immigration incident in U.S. history in Postville, Iowa, with infants having a 24% greater risk at being LBW Downloaded for mohamed ahmed (dr.mms2020@gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. 18 Part I u The Field of Pediatrics at birth. These findings reinforce the critical role the physician has in explicitly asking families about potential exposures to racialized stressors and trauma. The increased risk of disease for populations of color continues from infancy into childhood (see Table 2.1); racial/ethnic dispar
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i- ties are seen across almost all health indicators, with most relative gaps remaining stagnant or worsening over the past two decades. Compared with White children, Black children are about twice as likely to be diagnosed with asthma, more likely to be hospitalized for its treatment, and more likely to have fatal attacks. The Black- White disparity in asthma has grown steadily over time. Indigenous Nations children and youth (≤19 years) also experience negative health outcomes, with the highest rates of unintentional injury and mortality rates at least twice as high as for other racial/ethnic groups. Additionally, according to a 2017 NCHS brief, Latino youth age 2-19 have the highest rates of obesity in the 2000 CDC sex-/age- specific growth charts. The NCHS data show that 25.8% of Latino (followed by Black) children qualified as obese from 2015 to 2016. Black children are more likely to be exposed to witnessed, personal, or family violence (an example of an adverse childhood experi- ence), and exposure to these stressful life experiences is associated with academic, behavioral, and health problems. Notably, children with more stressful life experiences have a higher likelihood of experiencing ear infections, acute respiratory infections, obesity, eczema, viral infections, and teen pregnancy. EXPLAINING RACIAL DISPARITIES: A TAXONOMY OF RACISM Explanations of these ubiquitous racial gaps have focused on indi- vidual factors, including variation in individual genetic constitu- tion, behavioral risks, poverty, and access to (and use of) healthcare services. Scientists agree that “race” is a social construct that is not based on biology, despite the persistence of the idea that racial cat- egories reflect a racially distinctive genetic makeup that has a bearing on health. In fact, the genetic variation between individuals within a particular racial/ethnic group is far greater than the variability between “races.” Further, biologic ancestry is distinct and separate from the social construct of race. Despite the genetic data, many groups have been “racialized” over time. Notably, the U.S. Census Bureau’s demographic classifications reflect this process. In the mid- to-late 1800s the census counted “mulattos,” those of White and Black ancestry, as another race. Starting in the late 19th century, Eastern European immigrants and Jews were considered different races. As early as 1961, the U.S
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. Census identified Mexicans and Puerto Ricans as “White” even as racial classification varied by geography. All states collected birth records by 1919, but there was little uniformity on how race was col- lected, if at all, across states. It was not until 1989, when the National Center for Health Statistics (NCHS) recommended assigning “infant race” as that of the mother and that standard guidance and categories were issued for states on collecting racial data at birth. Existing categories were changed and continue to change based on the economic, cultural, or political utility of the time, rather than actual genetic distinction. Defining Racism Racism has consistently structured U.S. society and is based on “White supremacy,” a hierarchical idea that Whites, the dominant group, are intrinsically superior to other groups who are not classi- fied as “White” No single definition of racism exists, but one useful description is racial prejudice backed by power and resources. This conceptualization asserts that not only must there be prejudice but Strategic partnerships Advocacy Community capacity building Community organizing Civic engagement POLICY Living Conditions (Social Drivers) Root Causes Inequities (Systems of Power) Institutional Power (Structural Drivers) Individual health education Clinical care Risk Behaviors Disease & Injury Mortality Physical Environment • Land use • Transportation • Housing • Residential segregation • Exposure to toxins Economic Environment • Employment • Income • Retail businesses • Occupational hazards • Historical and intergenerational trauma • White supremacy • Racism • Classism • Sexism • Homophobia • Ableism • Xenophobia • Smoking • Poor nutrition • Low physical activity • Violence • Alcohol and other drugs • Sexual behavior • Communicable disease • Chronic disease • Injury (intentional and unintentional) • Weathering leading to increased morbidity • Infant mortality • Life expectancy • Weathering results in early mortality Social Environment • Experience of class, racism, gender, immigration • Violence • Culture: ads, media Service Environment • Health care • Education • Social services UPSTREAM (Prevention orientation) Public Health and Health Care Practice (Treatment orientation) DOWNSTREAM refers to the dominant approach of treating individual-level factors and/or contributors without wholly addressing structural, societal, and community factors. Upstream refers to acknowledging and addressing the structural, societal, community and individual-level factors that influence health. Whereas downstream ∗ Adapted from: Bay Area Regional Health Inequities Initiative (BARHII) Framework • Corporations and businesses •
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