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Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

BACKGROUND Families with versus without children are at greater eviction risk. Eviction is a perinatal, pediatric, and adult health concern. Most studies evaluate only formal evictions. METHODS Using cross-sectional surveys of 26 441 caregiver or young child ( RESULTS 3.9% of 26 441 caregivers reported 5 year eviction history (eviction), of which 57.0% were formal evictions. After controlling for covariates, we found associations were minimally different between formal versus informal evictions and were, therefore, combined. Compared to no evictions, evictions were associated with 1.43 (95% CI: 1.17–1.73), 1.55 (95% confidence interval [CI]: 1.32–1.82), and 1.24 (95% CI: 1.01–1.53) times greater odds of child fair or poor health, developmental risk, and hospital admission from the ED, respectively, as well as adverse caregiver and hardship outcomes. Adjusting separately for household income and for housing-related hardships in sensitivity analyses did not significantly alter results, although odds ratios were attenuated. Hospital admission from the ED was no longer significant. CONCLUSIONS Demonstrated associations between eviction and health and hardships support broad initiatives, such as housing-specific policies, income-focused benefits, and social determinants of health screening and community connections in health care settings. Such multifaceted efforts may decrease formal and informal eviction incidence and mitigate potential harmful associations for very young children and their families.

OBJECTIVES The current study examined longitudinal linkages between child sleep duration and children’s socioemotional, learning engagement, executive functioning, and academic outcomes across the full kindergarten (K) year. METHODS A measurement-burst design was employed to examine 3 different measures of child sleep duration in 7-day bursts at pre-K (July–August), early K (late September), mid-K (late November), and late K (mid-to-late April), using wrist actigraphy. These measures included mean amounts of child sleep per 24-hour period across the full week, proportion of 24-hour periods per week that children slept 10 or more hours, and proportion of nighttime sleep periods per week that children slept 10 or more hours. Children’s outcomes at early, mid-, and late K were provided by their K teachers blind to children’s sleep histories, and by assessments administered by project staff. RESULTS Among the 3 sleep measures examined, regularity of nighttime sleep in which children slept 10 or more hours per night, especially at pre-K, consistently predicted more favorable K outcomes in both socioemotional, learning engagement, and academic domains. Results suggested that establishing healthy nighttime sleep habits before K start was especially promotive of better K adjustment across the full K year. These findings were controlled for income-to-poverty threshold ratios, child health status, and number of missed school days. CONCLUSIONS Efforts to promote a favorable transition to first-time schooling should pay particular attention to sleep hygiene and regularity of 10-plus hours of nightly child sleep established before the start of K.

CONTEXT Previous reviews of mental health interventions have focused on adolescents (10–19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5–10 years). OBJECTIVE To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5–14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies. DATA SOURCES This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020. STUDY SELECTION We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5–14.9 years. DATA EXTRACTION Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality. RESULTS We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs. LIMITATIONS The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity. CONCLUSIONS This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

OBJECTIVES Poverty and low income are associated with increased risk for child maltreatment. The Earned Income Tax Credit (EITC) and Child Tax Credit (CTC) are among the largest antipoverty programs in the United States. We estimated associations between income transfer payments via the EITC and CTC and child maltreatment reports in the period shortly after families receive payments from these programs. METHODS We linked weekly EITC and CTC refund data from the Internal Revenue Service to state-specific child maltreatment report data from 48 states and the District of Columbia during the 2015 through 2018 tax seasons (January – April). We leveraged the natural experiment of a legislated change in the timing of EITC and CTC transfer payments to low-income families and quasi-experimental methods to estimate the association between EITC and CTC payments and child maltreatment reports. RESULTS EITC and CTC payments were associated with lower state-level rates of child maltreatment reports. For each additional $1000 in per-child EITC and CTC tax refunds, state-level rates of reported child maltreatment declined in the week of and 4 weeks following refund payments by an overall estimated 5.0% (95% confidence interval = 2.3%–7.7%). CONCLUSIONS Federal income assistance programs are associated with immediate reductions in child maltreatment reporting. These results are particularly relevant at this time, as expansions to such programs continue to be discussed at the state and federal levels.

OBJECTIVES To determine the role of race/ethnicity and poverty in the likelihood of children younger than age 3 years hospitalized because of child abuse and neglect-related injuries being reported to child protective services (CPS) and being assigned a specific maltreatment diagnostic code. METHODS We used population-based linked administrative data comprising of birth, hospitalization, and CPS records. Children were identified for maltreatment-related hospitalizations using standardized diagnostic codes. Regression models were used to compute crude and adjusted race/ethnicity estimates regarding the likelihood of being reported to CPS and assigned a specific maltreatment diagnostic code during the maltreatment-related hospitalization. RESULTS Of the 3907 children hospitalized because of child maltreatment, those with public health insurance were more likely than those with private insurance (relative risk [RR]: 1.29; 95% confidence interval [CI], 1.16-1.42) and those with Asian/Pacific Islander mothers were less likely than those with White mothers to be reported to CPS (RR: 0.78; 95% CI, 0.65-0.93). No differences were found for children with Black, Hispanic, and Native American mothers compared with those with White mothers for CPS reporting. However, children with Native American mothers (RR: 1.45; 95% CI, 1.11-1.90) and public health insurance (RR: 2.00; 95% CI, 1.63-2.45) were more likely to have a specific maltreatment diagnostic code, the second strongest predictor of a CPS report. CONCLUSIONS Race/ethnicity and poverty were factors for CPS reports during a child maltreatment-related hospitalization. It is necessary to implement programs and policies that mitigate implicit bias to prevent inequities in which children receive protective intervention.

BACKGROUND To determine the association between states’ total spending on benefit programs and child maltreatment outcomes. METHODS This was an ecological study of all US states during federal fiscal years 2010–2017. The primary predictor was states’ total annual spending on local, state, and federal benefit programs per person living ≤100% federal poverty limit, which was the sum of (1) cash, housing, and in-kind assistance, (2) housing infrastructure, (3) child care assistance, (4) refundable Earned Income Tax Credit, and (5) Medical Assistance Programs. The main outcomes were rates of maltreatment reporting, substantiations, foster care placements, and fatalities after adjustment for relevant confounders. Generalized estimating equations adjusted for federal spending and estimated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS States’ total spending was inversely associated with all maltreatment outcomes. For each additional $1000 states spent on benefit programs per person living in poverty, there was an associated −4.3% (adjusted IRR: 0.9573 [95% CI: 0.9486 to 0.9661]) difference in reporting, −4.0% (adjusted IRR: 0.903 [95% CI: 0.9534 to 0.9672]) difference in substantiations, −2.1% (adjusted IRR: 0.9795 [95% CI: 0.9759 to 0.9832]) difference in foster care placements, and −7.7% (adjusted IRR: 0.9229 [95% CI: 0.9128 to 0.9330]) difference in fatalities. In 2017, extrapolating $1000 of additional spending for each person living in poverty ($46.5 billion nationally, or 13.3% increase) might have resulted in 181 850 fewer reports, 28 575 fewer substantiations, 4168 fewer foster care placements, and 130 fewer fatalities. CONCLUSIONS State spending on benefit programs was associated with reductions in child maltreatment, which might offset some benefit program costs.

OBJECTIVES During infancy, the American Academy of Pediatrics Bright Futures fourth edition health supervision guidelines recommend frequent well-child visits (WCVs) in which providers are expected to screen for and address maternal depression, intimate partner violence (IPV), and health-related social needs (HRSN). We spread an evidence-based approach that implements these recommendations (Developmental Understanding and Legal Collaboration for Everyone; DULCE) with 3 aims for 6-month-old infants and their families: 75% receive all WCVs on time, 95% are screened for 7 HRSNs, and 90% of families with concrete supports needs and 75% of families with maternal depression or IPV receive support. METHODS Between January 2017 and July 2018, five DULCE teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, pediatric and behavioral health clinicians) from 3 communities in 2 states participated in a learning collaborative. Teams adapted DULCE using Plan-Do-Study-Act cycles, reported data, and shared learning monthly. Run charts were used to study measures. The main outcome was the percent of infants that received all WCVs on time. RESULTS The percentage of families who completed all WCVs on time increased from 46% to 65%. More than 95% of families were screened for HRSNs, 70% had ≥1 positive screen, and 86% and 71% of those received resource information for concrete supports and maternal depression and IPV, respectively. CONCLUSIONS Quality improvement–supported DULCE expansion increased by 50% the proportion of infants receiving all WCVs on time and reliably identified and addressed families’ HRSNs, via integration of existing resources.

OBJECTIVES The objective was to evaluate if 2 pediatric weight management interventions delivered to Hispanic, low-income children (one in a health center the other in a Young Men’s Christian Association) were effective in reducing BMI. We hypothesized that they would be equally effective. METHODS A total 407 children aged 6 to 12 years with BMI ≥ 85th percentile receiving care at 2 health centers were randomly assigned to a healthy weight clinic (HWC) at the health center or to a modified Healthy Weight and Your Child (M-HWYC) intervention delivered in Young Men’s Christian Associations. A total of 4037 children served as the comparison group. We completed a noninferiority test comparing the M-HWYC with the HWC, which was supported if the bounds of the 90% confidence interval (CI) for the difference in percentage of the 95th percentile (%BMIp95) change did not contain what we considered a minimally clinically important difference, on the basis of previous data (0.87). Then, using linear mixed models, we assessed yearly changes in BMI among intervention participants compared with the comparison sites. RESULTS The mean difference in %BMIp95 between the M-HWYC and the HWC was 0.75 (90% CI: 0.07 to 1.43), which did not support noninferiority. Compared with the comparison sites, per year, children in the HWC had a −0.23 (95% CI: −0.36 to −0.10) decrease in BMI and a −1.03 (95% CI −1.61 to −0.45) %BMIp95 decrease. There was no BMI effect in the M-HWYC. CONCLUSIONS We were unable to establish noninferiority of the M-HWYC. The HWC improved BMI, offering an effective treatment of those disproportionately affected.

* Abbreviations: CYSHCN — : children and youth with special health care needs FPL — : federal poverty level US children and youth rely on insurance to access health care.1 Families living in or near poverty may qualify for public coverage with income thresholds for eligibility varying from 138% to 325% of the federal poverty level (FPL) across states.2 Other families may have commercial insurance through an employer or direct purchase.3 Families lacking insurance pay out-of-pocket for health care. The adequacy of insurance varies across insurance types,4 with some providing better coverage and access to care than others.5,6 Households with children and youth with special health care needs (CYSHCN) with low-to-middle income (ie, 200% to 399% of FPL) may be particularly sensitive to insurance variations, yet little is known about family perceptions of insurance adequacy.1,3 We compared these perceptions across insurance types for CYSHCN living in low-to-middle income families. We performed a retrospective analysis of 4321 responses of parents of CYSHCN aged 0 to 18 years in the 2016–2017 National Survey of Children’s Health, with family income that was 200% to 399% of FPL, representing 6 056 833 CYSHCN nationally. National Survey of Children’s Health uses … Address correspondence to Jay G. Berry, MD MPH, Boston Children’s Hospital, 21 Autumn St, Room 212.2, Boston, MA 02115, E-mail: Jay.berry{at}childrens.harvard.edu

Childhood economic disadvantage is associated with lower cognitive and social-emotional skills, reduced educational attainment, and lower earnings in adulthood. Despite these robust correlations, it is unclear whether family income is the cause of differences observed between children growing up in poverty and their more fortunate peers or whether these differences are merely due to the many other aspects of family life that co-occur with poverty. Baby’s First Years is the first randomized controlled trial in the United States designed to identify the causal impact of poverty reduction on children’s early development. A total of 1000 low-income mothers of newborns were enrolled in the study and began receiving a monthly unconditional cash gift for the first several years of their children’s lives. Mothers were randomly assigned to receive either a large monthly cash gift or a nominal monthly cash gift. All monthly gifts are administered via debit card and can be freely spent with no restrictions. Baby’s First Years aims to answer whether poverty reduction in early childhood (1) improves children’s developmental outcomes and promotes healthier brain functioning, and (2) improves family functioning and better enables parents to support child development. Here we present the rationale and design of the study as well as potential implications for science and policy.

The New York City (NYC) Department of Education is the largest public school system in the United States, with an enrollment of >1.1 million students. Students who participate in school meal programs can have higher dietary quality than nonparticipating students. Historically, family income documentation qualifying students in the NYC Department of Education for free or reduced-price meals reimbursed by the National School Lunch Program perpetuated poverty stigma. Additionally, National School Lunch Program qualification paperwork was a deterrent to many vulnerable families to participate and impeded all eligible children’s access to nutritious meals, potentially magnifying food insecurity. The Healthy, Hunger-Free Kids Act of 2010 provided a viable option for schools to serve free meals to all students, regardless of income status, as a universal free lunch (UFL) through a Community Eligibility Provision if ≥40% of students already participated in another means-based program, such as the Supplemental Nutrition Assistance Program. In this case study, we describe the processes of (1) strategic coalition building of the Lunch 4 Learning campaign (a coalition of students, parents, school-based unions, teachers, pediatricians, community leaders, and children’s advocacy organizations) to bring UFL to all NYC public schools, (2) building political support, (3) developing a media strategy, and (4) using an evidence-based strategy to overcome political, administrative, and procedural challenges. The Lunch 4 Learning campaign successfully brought UFL to all NYC public schools in 2017. This case study informs further advocacy efforts to expand UFL in other school districts across the country and national UFL advocacy.

A slip of paper posted on a door can signal the beginning of a destructive process for children’s health. Each year, more than 2.3 million households receive eviction notices.1 Despite fair housing laws which ban discrimination against children and families, households with children are more likely to be evicted than childless households, even when controlling for family income and rent owed.2 The proportion of children in a neighborhood is a stronger predictor of eviction rates than neighborhood-level poverty, racial makeup, or proportion of single parent households.2 Nearly 1 in 7 children will experience eviction before their 15th birthday, including 1 in 4 children living in poverty.3 Eviction, like mass incarceration, police violence, or environmental contamination, disproportionately affects families of color and exacerbates health inequities. Because of generations of systemic racism, Black and Latinx households are more likely to be evicted than white households, with women of color especially impacted.4 Close to 20% of Black children will be evicted during childhood, compared with 11% of white children.3 The economic disruption of the coronavirus disease 2019 pandemic has compounded this long-standing eviction crisis. In spring 2021, 1 in 5 renters with children was behind on rent, compared with 1 in 10 childless households.5 The pandemic has reinforced disparities in evictions, with households of color more than twice as likely as white households to fall behind on rent.5 Emergency aid has been slow to reach families and a patchwork of state and federal eviction moratoria are soon … Address correspondence to Dana Goplerud, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore MD 21287, dgopler1{at}jhmi.edu, 410-955-4201

BACKGROUND AND OBJECTIVES Referrals of transgender and gender-diverse (trans) youth to medical clinics for gender-affirming care have increased. We described characteristics of trans youth in Canada at first referral visit. METHODS Baseline clinical and survey data (2017–2019) were collected for Trans Youth CAN!, a 10-clinic prospective cohort of n = 174 pubertal and postpubertal youth RESULTS Of youth, 137 were transmasculine (assigned female) and 37 transfeminine (assigned male); 69.0% were aged 14 to 15, 18.8% Indigenous, 6.6% visible minorities, 25.7% from immigrant families, and 27.1% low income. Most (66.0%) were gender-aware before age 12. Only 58.1% of transfeminine youth lived in their gender full-time versus 90.1% of transmasculine (P < .001). Although transmasculine youth were more likely than transfeminine youth to report depressive symptoms (21.2% vs 10.8%; P = .03) and anxiety (66.1% vs 33.3%; P < .001), suicidality was similarly high overall (past-year ideation: 34.5%, attempts: 16.8%). All were in school; 62.0% reported strong parental gender support, with parents the most common support persons (91.9%). Two-thirds of families reported external gender-related stressors. Youth had met with a range of providers (68.5% with a family physician). At clinic visit, 62.4% were prescribed hormonal suppression or hormone therapy, most commonly depot leuprolide acetate. CONCLUSIONS Trans youth in Canada attending clinics for hormonal suppression or gender-affirming hormones were generally healthy but with depression, anxiety, and support needs.

* Abbreviation: CPS — : child protective services Pediatricians have implicit and explicit racial biases that impact the health and well-being of children and their families.1,2 Similarly, effects of racism on diagnosis and reporting of suspected child abuse and neglect to child protective services (CPS) can have serious consequences. Although we and others are mandated to report suspected child abuse or neglect in all US states and territories, the threshold for reporting requires only “reasonable suspicion” of abuse or neglect.3 Pediatricians may also report families that they perceive need additional resources. Research on racial bias and physician reporting is limited.4 Disproportionality in reporting is widespread on the basis of race, culture, and ethnicity. Asian American and Hispanic children are underrepresented, but overrepresentation of Black children throughout the child protection system has been most widely described.5 Black children are reported at approximately twice the rate of white children, and the complex relationship of reporting with poverty and race has yet to be fully understood.4–6 Once reported, cases with Black children are more likely to be accepted for investigation, be confirmed, be brought to court, result in removal of the children from their families for longer periods of time, and take longer to be closed, possibly related to surveillance bias.5,7 Multiple points in this process are subject to bias, but the process begins with reporting.8,9 The concept of bias has been recognized and discussed within the medical community for at least half a century. Diagnostic errors due to bias can lead to errors in reporting.10 Although physicians have historically been key players in the development … Address correspondence to Vincent J. Palusci, MD, MS, FAAP, Department of Pediatrics, Grossman School of Medicine, New York University, 462 First Ave, Room GC-65, New York, NY 10016. E-mail: vincent.palusci{at}nyulangone.org

OBJECTIVES Parent-infant skin-to-skin contact immediately after birth increases initiation and duration of bodyfeeding. We hypothesized that providing ergonomic carriers to parents during pregnancy would increase the likelihood of breastfeeding and expressed human milk feeding through the first 6 months of life. METHODS A randomized two-arm, parallel-group trial was conducted between February 2018 and June 2019 in collaboration with a home-visiting program in a low-income community. At 30 weeks’ gestation, 50 parents were randomly assigned to receive an ergonomic infant carrier and instruction on proper use to facilitate increased physical contact with infants (intervention group), and 50 parents were assigned to a waitlist control group. Feeding outcomes were assessed with online surveys at 6 weeks, 3 months, and 6 months postpartum. RESULTS Parents in the intervention group were more likely to be breastfeeding or feeding expressed human milk at 6 months (68%) than control group parents (40%; P = .02). No significant differences were detected in feeding outcomes at 6 weeks (intervention: 78% versus control: 81%, P = .76) or 3 months (intervention: 66% versus control: 57%, P = .34). Exclusive human milk feeding did not differ between groups (intervention versus control at 6 weeks: 66% vs 49%, P = .20; 3 months: 45% vs 40%, P = .59; 6 months: 49% vs 26%, P = .06). CONCLUSIONS Infant carriers increased rates of breastfeeding and expressed human milk feeding at 6 months postpartum. Large-scale studies are warranted to further examine the efficacy and cost-effectiveness of providing carriers as an intervention to increase access to human milk.

BACKGROUND AND OBJECTIVES Studies supporta recent decline in public benefit enrollment among immigrant families. We aimed to describe health and resource use, barriers to use, and immigration-related fear in families with undocumented parents compared with families without undocumented parents. We also aimed to assess associations with discontinuation of public benefits and fear of deportation. METHODS We assessed immigration concerns and enrollment in Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with an 89-item anonymous, cross-sectional survey of English- and Spanish-speaking caregivers of hospitalized children. Multivariable logistic regression was used to assess associations with discontinuation of public benefits and fear of deportation. RESULTS Of 527 families approached, 399 enrolled (105 with 1 or more undocumented parent, 275 with no undocumented parent, and 19 with undisclosed immigration status). Compared with families without undocumented parents, families with undocumented parents had higher levels of poverty and food insecurity. Controlling for perceived eligibility, public benefit use was similar across groups. Of families with undocumented parents, 29% reported public benefit discontinuation because of immigration concerns, and 71% reported fear of deportation. Having an undocumented parent was associated with public benefit disenrollment (odds ratio: 46.7; 95% confidence interval: 5.9–370.4) and fear of deportation (odds ratio: 24.3; 95% confidence interval: 9.6–61.9). CONCLUSIONS Although families with undocumented parents had higher levels of poverty and food insecurity compared with families without undocumented parents, public benefit use was similar between groups. Immigration-related fear may be a barrier to public benefit use in this population.

* Abbreviations: ECEP — : early childhood education provider FIMR-CAT — : Fetal and Infant Mortality Review Community Action Team GMCHL — : grassroots maternal and child health leader HP — : Healthy People IMR — : infant mortality rate MCH — : maternal and child health SDOH — : social determinants of health SSWG — : Safe Sleep Work Group Indiana’s government is prioritizing the reduction of the state’s persistently high infant mortality levels. Despite improvements in overall state and Black infant mortality rates, high rates persist within Indianapolis zip codes, characterized by multigenerational poverty and underrepresented minorities (Table 1). These rates occur in the presence of high-quality health care and home-visiting programs working to address the leading causes of infant death (birth defects, preterm birth and low birth weight, maternal pregnancy complications, and sudden unexpected infant death).1 Numerous studies, however, link infant mortality to underlying root causes associated with the social determinants of health (SDOH).2–4 Addressing the SDOH requires sustainable improvements in social systems that influence women’s health and birth outcomes. Our work complements the work of health care by building the capacity of individuals and organizations within targeted zip codes to remove social inequities that impact birth outcomes. View this table: TABLE 1 Indiana Urban Zip Codes With Persistently High Infant Mortality Rates, 2014–2018 Our work with families motivated and informed our approach. First, many families have experienced infant mortality across multiple generations. Second, even with public communication campaigns focused on prenatal care, safe sleep practice, and women’s health, many residents are unaware of the leading and root causes of poor birth outcomes. Third, residents are not aware of the linkages between social demographics and poor birth outcomes. Fourth, neighborhood networks within communities are often insular; likewise, policy-making networks are insular. There is a need to merge community and policy networks to facilitate dialogue and share realities and solution strategies. Finally, … Address correspondence to Nancy L. Swigonski, MD, MPH, MBA, FAAP, Department of Pediatrics, School of Medicine, Indiana University, 410 W 10th St, Suite 2000, Indianapolis, IN 46202. E-mail: nswigons{at}iu.edu

OBJECTIVES: In this study, we aim to assess the associations over time between poverty and child weight status, asthma, and health-related quality of life (HRQoL). METHODS: We analyzed data for 3968 children from the Generation R Study, a population-based cohort study in the Netherlands. Net household income and the number of adults and children living from this income were measured at 4 time-points (during pregnancy and at ages 2, 3, and 6). Poverty was defined on the basis of the equivalized household income being RESULTS: In this cohort, 9.8% of children were born into poverty and 6.0% had experienced 3 to 4 episodes of poverty. Independent of current poverty status, children born into poverty had an odds ratio (OR) of 1.68 for having overweight/obesity and a lower physical HRQoL (β = −1.32) than those not born into poverty. Children having experienced 3 to 4 episodes of poverty had an OR of 1.94 for having asthma and a lower physical HRQoL (β = −3.32) compared with children from never-poor families. Transition out of poverty before age 2 was associated with lower risk of asthma and a higher physical HRQoL compared with children who remained in poverty. CONCLUSIONS: Being born into poverty or experiencing multiple episodes of poverty is associated with negative child health outcomes, such as having overweight, asthma, or a lower HRQoL. Support for children and families with a low household income is warranted.

* Abbreviations: SA — : social autopsy VA — : verbal autopsy In this issue of Pediatrics , Lapidot et al1 report the findings of modified verbal autopsies (VAs) conducted for infants from the ages of 4 days to 6 months who were brought in dead to the main teaching hospital in Lusaka, Zambia. Universal health coverage2 and attaining the Sustainable Development Goals3 can only be achieved if the causes of death are known and actions to intervene are monitored. Yet, 1 in 2 deaths in low- and middle-income settings goes unreported because few low- and middle-income countries have a fully functional civil registration and vital statistics system in which to register deaths.4 These unregistered deaths occur in deprived communities in which health care is limited and poverty abounds. The investigators are based in Lusaka at the university teaching hospital, at which infants who have died out of a hospital are brought to have the deaths registered. The primary aim of the study is to identify the pathologic causes of death. Postmortems are performed after consent from the family. When obtaining permission and recording demographic details of a child, the interviewers ask the family some open-ended questions about the events leading up to the death. It is these narratives that Lapidot et al1 report in this issue of Pediatrics . The authors call the stories “modified verbal autopsies,” although a standardized and validated questionnaire was not used and the analyses were retrospectively … Address correspondence to Elizabeth Molyneux, FRCPCH, Flat 4, Cap Martin, The Serpentine, Liverpool L23 6TD, UK. E-mail: emmolyneux{at}gmail.com

* Abbreviation: AACWA — : Adoption Assistance and Child Welfare Act Based upon recent investigation rates, as many as 37% of children born this year in the United States may become the subject of a child welfare system investigation. Among Black children, an estimated close to 50% are likely to be subject to such an investigation.1 Although rates of serious physical injury to children are on the decline,2 the number of children reported for neglect has increased. Child maltreatment investigations have become the foremost intervention to safeguard children in the United States. This focus on reporting, investigation, and child removal has a long history.3 Furthermore, the burden of the coercive aspects of the child welfare system is carried disproportionately by Black families. Allegations of maltreatment involving Black children are more likely to be reported to1 and substantiated by child welfare agencies than those involving white children.4 Once investigated, Black children are more likely to be removed from their homes than white children and subsequently less likely to be reunified.5,6 Although some researchers identified race as a significant factor in these disparities,4 others found no significant effect for race when controlling for poverty.7 Yet, regardless of the reasons disparities occur, they represent a significant problem because of the harm they cause Black families. We trace these … Address correspondence Mical Raz, MD, PhD, MSHP, Charles E. and Dale L. Phelps Professor in Public Policy and Health, University of Rochester, Rochester, NY 14618. E-mail: micalraz{at}rochester.edu

BACKGROUND AND OBJECTIVES: Heterogeneity in risk among low-income families suggests the need for tiered interventions to prevent disparities in school readiness. Smart Beginnings (SB) integrates two interventions: Video Interaction Project (VIP) (birth to 3 years), delivered universally to low-income families in pediatric primary care, and Family Check-Up (6 months to 3 years), targeted home visiting for families with additional family risks. Our objective was to assess initial SB impacts on parent-child activities and interactions at 6 months, reflecting early VIP exposure. METHODS: Two-site randomized controlled trial in New York City (84% Latinx) and Pittsburgh (81% Black), with postpartum enrollment and random assignment to treatment (SB) or control. At 6 months, we assessed parent-child interactions through surveys (StimQ, Parenting Your Baby) and observation (video-recorded play, coded by using Parent-Child Interaction Rating Scales – Infant Adaptation). RESULTS: A total of 403 families were enrolled at child’s birth (201 treatment) with 362 (89.8%) assessed at 6 months. Treatment families had increased StimQ, including total score (Cohen’s d = 0.28; P < .001) and domains reflecting reading (d = 0.23; P = .02) and teaching (d = 0.25; P = .01), and Parent-Child Interaction Rating Scales – Infant Adaptation, including a cognitive stimulation factor (d = 0.40; P < .001) and domains reflecting support for cognitive development (d = 0.36; P < .001), and language quantity (0.40; P < .001) and quality (d = 0.37; P < .001). Thus, significant effects emerged across a broad sample by using varied methodologies. CONCLUSIONS: Findings replicate and extend previous VIP findings across samples and assessment methodologies. Examining subsequent assessments will determine impacts and feasibility of the full SB model, including potential additive impacts of Family Check-Up for families at elevated risk.

BACKGROUND: Persistent disparities exist in early identification of autism spectrum disorder (ASD) among children from low-income families who are racial and/or ethnic minorities and where English is not the primary language. Parental literacy and level of maternal education may contribute to disparities. The Developmental Check-In (DCI) is a visually based ASD screening tool created to reduce literacy demands and to be easily administered and scored across settings. In a previous study, the DCI showed acceptable discriminative ability between ASD versus non-ASD in a young, underserved sample at high-risk for ASD. In this study, we tested the DCI among an unselected, general sample of young underserved children. METHODS: Six hundred twenty-four children ages 24 to 60 months were recruited through Head Start and Early Head Start. Parents completed the DCI, Modified Checklist for Autism in Toddlers, Revised with Follow-Up, and Social Communication Questionnaire. Children scoring positive on any measure received evaluation for ASD. Those screening negative on both Modified Checklist for Autism in Toddlers, Revised with Follow-Up and Social Communication Questionnaire were considered non-ASD. RESULTS: Parents were primarily Hispanic, reported high school education or less, and had public or no insurance. The DCI demonstrated good discriminative power (area under the curve = 0.80), performing well across all age groups, genders, levels of maternal education, primary language, and included ethnic and racial groups. Item-level analyses indicated that 24 of 26 DCI items discriminated ASD from non-ASD. CONCLUSIONS: The DCI is a promising ASD screening tool for young, underserved children and may be of particular value in screening for ASD for those with low literacy levels or with limited English proficiency.

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user’s adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

* Abbreviations: CTC — : Child Tax Credit EITC — : Earned Income Tax Credit NAM — : National Academy of Medicine TCJA — : Tax Cuts and Jobs Act WFTRA — : Working Families Tax Relief Act There is a clear link between poverty and suboptimal maternal-child health.1–3 Both the American Academy of Pediatrics and the National Academy of Medicine (NAM) have called for expansion of cash transfers in the form of tax credits to decrease child poverty.1,2 The NAM analyzed evidence-based, nonpartisan strategies to reduce child poverty by 50% over the next decade. They developed packages of these strategies, including combinations of increasing the Earned Income Tax Credit (EITC), the Child Tax Credit (CTC), child care subsidies, minimum wage, Social Security income, the Supplemental Nutrition Assistance Program, and housing vouchers. They also assessed a scaled-up work training program and eliminated immigration-related restrictions on welfare.2 Notably, increasing the CTC (in the form of a child allowance) to $3000 per child per year was the only policy the NAM found powerful enough to meet the 50% reduction goal on its own.2 Approximately 13 million children live in poverty, making the NAM’s goal an audacious one. However, we have an opportunity to make progress toward its achievement. The Working Families Tax Relief Act (WFTRA), components of which were recently included on a temporary basis in the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act passed in the US House of Representatives in response to the COVID-19 crisis, would modify the EITC and CTC in ways that align with some of the NAM's recommendations. It could decrease the poverty rate by 28%,4 equating to 3 million fewer children growing up in poverty. … Address correspondence to Lucy E. Marcil, MD, MPH, Department of Pediatrics, Boston Medical Center, 801 Albany St, Floor 3, Boston, MA 02118. E-mail: lucy.marcil{at}bmc.org

OBJECTIVES: In this study, we tested whether Recipe 4 Success, a preventive intervention featuring structured food preparation lessons, was successful in improving the following 4 protective factors related to overweight and obesity among families living in poverty: toddlers’ healthy eating habits, toddlers’ self-regulation, parents’ responsive feeding practices, and parents’ sensitive scaffolding. METHODS: This randomized controlled trial was open to families enrolled in Early Head Start home visits and included 73 parents and their toddlers aged 18 to 36 months. Multimethod assessments were conducted at baseline and posttreatment. RESULTS: Compared with toddlers in usual practice Early Head Start, toddlers in Recipe 4 Success consumed healthier meals and snacks (d = 0.57; P < .03; 95% confidence interval [CI]: 0.08–1.06) and displayed better self-regulation (d = 0.95; P < .001; 95% CI: 0.43–1.45). Compared with parents in usual practice Early Head Start, parents in Recipe 4 Success engaged in more responsive feeding practices (d = 0.87; P < .002; 95% CI: 0.34–1.40) and were better able to sensitively scaffold their toddlers’ learning and development (d = 0.58; P < .04; 95% CI: 0.07–1.09). CONCLUSIONS: This randomized controlled trial revealed medium to large intervention effects on 4 important protective factors that are related to overweight and obesity but are often compromised by living in poverty.

BACKGROUND: Health administrative data offer a vital source of data on maternal prenatal opioid exposure (POE). The impact of different methods to estimate POE, especially combining maternal and newborn records, is not known. METHODS: This population-based cross-sectional study included 454 746 hospital births with linked administrative data in Ontario, Canada, in 2014–2017. POE ascertainment included 3 sources: (1) prenatal opioid prescriptions, (2) maternal opioid-related hospital records, and (3) newborn hospital records with neonatal abstinence syndrome (NAS). Positive percent agreement was calculated comparing cases identified by source, and a comprehensive method was developed combining all 3 sources. We replicated common definitions of POE and NAS from existing literature and compared both number of cases ascertained and maternal socio-demographics and medical history using the comprehensive method. RESULTS: Using all 3 data sources, there were 9624 cases with POE (21.2 per 1000 births). Among these, positive percent agreement (95% confidence interval) was 79.0% (78.2–79.8) for prenatal opioid prescriptions, 19.0% (18.2–19.8) for maternal opioid-related hospital records, and 44.7% (43.7–45.7) for newborn NAS. Compared with other definitions, our comprehensive method identified up to 523% additional cases. Contrasting ascertainment with maternal opioid-related hospital records, newborn NAS, and prenatal opioid prescriptions respective rates of maternal low income were 57%, 48%, and 39%; mental health hospitalization history was 33%, 28%, and 17%; and infant discharge to social services was 8%, 13%, and 5%. CONCLUSIONS: Combining prenatal opioid prescriptions and maternal and newborn opioid-related hospital codes improves identification of a broader population of mothers and infants with POE.

OBJECTIVES: To determine impact of a primary care–based child obesity prevention intervention beginning during pregnancy on early childhood weight outcomes in low-income Hispanic families. METHODS: A randomized controlled trial comparing mother–infant pairs receiving either standard care or the Starting Early Program providing prenatal and postpartum nutrition counseling and nutrition parenting support groups targeting key obesity-related feeding practices in low-income groups. Primary outcomes were reduction in weight-for-age z-scores (WFAzs) from clinical anthropometric measures, obesity prevalence (weight for age ≥95th percentile), and excess weight gain (WFAz trajectory) from birth to age 3 years. Secondary outcomes included dose effects. RESULTS: Pregnant women (n = 566) were enrolled in the third trimester; 533 randomized to intervention (n = 266) or control (n = 267). Also, 358 children had their weight measured at age 2 years; 285 children had weight measured at age 3 years. Intervention infants had lower mean WFAz at 18 months (0.49 vs 0.73, P = .04) and 2 years (0.56 vs 0.81, P = .03) but not at 3 years (0.63 vs 0.59, P = .76). No group differences in obesity prevalence were found. When generalized estimating equations were used, significant average treatment effects were detected between 10-26 months (B = −0.19, P = .047), although not through age 3 years. In within group dose analyses at 3 years, obesity rates (26.4%, 22.5%, 8.0%, P = .02) decreased as attendance increased with low, medium, and high attendance. CONCLUSIONS: Mean WFAz and growth trajectories were lower for the intervention group through age 2 years, but there were no group differences at age 3. Further study is needed to enhance sustainability of effects beyond age 2.

* Abbreviations: COVID-19 — : coronavirus disease SNAP — : Supplemental Nutrition Assistance Program Nationwide closures of elementary and secondary schools due to the novel coronavirus disease (COVID-19) have severed nearly 60 million students from critical educational and health resources. As the impact of COVID-19 unfolds, pandemic-related trauma and economic instability will disproportionately impact children in poverty, who most heavily rely on school-based services for nutritional, physical, and mental health needs. Yet amid months of public health and political discourse and the passage of 4 federal relief bills, including the historically unmatched $2 trillion Coronavirus Aid, Relief, and Economic Security Act, measures to mitigate risk for educational and health disparities among children have been woefully lacking. Beyond provision of clinical and infection control guidance, the pediatric community must advocate for stronger action to ensure the educational, nutritional, physical, and mental health needs of children are met during periods of school closures and addressed during plans for reopening (Table 1). View this table: TABLE 1 Pediatric advocacy suggestions, tools, and resources. Action is needed to offset the risk for educational losses among all children as well as exacerbated educational disparities among children in poverty. Unforeseen extended school closures can lead to lower test scores, lower educational attainment, and decreased earning potential.1 During closures, students need reliable access to technology, a stable learning environment, and parents with the necessary time and skills to support for remote learning. Although remote learning presents a challenge for all families, those in poverty are at greater … Address correspondence to Abbey R. Masonbrink, MD, MPH, Department of Pediatrics, Children’s Mercy Kansas City, 2401 Gilham Rd, Kansas City, MO 64108. E-mail: armasonbrink{at}cmh.edu

* Abbreviation: COVID-19 — : coronavirus disease 2019 The coronavirus disease 2019 (COVID-19) pandemic has created a time of unprecedented isolation, despair, and harm. Although COVID-19 does not intrinsically discriminate on the basis of race, sex, or socioeconomic class, the effects of the pandemic seem to be more deleterious for minorities. According to some preliminary research, the pediatric population has been relatively spared the severe consequences of COVID-19.1 However, underneath the COVID-19 infections, there is a hidden pandemic that affects minority children in direct and indirect ways with potential long-term consequences. At the end of April 2020, the Centers for Disease Control and Prevention began to systematically collect ethnicity, race, and socioeconomic data at the national level. Although the compiled results are still pending, statewide data have revealed significant inequities in the rates of confirmed cases and mortality. For example, in Massachusetts, an estimated 35% to 40% of Massachusetts General Hospital’s patients with COVID-19 are Hispanic, in comparison with 9% of the patient population before the outbreak.2 Furthermore, the shortage of interpreters also posed additional challenges for communications of treatments and care to minority patients and families with limited English proficiency. Because the rates of COVID-19 among people of color seem to be higher, minority children are presumably even more likely to be exposed to infection from their parents and guardians. In addition, minority children are more likely to have underlying conditions that may exacerbate the severity of COVID-19 infections; for example, minority children are more likely to have major chronic diseases, such as, asthma and … Address correspondence to Adrian Jacques H. Ambrose, MD, MPH, FAPA, Office for Diversity and Community, Harvard University, 164 Longwood Ave, Second Floor, Boston, MA 02115. E-mail: adrianjacques_ambrose{at}hms.harvard.edu

BACKGROUND: Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act’s (ACA’s) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty. METHODS: We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010–2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers. RESULTS: A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers. CONCLUSIONS: ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.

Child health depends on family health. In this issue of Pediatrics , Johnston et al1 clearly illustrate challenges facing low-income mothers in gaining access to health insurance during the first year after childbirth. Although highlighting the positive impact of Medicaid expansion through the Patient Protection and Affordable Care Act (in some states), the number of mothers who are uninsured before, during, and after pregnancy in the United States is alarming. Of 185 World Health Organization member states with a population >100 000, the United States and the Dominican Republic were the only countries where maternal mortality increased between 2000 and 2017.2 Women with preexisting chronic conditions, living in poverty, and belonging to a racial and/or ethnic minority are disproportionately affected.3 Studies of women who have delivered a child have found that one-quarter were uninsured in the month before pregnancy, and more than half of the mothers had

* Abbreviations: AAP — : American Academy of Pediatrics VVN — : Vital Village Network The American dream is a fundamental ethos of the nation passed from generation to generation. In 1931, James Truslow Adams coined the term as “that dream of a land in which life should be better and richer and fuller for everyone.” Most Americans across all incomes still believe their children and grandchildren will achieve the American dream.1 Yet, in reality, it is out of most children’s reach. The American dream is intrinsically tied to the capacity for upward mobility, whereby children can grow up to surpass their parent’s income level. The groundbreaking work of Harvard Professor of Public Economics Dr Raj Chetty reveals that there is less upward mobility in the United States today than at any other time, likely because of lower overall economic growth and greater inequality in its distribution. Specifically, Chetty et al2 found that, since 1940, the fraction of children who earn more than their parents has fallen from >90% to ∼50%. However, the decline in the American dream is not equally distributed across the United States. Chetty et al3 has revealed great variation in upward mobility, with significant differences even among neighborhoods within the same city. Higher–upward-mobility areas are associated with less residential segregation and income inequality and greater … Address correspondence to Arvin Garg, MD, MPH, Department of Pediatrics, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655. E-mail: Arvin.Garg{at}umassmemorial.org

* Abbreviations: CIF — : children in immigrant families COVID-19 — : coronavirus disease DACA — : Deferred Action for Childhood Arrivals ICE — : Immigration and Customs Enforcement LEP — : limited English proficiency SDH — : social determinant of health TPS — : temporary protected status WIC — : Women, Infants, and Children Program Like many health conditions that disproportionately impact vulnerable populations of color, we expect that the coronavirus disease (COVID-19) pandemic will inequitably affect the health and livelihoods of immigrant families. One in 4 children (>18 million) in the United States lives in an immigrant family, in which the child or ≥1 parent was born outside the United States.1 Among children in immigrant families (CIF), >7 million live in “mixed-status” families, meaning ≥1 parent is not a US citizen.2 Before the COVID-19 pandemic, immigrant families faced increasingly restrictive policies and discrimination. Regardless of legal status, CIF experience increased health and social risks compared with peers in nonimmigrant families, including lower rates of health insurance coverage and higher poverty levels.3 The COVID-19 pandemic amplifies existing inequities and introduces new ones as immigrant families navigate school closures, lack of health insurance and paid leave, and decisions to seek medical care or public services amid ongoing immigration enforcement. Additionally, immigrant families are more likely to live in multigenerational households,4 heightening the risk of COVID-19 for multiple family members. Families with limited English proficiency (LEP) must decipher rapidly evolving public health directives, such as “shelter-in-place” orders and recommendations for mask-wearing, without multilingual and culturally relevant messaging. Underlying these challenges is the implicit presumption of a safe place in shelter-in-place and social distancing directives. For immigrant families seeking safe haven in the United States, “place” may include violence and abject poverty, both in home countries and at the US border. For CIF in US communities coping with persistent fears of immigration enforcement and family separation, … Address correspondence to Rushina Cholera, Duke University School of Medicine, 200 Morris St, 3rd Floor, Durham, NC 27701. E-mail: rushina.cholera{at}duke.edu

BACKGROUND: Material hardship has been associated with adverse health care use patterns for children with special health care needs (CSHCN). In this study, we assessed if resilience factors were associated with lower emergency department (ED) visits and unmet health care needs and if they buffered associations between material hardship and health care use for CSHCN and children without special health care needs. METHODS: A cross-sectional study using the 2016 National Survey of Children’s Health, restricted to low-income participants ( RESULTS: The sample consisted of 11 543 children (weighted: n = 28 465 581); 26% were CSHCN. Material hardship was associated with higher odds of ED visits and unmet health care needs for all children. Resilience factors were associated with lower odds of unmet health care needs for CSHCN (family resilience adjusted odds ratio: 0.58; 95% confidence interval: 0.36–0.94; neighborhood cohesion adjusted odds ratio: 0.53; 95% confidence interval: 0.32–0.88). For CSHCN, lower material hardship mediated associations between resilience factors and unmet health care needs. Neighborhood cohesion moderated the association between material hardship and ED visits (interaction term: P = .02). CONCLUSIONS: Among low-income CSHCN, resilience factors may buffer the effects of material hardship on health care use. Future research should evaluate how resilience factors can be incorporated into programs to support CSHCN.

BACKGROUND: Disparities in health service use have been described across a range of sociodemographic factors. Patterns of PICU use have not been thoroughly assessed. METHODS: This was a population-level, retrospective analysis of admissions to the Cincinnati Children’s Hospital Medical Center PICU between 2011 and 2016. Residential addresses of patients were geocoded and spatially joined to census tracts. Pediatric patients were eligible for inclusion if they resided within Hamilton County, Ohio. PICU admission and bed-day rates were calculated by using numerators of admissions and bed days, respectively, over a denominator of tract child population. Relationships between tract-level PICU use and child poverty were assessed by using Spearman’s ρ and analysis of variance. Analyses were event based; children admitted multiple times were counted as discrete admissions. RESULTS: There were 4071 included admissions involving 3129 unique children contributing a total of 12 297 PICU bed days. Child poverty was positively associated with PICU admission rates (r = 0.59; P < .001) and bed-day rates (r = 0.47; P < .001). When tracts were grouped into quintiles based on child poverty rates, the PICU bed-day rate ranged from 23.4 days per 1000 children in the lowest poverty quintile to 81.9 days in the highest poverty quintile (P < .001). CONCLUSIONS: The association between poverty and poor health outcomes includes pediatric intensive care use. This association exists for children who grow up in poverty and around poverty. Future efforts should characterize the interplay between patient- and neighborhood-level risk factors and explore neighborhood-level interventions to improve child health.

BACKGROUND:Prenatal and infancy home-visiting by nurses is promoted as a means of improving maternal life-course, but evidence of long-term effects is limited. We hypothesized that nurse-visitation would lead to long-term reductions in public-benefit costs, maternal substance abuse and depression, and that cost-savings would be greater for mothers with initially higher psychological resources.METHODS:We conducted an 18-year follow-up of 618 out of 742 low-income, primarily African-American mothers with no previous live births enrolled in an randomized clinical trial of prenatal and infancy home visiting by nurses. We compared nurse-visited and control-group women for public-benefit costs, rates of substance abuse and depression, and examined possible mediators of intervention effects.RESULTS:Nurse-visited women, compared with controls, incurred $17 310 less in public benefit costs (P = .03), an effect more pronounced for women with higher psychological resources ($28 847, P = .01). These savings compare with program costs of $12 578. There were no program effects on substance abuseor depression. Nurse-visited women were more likely to be married from child age 2 through 18 (19.2% vs 14.8%, P = .04), and those with higher psychological resources had 4.64 fewer cumulative years rearing subsequent children after the birth of the first child (P = .03). Pregnancy planning was a significant mediator of program effects on public benefit costs.CONCLUSIONS:Through child age 18, the program reduced public-benefit costs, an effect more pronounced for mothers with higher psychological resources and mediated by subsequent pregnancy planning. There were no effects on maternal substance abuse and depression.

* Abbreviation: ROR — : Reach Out and Read In 1989, while one of us (B.Z.) was director of the Division of Developmental and Behavioral Pediatrics at Boston City Hospital (now Boston Medical Center) and the other (R.N.) was a fellow, we began thinking about the role of books in the school readiness of vulnerable young children. Four years earlier, the National Institute of Education had dubbed reading aloud “the single most important activity for building the knowledge required for eventual success in reading.”1 But no pediatric textbook mentioned reading aloud, nor did the early editions of Bright Futures . Reach Out and Read (ROR) began with the idea that doctors have a special opportunity to encourage reading aloud in families that are facing the dual challenges of poverty and limited literacy.2 We recognized the indivisibility of health and education. A recent National Academy of Medicine report highlights the point, showing that the duration of education is a better predictor of health and long life than either cigarette smoking or obesity.3 Shifting forward 30 years, ROR, supported by more than 6000 clinics and practices and backed up by numerous peer-reviewed studies,4–19 now reaches ∼25% of low-income children. A policy statement by the American Academy of Pediatrics has identified literacy promotion as an essential component of primary care.20 And yet, the … Address correspondence to Barry Zuckerman, MD, Department of Pediatrics, Boston Medical Center, School of Medicine, Boston University, 72 E Concord St, Room 324L, Boston, MA 02118. E-mail: barry.zuckerman{at}bmc.org

* Abbreviation: GH — : global health Incredible advances in international travel and information technology have resulted in the shrinking of our planet. Correspondingly, the health of children in all countries is increasingly influenced by how the world deals with infectious diseases, environmental threats, armed conflict, forced migration, and poverty. Sustainable solutions to child health problems in the United States are interlinked with efforts to strengthen health care and social stability in other countries. As pediatricians, we should seek to understand the global patterns of diseases, find solutions to the inequities between and within national health systems, and practice cultural humility. In response to these changes, most US residency programs offer international field experiences, and the number offering global health (GH) tracks continues to grow.1 Several studies describe a significant surge in GH training over the last 3 decades with surveys of pediatric residency program directors and recently graduated pediatric residents. In this month’s issue of Pediatrics , Chan et al2 shift the GH spotlight beyond the training period and report … Address correspondence to Suzinne Pak-Gorstein, MD, MPH, PhD, Department of Pediatrics, University of Washington, 6016 First Ave NW, Seattle, WA 98107. E-mail: spakgor{at}uw.edu

BACKGROUND: Provider adherence to best practice guidelines (ask, advise, refer [AAR]) for addressing child tobacco smoke exposure (TSE) motivates parents to reduce TSE. However, high-risk, vulnerable populations of smokers may require more intensive treatment. We hypothesized that a pragmatic, multilevel treatment model including AAR coupled with individualized, telephone-based behavioral counseling promoting child TSE reduction would demonstrate greater child TSE reduction than would standard AAR. METHODS: In this 2-arm randomized controlled trial, we trained pediatric providers in systems serving low-income communities to improve AAR adherence by using decision aid prompts embedded in routine electronic health record assessments. Providers faxed referrals to the study and received ongoing AAR adherence feedback. Referred participants were eligible if they were daily smokers, >17 years old, and spoke English. Participants were randomly assigned to telephone-based behavioral counseling (AAR and counseling) or nutrition education (AAR and attention control). Participants completed prerandomization and 3-month follow-up assessments. RESULTS: Of providers, >80% (n = 334) adhered to AAR procedures and faxed 2949 referrals. Participants (n = 327) were 83% women, 83% African American, and 79% low income (below poverty level). Intention-to-treat logistic regression showed robust, positive treatment effects: more parents in AAR and counseling than in AAR and attention control eliminated all sources of TSE (45.8% vs 29.9%; odds ratio 1.99 [95% confidence interval 1.44–2.74]) and quit smoking (28.2% vs 8.2%; odds ratio 3.78 [95% confidence interval 1.51–9.52]). CONCLUSIONS: The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice.

Children growing up in the United States today are more ethnically and racially diverse than at any time in the nation’s history. Because of rising income inequality, almost half of the 72 million children in the United States are also growing up in low-income families, with immigrant and children of color disproportionately likely to be within their ranks. Children in low-income households are more likely to face a number of social challenges, including constrained access to the Internet and devices that connect to it (ie, digital inequality), which can exacerbate other, more entrenched disparities between them and their more privileged counterparts. Although the American Academy of Pediatrics’ new guidelines encourage clinicians to reduce children’s overexposure to technology, we argue for a more nuanced approach that also considers how digital inequality can reduce low-income children’s access to a range of social opportunities. We review previous research on how digital inequality affects children’s learning and development and identify areas where more research is needed on how digital inequality relates to specific aspects of children’s developmental trajectories, and to identify what interventions at the family, school, and community levels can mitigate the adverse effects of digital inequality as children move through their formal schooling. On the basis of the evidence to date, we conclude with guidelines for clinicians related to supporting digital connectivity and more equitable access to social opportunity for the increasingly diverse population of children growing up in the United States.