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Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Objectives Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. Methods We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. Results Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. Conclusions In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

* Abbreviations: aOR — : adjusted odds ratio CI — : confidence interval ED — : emergency department RR — : relative reduction Pain caused by long bone fractures is a common reason for opioid prescribing in the emergency department (ED) setting.1 Approximately 40% of opioid overdose deaths involve a prescription,2 and in response, opioid prescribing has declined in the last decade.3 We previously demonstrated racial and/or ethnic disparities in the ED management of pain among children with long bone fractures.4 We now perform this study to investigate whether racial and/or ethnic differences in provision of outpatient opioid prescriptions for children discharged from the ED with long bone fractures have attenuated over time. We performed a retrospective cross-sectional study of children aged 4 to

Police violence in the United States represents a pressing public health crisis impacting youth, particularly youth of color. This article reviews the recent epidemiology of police executions and conflicts involving children, adolescents, and young adults. The roles of social determinants of health and centuries-long history of white supremacy and racism as root causes of adverse policing are emphasized. The article summarizes the evidence as to how direct and vicarious experiences of police violence impact youth academic, behavioral, and health outcomes. Recommendations are provided for pediatricians to address this public health crisis through clinical practice, education, advocacy, and research.

Black, Native, and Latinx populations represent the racial and ethnic groups most impacted by poverty. This unequal distribution of poverty must be understood as a consequence of policy decisions—some that have sanctioned violence and others that have created norms—that continue to shape who has access to power, resources, rights, and protections. In this review, we draw on scholarship from multiple disciplines, including pediatrics, public health, environmental health, epidemiology, social and biomedical science, law, policy, and urban planning to explore the central question—What is the relationship between structural racism, poverty, and pediatric health? We discuss historic and present-day events that are critical to the understanding of poverty in the context of American racism and pediatric health. We challenge conventional paradigms that treat racialized poverty as an inherent part of American society. We put forth a conceptual framework to illustrate how white supremacy and American capitalism drive structural racism and shape the racial distribution of resources and power where children and adolescents live, learn, and play, ultimately contributing to pediatric health inequities. Finally, we offer antipoverty strategies grounded in antiracist practices that contend with the compounding, generational impact of racism and poverty on heath to improve child, adolescent, and family health.

* Abbreviations: COVID-19 — : coronavirus disease 2019 PART — : Pediatricians Against Racism and Trauma We have seen the horrifying cell phone and surveillance video footage of the murder of George Floyd replay again and again in the last few weeks. The aftermath begs the question why this particular murder of a Black man by a police officer has sparked the international response so few have received.1 Scores of other Black men, women, and children have been killed by police since the 2014 murder of Eric Garner in New York City, in which he suffered an illegal chokehold and uttered the devastating refrain “I can’t breathe,” and countless others have been murdered over generations. These cases represent just the tip of the iceberg because these murders happened to be recorded on bystander cell phone video or police webcam capture. Moreover, it is the tip of another iceberg because these cases represent modern-day lynchings. The lynching of Black people in the United States was routine before the “civil rights era,” when there were major legal advances to change the treatment of Black Americans in this country. However, it was not until February 2020 that federal legislation, the Emmett Till Antilynching Act, was passed by the House of Representatives but is still … Address correspondence to Benard P. Dreyer, MD, FAAP, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, New York University Grossman School of Medicine and Department of Pediatrics, Bellevue Hospital Center, 550 First Ave, New York, NY 10016. E-mail: benard.dreyer{at}nyulangone.org

* Abbreviation: SDoH — : social determinant of health Race, and more specifically, racism, is recognized as an important social determinant of health (SDoH) and a key driver of health inequities.1–3 The study “Race, Postoperative Complications, and Death in Apparently Healthy Children” in this issue of Pediatrics provides new evidence of race as a critical social determinant of surgical outcomes.4 The investigators demonstrate that apparently healthy Black children had a higher risk of postoperative mortality, complications, and serious adverse events than their white counterparts. Identifying these disparities using the National Surgical Quality Improvement Program pediatric database highlights the importance of health care practices to more deliberately consider equity in their quality improvement portfolios. The analyses were done among children with American Society of Anesthesiologists physical status 1 (normal healthy patients) or 2 (patients with mild systemic disease, such as mild asthma). By excluding children with significant comorbidities, this study helps advance knowledge beyond most previous pediatric disparities research focused on identifying disparities by exploring potential root causes. The findings suggest that, although preoperative comorbidities have previously been proposed as a factor contributing to postoperative disparities, they do not explain the results in the current study. Implicit racial bias has been proposed as another potential source of health care … Address correspondence to Tiffani J. Johnson, MD, MSc, Department of Emergency Medicine, University of California, Davis, 4150 V St, Suite 2100, Sacramento, CA 95817. E-mail: tjo{at}ucdavis.edu

OBJECTIVES: To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS: We performed a 3-year retrospective cross-sectional study of children RESULTS: In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51–1.95]; Hispanic: 1.32 [1.16–1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14–1.76]; Hispanic: 1.38 [1.04–1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77–0.95]; Hispanic: aOR 0.86 [0.76–0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67–0.90]; Hispanic: aOR 0.80 [0.67–0.95]). CONCLUSIONS: There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.

Background and objectivesThe general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.MethodsWe measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.ResultsAmong 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean=0.49, standard deviation=0.34) and Child Race IAT (mean=0.55, standard deviation=0.37). There was no significant difference between Adult and Child Race IAT scores (difference=0.06, P=.15). Implicit bias was not associated with resident demographic characteristics, including specialty.ConclusionsThis is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.

Purpose: Research has shown racial/ethnic variability in the quality of pediatric emergency care. Wait time is an important process of care quality measure in the pediatric emergency department (PED) that can affect satisfaction and clinical outcomes. Our objective was to determine if there are racial/ethnic differences in wait time for children presenting to PEDs, and to examine between-site versus within-site differences. Methods: Retrospective cohort study using the Pediatric Emergency Care Applied Research Network …

Research Objective: Despite known benefits of physician workforce diversity, certain racial and ethnic groups remain underrepresented in academic pediatrics. Research in the general labor market suggests that racial bias exists in all phases of the hiring process and impacts workforce diversity. Research on physician bias has primarily focused on its impact on patient care. There is little research about unconscious racial attitudes among pediatric faculty leaders who are generally responsible for decisions on workforce recruitment …

BACKGROUND AND OBJECTIVES:In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED.METHODS:This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site.RESULTS:Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [CI] 2.4%–2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; CI 0.36–0.53), Hispanic (aOR 0.65; CI 0.53–0.81), and other NH (aOR 0.68; CI 0.52–0.87) children remained less likely to receive antibiotics for viral ARTIs.CONCLUSIONS:Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias.

Objectives The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. Methods Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant's hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. Results The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. Conclusions Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.

A previously healthy 11-year-old girl who presented to the emergency department with 8 days of headache and right-sided weakness was found to have 2 cerebral abscesses. Brain abscess is an uncommon finding for children in the emergency department. With this case, we review the clinical presentation, evaluation, and management of this unusual but potentially life-threatening condition.

OBJECTIVE:To determine if race/ethnicity-based differences exist in the management of pediatric abdominal pain in emergency departments (EDs).METHODS:Secondary analysis of data from the 2006–2009 National Hospital Ambulatory Medical Care Survey regarding 2298 visits by patients ≤21 years old who presented to EDs with abdominal pain. Main outcomes were documentation of pain score and receipt of any analgesics, analgesics for severe pain (defined as ≥7 on a 10-point scale), and narcotic analgesics. Secondary outcomes included diagnostic tests obtained, length of stay (LOS), 72-hour return visits, and admission.RESULTS:Of patient visits, 70.1% were female, 52.6% were from non-Hispanic white, 23.5% were from non-Hispanic black, 20.6% were from Hispanic, and 3.3% were from “other” racial/ethnic groups; patients’ mean age was 14.5 years. Multivariate logistic regression models adjusting for confounders revealed that non-Hispanic black patients were less likely to receive any analgesic (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.43–0.87) or a narcotic analgesic (OR: 0.38; 95% CI: 0.18–0.81) than non-Hispanic white patients (referent group). This finding was also true for non-Hispanic black and “other” race/ethnicity patients with severe pain (ORs [95% CI]: 0.43 [0.22–0.87] and 0.02 [0.00–0.19], respectively). Non-Hispanic black and Hispanic patients were more likely to have a prolonged LOS than non-Hispanic white patients (ORs [95% CI]: 1.68 [1.13–2.51] and 1.64 [1.09–2.47], respectively). No significant race/ethnicity-based disparities were identified in documentation of pain score, use of diagnostic procedures, 72-hour return visits, or hospital admissions.CONCLUSIONS:Race/ethnicity-based disparities exist in ED analgesic use and LOS for pediatric abdominal pain. Recognizing these disparities may help investigators eliminate inequalities in care.