The Prenatal Neighborhood Environment and Geographic Hotspots of Infants with At-risk Birthweights in New York City.

Infants born with low or high ("at-risk") birthweights are at greater risk of adverse health outcomes across the life course. Our objective was to examine whether geographic hotspots of low and high birthweight prevalence in New York City had different patterns of neighborhood risk factors. We performed census tract-level geospatial clustering analyses using (1) birthweight prevalence and maternal residential address from an all-payer claims database and (2) domains of neighborhood risk factors (socioeconomic and food environment) from national and local datasets. We then used logistic regression analysis to identify specific neighborhood risk factors associated with low and high birthweight hotspots. This study examined 2088 census tracts representing 419,025 infants. We found almost no overlap (1.5%) between low and high birthweight hotspots. The majority of low birthweight hotspots (87.2%) overlapped with a socioeconomic risk factor and 95.7% overlapped with a food environment risk factor. Half of high birthweight hotspots (50.0%) overlapped with a socioeconomic risk factor and 48.8% overlapped with a food environment risk factor. Low birthweight hotspots were associated with high prevalence of excessive housing cost, unemployment, and poor food environment. High birthweight hotspots were associated with high prevalence of uninsured persons and convenience stores. Programs and policies that aim to prevent disparities in infant birthweight should examine the broader context by which hotspots of at-risk birthweight overlap with neighborhood risk factors. Multi-level strategies that include the neighborhood context are needed to address prenatal pathways leading to low and high birthweight outcomes.

Social Capital as a Positive Social Determinant of Health: A Narrative Review.

Social determinants of health influence child health behavior, development, and outcomes. This paper frames social capital, or the benefits that a child receives from social relationships, as a positive social determinant of health that helps children exposed to adversity achieve healthy outcomes across the life course. Children are uniquely dependent on their relationships with surrounding adults for material and nonmaterial resources. We identify and define three relevant aspects of social capital: 1) social support, which is embedded in a 2) social network, which is a structure through which 3) social cohesion can be observed. Social support is direct assistance available through social relationships and can be received indirectly through a caregiver or directly by a child. A child's social network describes the people in a child's life and the relationships between them. Social cohesion represents the strength of a group to which a child belongs (eg, family, community). Pediatric primary care practices play an important role in fostering social relationships between families, the health care system, and the community. Further research is needed to develop definitional and measurement rigor for social capital, to evaluate interventions (eg, peer health educators) that may improve health outcomes through social capital, and to broaden our understanding of how social relationships influence health outcomes.

Association Between Outdoor Air Pollution Levels and Inpatient Outcomes in Pediatric Pneumonia Hospitalizations, 2007 to 2008.

OBJECTIVE: Pneumonia is a leading cause of pediatric admissions. Although air pollutants are associated with poor outcomes, few national studies have examined associations between pollutant levels and inpatient pediatric pneumonia outcomes. We examined the relationship between ozone (O3) and fine particulate matter with a diameter ≤2.5 µm (PM2.5) and outcomes related to disease severity. METHODS: In this cross-sectional study, we obtained discharge data from the 2007 to 2008 Nationwide Inpatient Sample and pollution data from the Air Quality System. Patients ≤18years with a principal diagnosis of pneumonia were included. Discharge data were linked to O3 and PM2.5 levels (predictors) from the patient's ZIP Code (not publicly available) from day of admission. Outcomes were mortality, intubation, length of stay (LOS), and total costs. We calculated weighted national estimates and performed multivariable analyses adjusting for sociodemographic and hospital factors. RESULTS: There were a total of 57,972 (278,871 weighted) subjects. Median PM2.5 level was 9.5 (interquartile range [IQR] 6.8-13.4) µg/m3. Median O3 level was 35.6 (IQR 28.2-45.2) parts per billion. Mortality was 0.1%; 0.75% of patients were intubated. Median LOS was 2 (IQR 2-4) days. Median costs were $3089 (IQR $2023-$5177). Greater levels of PM2.5 and O3 were associated with mortality, longer LOS, and greater costs. Greater O3 levels were associated with increased odds of intubation. CONCLUSIONS: Greater levels of O3 and PM2.5 were associated with more severe presentations of pneumonia. Future work should examine these relationships in more recent years and over a longer time period.

Characteristics Associated With Adding Cereal Into the Bottle Among Immigrant Mother-Infant Dyads of Low Socioeconomic Status and Hispanic Ethnicity.

OBJECTIVE: Determine maternal and infant characteristics associated with adding cereal into the bottle. DESIGN: Secondary data analysis. PARTICIPANTS: Study participants were immigrant, low-income, urban mother-infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success. MAIN OUTCOME MEASURES: Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament). ANALYSIS: Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant (P < .05) variables identified in unadjusted analyses. RESULTS: Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single (P = .02), had moderate to severe depressive symptoms (P = .01) and perceived their infant had a difficult temperament (P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal (P = .02). CONCLUSIONS AND IMPLICATIONS: Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

Redesigning Health Care Practices to Address Childhood Poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians.

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Determinants of Health and Pediatric Primary Care Practices.

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Disparities in Mortality and Morbidity in Pediatric Asthma Hospitalizations, 2007 to 2011.

OBJECTIVE: Asthma is a leading cause of pediatric admissions. Although several factors including race have been linked to increased overall asthma morbidity and mortality, few studies have explored factors associated with inpatient asthma outcomes. We examined factors associated with mortality and morbidity in children admitted for asthma. METHODS: Data were obtained from the US Nationwide Inpatient Sample for 2007 to 2011. Patients 2 to 18 years old with a primary diagnosis of asthma were included. Predictor variables were sociodemographic and hospital factors and acute/chronic secondary diagnoses. Outcomes were mortality, intubation, length of stay (LOS), and costs. Weighted national estimates were calculated. Multivariable analyses were performed. RESULTS: There were 97,379 (478,546 weighted) asthma admissions. Most patients were male (60.6%); 30% were white, 28% black, and 18% Hispanic. Mortality rate was 0.03%, and 0.3% were intubated. Median LOS was 2 (interquartile range, 1-3) days. Median costs were $2,950 (interquartile range, $1990-$4610). Native American race, older age (13-18 years), and West region were significant independent predictors of mortality. Intubation rate was lower in Hispanic compared with white children (P = .028). LOS was shorter in Asian compared with white children (P = .022) but longer in children with public insurance and from low income areas (P < .001). Average costs were higher in black, Hispanic, and Asian compared with white children (P < .05). CONCLUSIONS: With the exception of Native Americans, race/ethnicity is not associated with inpatient asthma mortality and has varied effects on morbidity. Recognition of factors associated with increased asthma mortality and morbidity might allow for earlier, more effective treatment and avoidance of complications.

Infant media exposure and toddler development.

OBJECTIVE: To determine whether duration and content of media exposure in 6-month-old infants are associated with development at age 14 months. DESIGN: Longitudinal analysis of 259 mother-infant dyads participating in a long-term study related to early child development, from November 23, 2005, through January 14, 2008. SETTING: An urban public hospital. PARTICIPANTS: Mothers with low socioeconomic status and their infants. MAIN EXPOSURE: Duration and content of media exposure at age 6 months. MAIN OUTCOME MEASURES: Cognitive and language development at age 14 months. RESULTS: Of 259 infants, 249 (96.1%) were exposed to media at age 6 months, with mean (SD) total exposure of 152.7 (124.5) min/d. In unadjusted and adjusted analyses, duration of media exposure at age 6 months was associated with lower cognitive development at age 14 months (unadjusted: r = -0.17, P < .01; adjusted: ß = -0.15, P = .02) and lower language development (r = -0.16, P < .01; ß = -0.16, P < .01). Of 3 types of content assessed, only 1 (older child/adult-oriented) was associated with lower cognitive and language development at age 14 months. No significant associations were seen with exposure to young child-oriented educational or noneducational content. CONCLUSIONS: This study is the first, to our knowledge, to have longitudinally assessed associations between media exposure in infancy and subsequent developmental outcomes in children from families with low socioeconomic status in the United States. Findings provide strong evidence in support of the American Academy of Pediatrics recommendations of no media exposure prior to age 2 years, although further research is needed.

Is exposure to media intended for preschool children associated with less parent-child shared reading aloud and teaching activities?

OBJECTIVE: To determine whether electronic media exposure is associated with decreased parental reading and teaching activities in the homes of preschool children. METHODS: A convenience sample presenting for well-child care to an urban hospital pediatric clinic was enrolled. Inclusion criteria were: child's age 3 to 5 years and not yet in kindergarten. Electronic media exposure (TV, movies/video, computer/video games) was assessed with a 24-hour recall diary and characterized on the basis of industry ratings. Reading aloud and teaching activities were assessed with the StimQ-Preschool READ and PIDA (Parental Involvement in Developmental Advance) subscales, respectively. RESULTS: A total of 77 families were assessed. Children were exposed to a mean (SD) of 200.8 (128.9) minutes per day of media, including 78.2 (63.7) minutes of educational young child-oriented, 62.0 (65.6) minutes of noneducational young child-oriented, 14.8 (41.4) minutes of school age/teen-oriented, and 29.2 (56.6) minutes of adult-oriented media, as well as to 16.6 (47.5) minutes of media of unknown type. A total of 79.2% watched 2 or more hours per day. Noneducational young child-oriented exposure was associated with fewer reading (semipartial correlation coefficient [SR] = -0.24, P = .02) and teaching (SR = -0.27, P = .01) activities; similar relationships were not found for other media categories. Children exposed to 2 or more hours of total electronic media per day had 1.6 (95% confidence interval, 0.4-2.9) fewer days per week of reading than children exposed to less than 2 hours (SR = -0.27, P = .01). CONCLUSIONS: This study found an association between increased exposure to noneducational young child-oriented media and decreased teaching and reading activities in the home. This association represents a mechanism by which media exposure could adversely affect development.

Attitudes about shared reading among at-risk mothers of newborn babies.

OBJECTIVE: Attitudes about shared reading among at-risk mothers of newborn babies have not been the focus of previous study. Better understanding of factors associated with these attitudes would facilitate pediatricians' provision of anticipatory guidance. We sought to assess sociodemographic correlates of attitudes regarding and resources available for shared reading among multiethnic, low socioeconomic status (SES) mothers of newborns. METHODS: This was a cross-sectional analysis of consecutive mother-infant dyads enrolled during the postpartum period onto an urban public hospital. Dependent variables were attitudes and resources related to shared reading with infants. Independent variables were family sociodemographics, reading difficulties, and social risks. RESULTS: A total of 211 mother-newborn dyads were assessed; 23.7% reported not planning to look at books together until 12 months or later, 42.2% reported no baby books in the home, and 19.9% reported concerns about shared reading. In multiple logistic regression analyses, independent significant associations with not planning to share books together in infancy were lower maternal education, not speaking English, and firstborn. Independent significant associations of not having baby books were not speaking English, firstborn, and perceived difficulty reading in their native language. CONCLUSIONS: Many at-risk mothers of newborn babies do not report plans to read in infancy and do not have appropriate books in the home. Consideration should be given to universal provision of early anticipatory guidance addressing shared reading, either during the postpartum period or during initial well-child care visits.