Disparities In Outcomes For Children Research Articles

Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience

PurposeIntestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop–Koop (BK) approach to JIA in improving outcomes.MethodsA retrospective cohort study was performed on children with complex JIA (Type 2–4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05.ResultsA total of 122 neonates presented with JIA in 1/2018–12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018–2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41–0.98) with the increased use of BK.ConclusionIncreased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.

Pediatric Cataract: Disparately Blinding Globally and in the United States

ABSTRACT Childhood cataract is a complex condition requiring longitudinal care, including early diagnosis, timely referral to a specialist, early surgical intervention, and dedicated postoperative care. Adherence to refractive correction and amblyopia therapy are critical for visual rehabilitation, even months to years after the cataract is removed. We review the impact of the social determinants of health on each step in the visual rehabilitation pathway for children with congenital and infantile cataracts. Children from socioeconomically marginalized backgrounds are more likely to experience delays in access to care and utilization of surgical services. They are also less likely to adhere to amblyopia therapy, with corresponding decrements in visual outcomes. Additional sociocultural factors, including parental stress, self-efficacy, and health literacy, pose barriers for these children. Standardizing clinical roles, improving health communication, managing parental stress, and implementing systemic policy changes may alleviate socioeconomic disparities in outcomes for children with cataracts.

Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease

BackgroundRacial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity. ObjectivesWe sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes. MethodsPediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery were linked to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards. ResultsOf 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04). ConclusionsChildren in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.

Measuring disparities in event-free survival among children with acute lymphoblastic leukemia in an academic institute in Oklahoma, 2005–2019

BackgroundAcute lymphoblastic leukemia (ALL) is the most common type of childhood cancer. While there have been successes in the treatment of leukemia, less information is available on reasons for disparities in event-free survival (EFS) among underserved populations. MethodsWe partnered with a children’s hospital at an academic institution to abstract data from the institution’s cancer registry, the state cancer registry, and electronic medical records on cancer diagnosis, treatment, and outcomes for children with ALL (n = 275) diagnosed from 2005 to 2019 prior to age 20. We evaluated the relation between 1) race/ethnicity, 2) distance to the children’s hospital, and 3) area deprivation with EFS, defined as time from diagnosis to relapse, death, or the end of the study period. We evaluated differences in EFS using Kaplan-Meier analysis with the log-rank test. We used the Cox Proportional Hazards Model for multivariable survival analyses. ResultsMost children were diagnosed with ALL under five years of age (45%) and with Pre-B ALL (87%). Twelve percent of children experienced a relapse and 5% died during induction or remission. EFS at 5 years was 82%. Non-Hispanic (NH) Black children had worse, though imprecise, EFS compared to NH White children (Adjusted Hazard Ratio: 2.07, 95% CI: 0.80, 5.38). Children residing in areas with higher deprivation had a higher adjusted hazard of poor outcomes compared to the least deprived areas, though estimates were imprecise (2nd quartile HR: 1.51, 3rd quartile: 1.85, 4th quartile: 1.62). We observed no association between distance to the children’s hospital and EFS. ConclusionWe observed poorer EFS for NH Black children and children residing in areas with high deprivation, though the estimates were not statistically significant. Our next steps include further evaluating socioeconomic factors in both rural and urban children to identify disparities in outcomes for children with ALL and other childhood cancers.

1012-P: Neighborhood Disadvantage, Childhood Opportunity Index, and Glycemic Control for Children with Type 1 Diabetes?

Background: Disparities in outcomes for children with type 1 diabetes (T1DM) are associated with poverty and race. However, little is known regarding the impact of systemic racism. Objective: This aim of this study is to determine if neighborhood concentrated disadvantage index (NCDI) or Childhood Opportunity Index (COI) are associated with HbA1c and diabetes ketoacidosis (DKA) in children ≤ 18 years of age with type 1 diabetes. Methods: The retrospective secondary data analysis included data from children ≤ 18 years of age with a diagnosis of T1DM for ≥ 6 months seen in 2017 who reside in Kentucky (n=675) . NCDI scores were calculated based on the NIH PhenX Toolkit protocol. The tool was developed from a principal components analysis of six variables at the census tract level. COI was obtained from diversitydatakids.org. Univariate analyses were performed using Kruskal-Wallis test or Pearson’s correlation. Multiple linear regression analysis was conducted to to evaluate HbA1C and multivariate Poisson model was used for DKA. Results: Prior to controlling for age, race, and insurance type, NCDI (p&amp;lt;0.001) and COI (p&amp;lt; 0.001) were significant predictors for HbA1c. For every 1 unit increase in COI, the predicted value of AIc level decreased by 8.66 (p=0.0004) . NCDI and COI were not significant when controlling for age, race, and insurance. NCDI and COI were not significant predictors of DKA episodes. Conclusions: This study identified NCDI and COI as predictors of HbA1c in children and adolescents with T1DM only in univariate analysis. While NCDI and COI have been shown to correlate with structural racism, these findings suggest that more research is needed in larger and more diverse samples to disentangle the complex relationships among race, racism, and poverty. Understanding the mechanisms through which racism impacts outcomes for children with T1DM is essential to improving health equity. Disclosure M.B.Coriell: None. K.S.Jawad: None. Y.B.Feygin: None. S.Watson: None. M.D.Stevenson: None. B.A.Wattles: Research Support; Merck &amp; Co., Inc. V.F.Jones: None. J.Porter: None. D.W.Davis: None.

Family’s social economic status and child educational outcomes in China: The mediating effects of parenting practices and children’s learning attitudes

Abstract This study utilizes the 2012–2016 CFPS dataset and employs the structural equation modelling techniques to illustrate the mediating effects of parental practices and children’s learning attitudes between family social economic status (SES) and the child educational outcomes. Firstly, the results show that relative to family income and parental occupational levels, the key variable significantly links with children’s education as measured by children’s Chinese and math scores is parental educational levels. Parental education also bridges the gap in possible disparities in child outcomes arising from differences in region and Hukou. Secondly, the findings demonstrate the significant association between two mediators and child educational outcomes. It shows the importance of improving parenting practices and children’s learning attitudes for child development. Relevant policies or programs can be established to narrow the educational disparities among children between the lower and higher SES families. The findings are positive in that educational disparities can be narrowed and the vicious cycle of cultural reproduction can be broken.

Increasing health facility deliveries in Cambodia and its influence on child health

BackgroundA growing number of women in Cambodia are seeking support from health facilities during delivery, up from 8% in 2000 to 82% in 2014. This growth may be attributed to increased national level attention to incentivize hospital births and reduce potential barriers. This paper address three related questions regarding the impact of increased utilization of health care in Cambodia. First, did increasing health facility deliveries occur most among disadvantaged women? Second, as health facility utilization increased, did the benefit of delivery location on child health outcomes weaken? Finally, did socioeconomic disparities in child outcomes decline as a result of increased health facility deliveries?MethodsData is from the 2010 and 2014 Cambodian Demographic and health surveys. Regression models include logistic regression to predict utilization of a health facility, linear regression to predict child nutritional status and Cox regression to measure child survival. Propensity score matching was used to account for selectivity.ResultsAnalysis shows that health facility delivery is associated with better nutritional status and survival and the effectiveness of a health center delivery remains with this rapidly increasing care. However, the largest increases in delivery at a health facility did not occur among less educated, less wealthy, and rural Cambodian women, and inequalities in child health outcomes remain.ConclusionsCambodian women have participated in a rapid increase in health center deliveries and those health facility deliveries remain beneficial for future child outcomes. However, initiatives to increase care are not addressing inequity in access to care among disadvantaged women. Additionally, disparities in children’s health outcomes remain, suggesting that health facility births are not sufficient in reducing disparities among children of disadvantaged mothers. Moving forward, current initiatives are rapidly increasing facility deliveries and maintaining their efficacy, but further efforts need to be placed on targeting disadvantaged women and their children.

Correction to: Do Insurance Mandates Affect Racial Disparities in Outcomes for Children with Autism?

The original version of this article unfortunately contained a mistake in the analysis of the Tables4 and 5.

Do Insurance Mandates Affect Racial Disparities in Outcomes for Children with Autism?

Objective The study investigated whether state mandates for private insurers to provide services for children with autism influence racial disparities in outcomes. Methods The study used 2005/2006 and 2009/2010 waves of the National Survey of Children with Special Health Care Needs. Children with a current diagnosis of autism were included in the sample. Children residing in 14 states and the District of Columbia that were not covered by the mandate in the 2005/2006 survey, but were covered in the 2009/2010 survey, served as the mandate group. Children residing in 32 states that were not covered by a mandate in either wave served as the comparison group. Outcome measures assessed included care quality, family economics, and child health. A difference-in-difference-in-differences (DDD) approach was used to assess the impact of the mandates on racial disparities in outcomes. Results Non-white children had less access to family-centered care compared to white children in both waves of data, but this difference was not apparent across mandate and comparison states as only the comparison states had significant differences. Parents of non-white children reported paying less in annual out-of-pocket expenses compared to parents of white children across waves and groups. DDD estimates did not provide evidence that the mandates had statistically significant effects on improving or worsening racial disparities for any outcome measure. Conclusions This study did not find evidence that state mandates on private insurers affected racial disparities in outcomes for children with autism.

The Influence of Family Reunification Services on Racial/Ethnic Disparities in Permanency Outcomes for Children in the Child Welfare System

This study examined racial/ethnic differences in mothers' use of court-mandated family reunification services, including parent training, substance abuse treatment, and mental health treatment; and the influence of these services on racial/ethnic disparities on two permanency outcomes: family reunification and length of time in the child welfare system. Methods included a retrospective design using in-depth case record review and administrative data (N = 403). Results indicated racial/ethnic differences in service use and permanency outcomes. Across racial/ethnic groups, substance abuse treatment was associated with a shorter length of time in the child welfare system. Implications for child welfare services among racially/ethnically diverse families are discussed.

Emerging Technologies and Their Impact on Disability

Technological innovation is transforming the prevalence and functional impact of child disability, the scale of social disparities in child disability, and perhaps the essential meaning of disability in an increasingly technology-dominated world. In this article, Paul Wise investigates several specific facets of this transformation. He begins by showing how technological change influences the definition of disability, noting that all technology attempts to address some deficiency in human capacity or in the human condition. Wise then looks at the impact of technology on childhood disabilities. Technical improvements in the physical environment, such as better housing, safer roads, and poison-prevention packaging, have significantly reduced childhood injury and disability. Other technological breakthroughs, such as those that identify genetic disorders that may lead to pregnancy termination, raise difficult moral and ethical issues. Technologies that identify potential health risks are also problematic in the absence of any efficient treatment. Wise stresses the imbalance in the existing health care delivery system, which is geared toward treating childhood physical illnesses that are declining in prevalence at a time when mental and emotional conditions, many of which are not yet well understood, are on the rise. This mismatch, Wise says, poses complex challenges to caring for disabled children, particularly in providing them with highly coordinated and integrated systems of care. Technology can also widen social disparities in health care for people, including children with disabilities. As Wise observes, efficacy--the ability of a technology to change health outcomes--is key to understanding the relationship of technology to social disparities. As technological innovation enhances efficacy, access to that technology becomes more important. Health outcomes may improve for those who can afford the technology, for example, but not for others. Hence, as efficacy grows, so too does the burden on society to provide access to technology equitably to all those in need. Without such access, technological innovation will likely expand disparities in child outcomes rather than reduce them.

Parent’s Time with Children: Does Time Matter for Children’s Cognitive Achievement?

The time parents spend with children is the central construct in theories of child devel opment and human capital formation. According to human capital theory, the amount of time parents spend with children can be seen as crucial inputs in the production of child wellbeing (Becker 1981). Parent-child interactions create social capital, or the social interactions that facilitate the intergenerational transmission of knowledge and skills (Coleman 1988). Conversely, theories in developmental psychology contend that long periods of daily separation, particularly during early childhood, can be disruptive, leaving parents less sensitive and responsive to their children's needs, thus leaving children less exposed to the stimulation necessary for their cognitive development (Vaughn et al. 1980; Belsky 2001). More importantly, the literature points to key disparities in the quantity and type of parent child interactions?the verbal interactions and the type of activities performed together, for example?that suggests that children are socialized in ways that reinforce existing inequalities (Lareau 2003; Hoff 2003). These studies suggest that there may be important differences in how time is used and that these differences may contribute to socioeconomic disparities in child outcomes. In spite of these studies, research that has sought to establish an empirical link between time with children and child outcomes is relatively limited. This article provides a brief review of the literature on parental time and child cognitive outcomes, relates recent, new findings by the author to this literature, and discusses how these findings may help guide future research.

Modernity’s paradox and the structural determinants of child health and well-being

The decline in indicators of human development linked to rising social inequalities, despite post-modern society’s unprecedented economic prosperity, has been called ‘modernity’s paradox’ (Keating and Hertzman 1999). Scholars of developmental health suggest that micro-level influences from the social, economic and psychological circumstances in early life may explain social inequalities across the lifespan. However, children’s poor developmental and health outcomes are also a product of the wider contexts of their lives. This paper extends the human developmental framework by linking the proximal determinants of health and well-being with macro-level forces. It reviews recent changes in the political, economic and social environments in developed countries, to provide insights into the recent trends in poor outcomes in children and youth, which remain paradoxical given the expectations of economic prosperity and the advances in medical and other technologies. The paper concludes with policy and research recommendations to reduce social disparities in child outcomes.