Parent and staff perceptions of racism in a single-center neonatal intensive care unit.

IMPACT: In alignment with previous literature, NICU parents reported experiencing racism and NICU staff reported witnessing racism in the NICU. Our study also uniquely describes personal experiences with racism by staff in the NICU. NICU staff reported witnessing and experiencing racism more often than parents reported. Black staff reported witnessing and experiencing more racism than white staff. Differences in reporting is likely influenced by variations in lived experience, social identities, psychological safety, and levels of awareness. Future studies are necessary to prevent and accurately measure racism in the NICU.

Associations between Social Adversity and Biomarkers of Inflammation, Stress, and Aging in Children.

BACKGROUND: Prior work has found relationships between childhood social adversity and biomarkers of stress, but knowledge gaps remain. To help address these gaps, we explored associations between social adversity and biomarkers of inflammation (interleukin-1ß [IL-1ß], IL-6, IL-8, tumor necrosis factor-alpha [TNF-α], and salivary cytokine hierarchical "clusters" based on the three interleukins), neuroendocrine function (cortisol, cortisone, dehydroepiandrosterone, testosterone, and progesterone), neuromodulation (N-arachidonoylethanolamine, stearoylethanolamine, oleoylethanolamide, and palmitoylethanolamide), and epigenetic aging (Pediatric-Buccal-Epigenetic clock). METHODS: We collected biomarker samples of children ages 0-17 recruited from an acute care pediatrics clinic and examined their associations with caregiver-endorsed education, income, social risk factors, and cumulative adversity. We calculated regression-adjusted means for each biomarker and compared associations with social factors using Wald tests. We used logistic regression to predict being in the highest cytokine cluster based on social predictors. RESULTS: Our final sample included 537 children but varied based on each biomarker. Cumulative social adversity was significantly associated with having higher levels of all inflammatory markers and with cortisol, displaying a U-shaped distribution. There were no significant relationships between cumulative social adversity and cortisone, neuromodulation biomarkers or epigenetic aging. CONCLUSION: Our findings support prior work suggesting that social stress exposures contribute to increased inflammation in children. IMPACT: Our study is one of the largest studies examining associations between childhood social adversity and biomarkers of inflammation, neuroendocrine function, neuromodulation, and epigenetic aging. It is one of the largest studies to link childhood social adversity to biomarkers of inflammation, and the first of which we are aware to link cumulative social adversity to cytokine clusters. It is also one of the largest studies to examine associations between steroids and epigenetic aging among children, and one of the only studies of which we are aware to examine associations between social adversity and endocannabinoids among children. CLINICAL TRIAL REGISTRATION: NCT02746393.

Structural Racism Operationalized via Adverse Social Events in a Single-Center Neonatal Intensive Care Unit.

OBJECTIVE: To evaluate structural racism in the neonatal intensive care unit (NICU) by determining if differences in adverse social events occur by racialized groups. STUDY DESIGN: Retrospective cohort study of 3290 infants hospitalized in a single center NICU between 2017 and 2019 in the Racial and Ethnic Justice in Outcomes in Neonatal Intensive Care (REJOICE) study. Demographics and adverse social events including infant urine toxicology screening, child protective services (CPS) referrals, behavioral contracts, and security emergency response calls were collected from electronic medical records. Logistic regression models were fit to test the association of race/ethnicity and adverse social events, adjusting for length of stay. Racial/ethnic groups were compared with a White referent group. RESULTS: There were 205 families (6.2%) that experienced an adverse social event. Black families were more likely to have experienced a CPS referral and a urine toxicology screen (OR, 3.6; 95% CI, 2.2-6.1 and OR, 2.2; 95% CI, 1.4-3.5). American Indian and Alaskan Native families were also more likely to experience CPS referrals and urine toxicology screens (OR, 15.8; 95% CI, 6.9-36.0 an OR, 7.6; 95% CI, 3.4-17.2). Black families were more likely to experience behavioral contracts and security emergency response calls. Latinx families had a similar risk of adverse events, and Asian families were less likely to experience adverse events. CONCLUSIONS: We found racial inequities in adverse social events in a single-center NICU. Investigation of generalizability is necessary to develop widespread strategies to address institutional and societal structural racism and to prevent adverse social events.

Structural racism is associated with adverse postnatal outcomes among Black preterm infants.

BACKGROUND: Structural racism contributes to racial disparities in adverse perinatal outcomes. We sought to determine if structural racism is associated with adverse outcomes among Black preterm infants postnatally. METHODS: Observational cohort study of 13,321 Black birthing people who delivered preterm (gestational age 22-36 weeks) in California in 2011-2017 using a statewide birth cohort database and the American Community Survey. Racial and income segregation was quantified by the Index of Concentration at the Extremes (ICE) scores. Multivariable generalized estimating equations regression models were fit to test the association between ICE scores and adverse postnatal outcomes: frequent acute care visits, readmissions, and pre- and post-discharge death, adjusting for infant and birthing person characteristics and social factors. RESULTS: Black birthing people who delivered preterm in the least privileged ICE tertiles were more likely to have infants who experienced frequent acute care visits (crude risk ratio [cRR] 1.3 95% CI 1.2-1.4), readmissions (cRR 1.1 95% CI 1.0-1.2), and post-discharge death (cRR 1.9 95% CI 1.2-3.1) in their first year compared to those in the privileged tertile. Results did not differ significantly after adjusting for infant or birthing person characteristics. CONCLUSION: Structural racism contributes to adverse outcomes for Black preterm infants after hospital discharge. IMPACT STATEMENT: Structural racism, measured by racial and income segregation, was associated with adverse postnatal outcomes among Black preterm infants including frequent acute care visits, rehospitalizations, and death after hospital discharge. This study extends our understanding of the impact of structural racism on the health of Black preterm infants beyond the perinatal period and provides reinforcement to the concept of structural racism contributing to racial disparities in poor postnatal outcomes for preterm infants. Identifying structural racism as a primary cause of racial disparities in the postnatal period is necessary to prioritize and implement appropriate structural interventions to improve outcomes.

Social Risk Factor Documentation in Emergency Departments.

STUDY OBJECTIVE: Social Z codes are International Classification of Diseases, Tenth Revision, Clinical Modification codes that provide one way of documenting social risk factors in electronic health records. Despite the utility and availability of these codes, no study has examined social Z code documentation prevalence in emergency department (ED) settings. METHODS: In this descriptive, cross-sectional study of all ED visits included in the 2018 Nationwide Emergency Department Sample, we estimated the prevalence of social Z code documentation and used logistic regression to examine the association between documentation and patient and hospital characteristics. RESULTS: Of more than 35.8 million adult and pediatric ED visits, there was a 1.21% weighted prevalence (n=452,499) of at least 1 documented social Z code. Social Z codes were significantly more likely to be documented in ED visits among patients aged 35 to 64 compared to patients aged 18 to 34 (18.6/1000 [16.9 to 20.4] versus 12.7/1000 [11.5 to 14.0], odds ratio (OR) 1.47 [1.42 to 1.53]), male patients (16.6/1000 [15.1 to 18.2] versus female 8.5/1000 [7.8 to 9.2], OR 1.97 [1.89 to 2.06]), patients with Medicaid compared to patients with private insurance (15.9/1000 [14.4 to 17.6] versus (6.6/1000 [6.0 to 7.2], OR 2.45 [1.30 to 1.63]), and patients who had a Charlson Comorbidity Index≥1 compared to those with a Charlson Comorbidity Index of 0 (ranges 15.0 to 16.6/1000 versus 10.6/1000 [9.6 to 11.7], ORs ranging 1.43 to 1.58). ED visits with a primary diagnosis of mental, behavioral, and neurodevelopmental illness had the strongest positive association with social Z code documentation (85.6/1000 [78.4 to 93.4], OR 10.75 [9.88 to 11.70]) compared to ED visits without this primary diagnosis. CONCLUSION: We found a very low prevalence of social Z code documentation in ED visits nationwide. More systematic social Z code documentation could support targeted social interventions, social risk payment adjustments, and future policy reforms.

Interpregnancy Interval and Birth Outcomes: A Propensity Matching Study in the California Population.

INTRODUCTION: Previous studies that used traditional multivariable and sibling matched analyses to investigate interpregnancy interval (IPI) and birth outcomes have reached mixed conclusions about a minimum recommended IPI, raising concerns about confounding. Our objective was to isolate the contribution of interpregnancy interval to the risk for adverse birth outcomes using propensity score matching. METHODS: For this retrospective cohort study, data were drawn from a California Department of Health Care Access and Information database with linked vital records and hospital discharge records (2007-2012). We compared short IPIs of < 6, 6-11, and 12-17 months to a referent IPI of 18-23 months using 1:1 exact propensity score matching on 13 maternal sociodemographic and clinical factors. We used logistic regression to calculate the odds of preterm birth, early-term birth, and small for gestational age (SGA). RESULTS: Of 144,733 women, 73.6% had IPIs < 18 months, 5.5% delivered preterm, 27.0% delivered early-term, and 6.0% had SGA infants. In the propensity matched sample (n = 83,788), odds of preterm birth were increased among women with IPI < 6 and 6-11 months (OR 1.89, 95% CI 1.71-2.0; OR 1.22, 95% CI 1.13-1.31, respectively) and not with IPI 12-17 months (OR 1.01, 95% CI 0.94-1.09); a similar pattern emerged for early-term birth. The odds of SGA were slightly elevated only for intervals < 6 months (OR 1.10, 95% CI 1.00-1.20, p < .05). DISCUSSION: This study demonstrates a dose response association between short IPI and adverse birth outcomes, with no increased risk beyond 12 months. Findings suggest that longer IPI recommendations may be overly proscriptive.

The National Academy of Medicine Social Care Framework and COVID-19 Care Innovations.

Despite social care interventions gaining traction in the US healthcare sector in recent years, the scaling of healthcare practices to address social adversity and coordinate care across sectors has been modest. Against this backdrop, the coronavirus pandemic arrived, which re-emphasized the interdependence of the health and social care sectors and motivated health systems to scale tools for identifying and addressing social needs. A framework on integrating social care into health care delivery developed by the National Academies of Science, Engineering, and Medicine provides a useful organizing tool to understand the social care integration innovations spurred by COVID-19, including novel approaches to social risk screening and social care interventions. As the effects of the pandemic are likely to exacerbate socioeconomic barriers to health, it is an appropriate time to apply lessons learned during the recent months to re-evaluate efforts to strengthen, scale, and sustain the health care sector's social care activities.

Patient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings.

BACKGROUND: Social isolation is a known predictor of mortality that disproportionately affects vulnerable populations in the USA. Although experts began to recognize it as a public health crisis prior to 2020, the novel coronavirus pandemic has accelerated recognition of social isolation as a serious threat to health and well-being. OBJECTIVE: Examine patient experiences with screening and assistance for social isolation in primary care settings, and whether patient experiences with these activities are associated with the severity of reported social isolation. DESIGN: Cross-sectional survey conducted in 2018. PARTICIPANTS: Adults (N = 251) were recruited from 3 primary care clinics in Boston, Chicago, and San Francisco. MAIN MEASURES: A modified version of the Berkman-Syme Social Network Index (SNI), endorsed by the National Academies of Sciences, Engineering, and Medicine; items to assess for prior experiences with screening and assistance for social isolation. KEY RESULTS: In the sample population, 12.4% reported the highest levels of social isolation (SNI = 0/1), compared to 36.7%, 34.7%, and 16.3% (SNI = 2-4, respectively). Most patients had not been asked about social isolation in a healthcare setting (87.3%), despite reporting no discomfort with social isolation screening (93.9%). Neither discomfort with nor participation in prior screening for social isolation was associated with social isolation levels. Desire for assistance with social isolation (3.2%) was associated with a higher level of social isolation (AOR = 6.0, 95% CI, 1.3-28.8), as well as poor or fair health status (AOR = 9.1; 95% CI, 1.3-64.1). CONCLUSIONS: In this study, few patients reported being screened previously for social isolation in a primary care setting, despite low levels of discomfort with screening. Providers should consider broadening social isolation screening and referral practices in healthcare settings, especially among sicker and more isolated patients who express higher levels of interest in assistance with social isolation.

Salivary cytokine cluster moderates the association between caregivers perceived stress and emotional functioning in youth.

Some individuals exposed to early life stress show evidence of enhanced systemic inflammation and are at greater risk for psychopathology. In the current study, caregivers and their offspring (0-17 years) were recruited at a pediatric clinic visit at the University of California, San Francisco (UCSF). Mothers and seven-year-old children from the Growing Up inSingaporeTowards healthy Outcomes (GUSTO) prospective birth cohort were used as a replication cohort. Caregivers perceived stress was measured to determine potential intergenerational effects on the children's functioning and inflammation levels. Children's emotional functioning in the UCSF cohort was evaluated using the Pediatric Quality of Life (PedsQL) inventory. Child emotional and behavioral functioning was measured using the Child Behavior Checklist (CBCL) in GUSTO. Saliva was collected from the children and salivary levels of IL-6, IL-1ß, IL-8 and TNF-α were measured using an electrochemiluminescent cytokine multiplex panel. Child IL-6, IL-1ß, IL-8 cytokine levels were clustered into low, average, and high cytokine cluster groups using hierarchical cluster analysis. We did not find that salivary cytokine clusters were significantly associated with children's emotional or behavioral function. However, cytokine clusters did significantly moderate the association between increased caregiver perceived stress and reduced child emotional functioning (UCSF cohort) and increased Attention-Deficit-Hyperactivity (ADH) problems (GUSTO cohort, uncorrected Cohen's F2 = 0.02). Using a cytokine clustering technique may be useful in identifying those children exposed to increased caregiver perceived stress that are at risk of emotional and attention deficit hyperactivity problems.

Newborn metabolic vulnerability profile identifies preterm infants at risk for mortality and morbidity.

BACKGROUND: Identifying preterm infants at risk for mortality or major morbidity traditionally relies on gestational age, birth weight, and other clinical characteristics that offer underwhelming utility. We sought to determine whether a newborn metabolic vulnerability profile at birth can be used to evaluate risk for neonatal mortality and major morbidity in preterm infants. METHODS: This was a population-based retrospective cohort study of preterm infants born between 2005 and 2011 in California. We created a newborn metabolic vulnerability profile wherein maternal/infant characteristics along with routine newborn screening metabolites were evaluated for their association with neonatal mortality or major morbidity. RESULTS: Nine thousand six hundred and thirty-nine (9.2%) preterm infants experienced mortality or at least one complication. Six characteristics and 19 metabolites were included in the final metabolic vulnerability model. The model demonstrated exceptional performance for the composite outcome of mortality or any major morbidity (AUC 0.923 (95% CI: 0.917-0.929). Performance was maintained across mortality and morbidity subgroups (AUCs 0.893-0.979). CONCLUSIONS: Metabolites measured as part of routine newborn screening can be used to create a metabolic vulnerability profile. These findings lay the foundation for targeted clinical monitoring and further investigation of biological pathways that may increase the risk of neonatal death or major complications in infants born preterm. IMPACT: We built a newborn metabolic vulnerability profile that could identify preterm infants at risk for major morbidity and mortality. Identifying high-risk infants by this method is novel to the field and outperforms models currently in use that rely primarily on infant characteristics. Utilizing the newborn metabolic vulnerability profile for precision clinical monitoring and targeted investigation of etiologic pathways could lead to reductions in the incidence and severity of major morbidities associated with preterm birth.

Cohort study of respiratory hospital admissions, air quality and sociodemographic factors in preterm infants born in California.

BACKGROUND: Preterm infants suffer from respiratory morbidity especially during the first year of life. OBJECTIVE: To investigate the association of air quality and sociodemographic indicators on hospital admission rates for respiratory causes. METHODS: This is a retrospective cohort study. We identified all live-born preterm infants in California from 2007 to 2012 in a population-based administrative data set and linked them to a data set measuring several air quality and sociodemographic indicators at the census tract level. All sociodemographic and air quality predictors were divided into quartiles (first quartile most favourable to the fourth quartile least favourable). Mixed effect logistic models to account for clustering at the census tract level were used to investigate associations between chronic air quality and sociodemographic indicators respiratory hospital admission during the first year of life. RESULTS: Of 205 178 preterm infants, 5.9% (n = 12 033) were admitted to the hospital for respiratory causes during the first year. In the univariate analysis, comparing the first to the fourth quartile of chronic ozone (risk ratio [RR] 1.29, 95% confidence interval [CI] 1.21, 1.37), diesel (RR 1.10, 95% CI 1.02, 1.17) and particulate matter 2.5 (RR 1.07, 95% CI 1.01, 1.14) exposure were associated with hospital admission during the first year. Following adjustment for confounders, the risk ratios for hospital admission during the first year were 1.53 (95% CI 1.37, 1.72) in relation to educational attainment (per cent of the population over age 25 with less than a high school education) and 1.23 (95% CI 1.09, 1.38) for poverty (per cent of the population living below two times the federal poverty level). CONCLUSIONS: Among preterm infants, respiratory hospital admissions in the first year in California are associated with socioeconomic characteristics of the neighbourhood an individual is living in.

Practice Capacity to Address Patients' Social Needs and Physician Satisfaction and Perceived Quality of Care.

Recent studies have explored clinician impacts of health care-based interventions that respond to patients' social and economic needs. These studies were limited by available clinician data. We used the Commonwealth International Health Policy Survey of 890 primary care physicians to examine associations between clinic capacity to respond to patients' social needs and physician satisfaction, stress, and perceived medical care quality. Results suggest that perceived capacity to address social needs is strongly associated with both clinician satisfaction and perceived medical care quality. Our findings add to a growing literature on the potential return on investment of clinical interventions to address social needs.

Depression Predicts Prolonged Length of Hospital Stay in Pediatric Inflammatory Bowel Disease.

OBJECTIVE: Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures. METHODS: Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders. RESULTS: For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53). CONCLUSIONS: Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.

Initial Metabolic Profiles Are Associated with 7-Day Survival among Infants Born at 22-25 Weeks of Gestation.

OBJECTIVE: To evaluate the association between early metabolic profiles combined with infant characteristics and survival past 7 days of age in infants born at 22-25 weeks of gestation. STUDY DESIGN: This nested case-control consisted of 465 singleton live births in California from 2005 to 2011 at 22-25 weeks of gestation. All infants had newborn metabolic screening data available. Data included linked birth certificate and mother and infant hospital discharge records. Mortality was derived from linked death certificates and death discharge information. Each death within 7 days was matched to 4 surviving controls by gestational age and birth weight z score category, leaving 93 cases and 372 controls. The association between explanatory variables and 7-day survival was modeled via stepwise logistic regression. Infant characteristics, 42 metabolites, and 12 metabolite ratios were considered for model inclusion. Model performance was assessed via area under the curve. RESULTS: The final model included 1 characteristic and 11 metabolites. The model demonstrated a strong association between metabolic patterns and infant survival (area under the curve [AUC] 0.885, 95% CI 0.851-0.920). Furthermore, a model with just the selected metabolites performed better (AUC 0.879, 95% CI 0.841-0.916) than a model with multiple clinical characteristics (AUC 0.685, 95% CI 0.627-0.742). CONCLUSIONS: Use of metabolomics significantly strengthens the association with 7-day survival in infants born extremely premature. Physicians may be able to use metabolic profiles at birth to refine mortality risks and inform postnatal counseling for infants born at <26 weeks of gestation.

Perspectives from the Society for Pediatric Research: interventions targeting social needs in pediatric clinical care.

The social determinants of health (SDoH) are defined by the World Health Organization as the "conditions in which people are born, grow, live, work, and age." Within pediatrics, studies have highlighted links between these underlying social, economic, and environmental conditions, and a range of health outcomes related to both acute and chronic disease. Additionally, within the adult literature, multiple studies have shown significant links between social problems experienced during childhood and "adult diseases" such as diabetes mellitus and hypertension. A variety of potential mechanisms for such links have been explored including differential access to care, exposure to carcinogens and pathogens, health-affecting behaviors, and physiologic responses to allostatic load (i.e., toxic stress). This robust literature supports the importance of the SDoH and the development and evaluation of social needs interventions. These interventions are also driven by evolving economic realities, most importantly, the shift from fee-for-service to value-based payment models. This article reviews existing evidence regarding pediatric-focused clinical interventions that address the SDoH, those that target basic needs such as food insecurity, housing insecurity, and diminished access to care. The paper summarizes common challenges encountered in the evaluation of such interventions. Finally, the paper concludes by introducing key opportunities for future inquiry.

Hospital Characteristics Associated With Social Needs Activities in the US.

This study assesses what hospital characteristics, including hospital participation in payment and delivery reform, are associated with activities related to health-related social needs.

Two Sides of the Same Coin: Pediatric-Onset and Adult-Onset Common Variable Immune Deficiency.

PURPOSE: Common variable immunodeficiency (CVID) is a complex, heterogeneous immunodeficiency characterized by hypogammaglobulinemia, recurrent infections, and poor antibody response to vaccination. While antibiotics and immunoglobulin prophylaxis have significantly reduced infectious complications, non-infectious complications of autoimmunity, inflammatory lung disease, enteropathy, and malignancy remain of great concern. Previous studies have suggested that CVID patients diagnosed in childhood are more severely affected by these complications than adults diagnosed later in life. We sought to discern whether the rates of various infectious and non-infectious conditions differed between pediatric-diagnosed (ages 17 or younger) versus adult-diagnosed CVID (ages 18 or older). METHODS: Using the United States Immunodeficiency Network (USIDNET) database, we performed a retrospective analysis of 457 children and adults with CVID, stratified by age at diagnosis. Chi-squared testing was used to compare pediatric versus adult groups. RESULTS: After correcting for multiple comparisons, we identified few statistically significant differences (p ≤ 0.0004) between pediatric and adult groups. Pediatric-onset CVID patients had more frequent diagnoses of otitis media, developmental delay, and failure to thrive compared with adult-onset CVID patients. Adult CVID patients were more frequently diagnosed with bronchitis, arthritis, depression, and fatigue. Diagnoses of autoimmunity, lymphoma, and other malignancies were higher in adults but not to a significant degree. Serum immunoglobulins (IgG, IgA, and IgM) and lymphocyte subsets did not differ significantly between the two groups. When complications of infections and co-morbid conditions were viewed categorically, there were few differences between pediatric-onset and adult-onset CVID patients. CONCLUSIONS: These results suggest that pediatric CVID is not a distinct phenotype. Major features were comparable across the groups. This study underscores the need for continued longitudinal study of pediatric and early-onset CVID patients to further characterize accrual of features over time.