Addiction Management in Hospitalized Patients With Intravenous Drug Use-Associated Infective Endocarditis.

BACKGROUND: Infections related to intravenous drug use and opioid use disorders (OUDs) are increasing nationwide. Endocarditis is a recognized complication of intravenous drug use, and inpatient treatment typically focuses on infection management without attention to underlying addiction. OBJECTIVE: A comprehensive intervention for inpatients with infective endocarditis and intravenous drug use was implemented by a multidisciplinary team at a large midwestern hospital. The team included behavioral health/addiction medicine, infectious disease, pain medicine, cardiothoracic surgery, pharmacy, and nursing to address the OUD while managing the infection. The intervention was assessed by measuring the initiation of medication-assisted treatment and endocarditis-related readmissions. METHODS: Patients were identified from the medical records using discharge diagnosis codes for OUDs and infective endocarditis. In addition to medical management of infective endocarditis, the multidisciplinary intervention included early involvement of addiction medicine and the pain management at the time of admission. Patient interventions included education, motivational interviewing, behavioral health engagement, collaborative pain management, individual/family therapy, medication evaluation, and initiation of medication-assisted treatment. Caregivers were also educated on OUDs and ways to support patients undergoing interventions. RESULTS: Both the historical control group (N = 37) and the intervention group (N = 33) were comparable in age, gender, race, marital status, psychiatric history, and smoking but differed by employment status, religious affiliation, and use of psychiatric medications. At discharge, 18.9% of the control group and 54.5% in the intervention group were initiated on medication-assisted treatment for OUDs. No differences in readmission rates were found. CONCLUSION: Multidisciplinary teams for treating inpatients with intravenous drug use and infective endocarditis are feasible and can increase the uptake of OUD-specific treatment.

Defibrotide for Treatment of Severe Veno-Occlusive Disease in Pediatrics and Adults: An Exploratory Analysis Using Data from the Center for International Blood and Marrow Transplant Research.

Veno-occlusive disease (VOD) is an early and serious complication of hematopoietic cell transplantation (HCT) that is associated with inferior survival, particularly when it is complicated by multiorgan failure (severe VOD). We evaluated the efficacy of defibrotide in the treatment of severe VOD using observational data from the Center for International Blood and Marrow Transplant Research (CIBMTR). Eight thousand three hundred forty-one patients treated by HCT between 2008 and 2011 were identified from the CIBMTR clinical database; 3.2% met criteria for VOD and 1.2% met criteria for severe VOD. Patients with a diagnosis of VOD as reported to the CIBMTR by their transplanting centers, who had no prior history of cirrhosis, and who had a maximum total bilirubin level > 2.0 mg/dL by day +100 post-HCT were selected for study. Severe VOD was defined as VOD occurring in the setting of renal impairment requiring dialysis or any noninfectious pulmonary abnormality. Patients with severe VOD were divided into 2 groups for analysis: those treated with defibrotide (n = 41) and those not treated with defibrotide (n = 55). Patients in the nondefibrotide group were older, were more likely to be male, were more likely to have a history of previous fungal infection, and had a higher proportion of clinically significant pre-existing disease or organ impairment. Survival rate at day +100 was 39% (95% CI, 24.8% to 54.3%) in patients receiving defibrotide and 30.9% (95% CI, 19.5% to 43.6%) in those not receiving defibrotide. Resolution rate of VOD at day +100 was 51% in the defibrotide group and 29% in the nondefibrotide group (difference, 22.1%; 95% CI, 2.6% to 42%). The results of our study are consistent with previously reported experiences with defibrotide, confirm the poor outcome of this syndrome, and suggest defibrotide is effective in the treatment of severe VOD.

Reduced intensity haplo plus single cord transplant compared to double cord transplant: improved engraftment and graft-versus-host disease-free, relapse-free survival.

Umbilical cord blood stem cell transplants are commonly used in adults lacking HLA-identical donors. Delays in hematopoietic recovery contribute to mortality and morbidity. To hasten recovery, we used co-infusion of progenitor cells from a partially matched related donor and from an umbilical cord blood graft (haplo-cord transplant). Here we compared the outcomes of haplo-cord and double-cord transplants. A total of 97 adults underwent reduced intensity conditioning followed by haplo-cord transplant and 193 patients received reduced intensity conditioning followed by double umbilical cord blood transplantation. Patients in the haplo-cord group were more often from minority groups and had more advanced malignancy. Haplo-cord recipients received fludarabine-melphalan-anti-thymocyte globulin. Double umbilical cord blood recipients received fludarabine-cyclophosphamide and low-dose total body irradiation. In a multivariate analysis, haplo-cord had faster neutrophil (HR=1.42, P=0.007) and platelet (HR=2.54, P<0.0001) recovery, lower risk of grade II-IV acute graft-versus-host disease (HR=0.26, P<0.0001) and chronic graft-versus-host disease (HR=0.06, P<0.0001). Haplo-cord was associated with decreased risk of relapse (HR 0.48, P=0.001). Graft-versus-host disease-free, relapse-free survival was superior with haplo-cord (HR 0.63, P=0.002) but not overall survival (HR=0.97, P=0.85). Haplo-cord transplantation using fludarabine-melphalan-thymoglobulin conditioning hastens hematopoietic recovery with a lower risk of relapse relative to double umbilical cord blood transplantation using the commonly used fludarabine-cyclophosphamide-low-dose total body irradiation conditioning. Graft-versus-host disease-free and relapse-free survival is significantly improved. Haplo-cord is a readily available graft source that improves outcomes and access to transplant for those lacking HLA-matched donors. Trials registered at clinicaltrials.gov identifiers 00943800 and 01810588.

Why do parents bring children to the emergency department for nonurgent conditions? A qualitative study.

OBJECTIVE: Nonurgent conditions account for 58% to 82% of pediatric emergency department (ED) visits, but only 1 preliminary qualitative study has examined reasons why parents bring children to the ED for nonurgent care. The aim of this study was to identify parents' reasons for choosing the ED over their primary care provider (PCP) for nonurgent pediatric care. METHODS: Audiotaped ethnographic interviews in English and Spanish were conducted of parents of children presenting for nonurgent care on weekdays from 8 AM to 4 PM at a children's hospital ED over a 4-week period. RESULTS: For the 31 families interviewed, the mean parental age was 28 years, and mean child age, 3 years. Reasons cited by caregivers for choosing the ED over their child's PCP were long appointment waits, dissatisfaction with the PCP, communication problems (accents and unhelpful staff at PCP), health care provider referral, efficiency, ED resources, convenience, quality of care, and ED expertise with children. Some parents said they would like education on the urgency of pediatric problems. CONCLUSIONS: Parents bring their children to the ED for nonurgent care because of problems with their PCP, PCP referral, and perceived advantages to ED care. Although parents report that education on the urgency of pediatric conditions would be helpful, substantial reduction of pediatric nonurgent ED use may require improvements in families' PCP office access, efficiency, experiences, and appointment scheduling.

The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children.

BACKGROUND AND OBJECTIVE: Fifty-five million Americans speak a non-English primary language at home, but little is known about health disparities for children in non-English-primary-language households. Our study objective was to examine whether disparities in medical and dental health, access to care, and use of services exist for children in non-English-primary-language households. METHODS: The National Survey of Childhood Health was a telephone survey in 2003-2004 of a nationwide sample of parents of 102 353 children 0 to 17 years old. Disparities in medical and oral health and health care were examined for children in a non-English-primary-language household compared with children in English- primary-language households, both in bivariate analyses and in multivariable analyses that adjusted for 8 covariates (child's age, race/ethnicity, and medical or dental insurance coverage, caregiver's highest educational attainment and employment status, number of children and adults in the household, and poverty status). RESULTS: Children in non-English-primary-language households were significantly more likely than children in English-primary-language households to be poor (42% vs 13%) and Latino or Asian/Pacific Islander. Significantly higher proportions of children in non-English-primary-language households were not in excellent/very good health (43% vs 12%), were overweight/at risk for overweight (48% vs 39%), had teeth in fair/poor condition (27% vs 7%), and were uninsured (27% vs 6%), sporadically insured (20% vs 10%), and lacked dental insurance (39% vs 20%). Children in non-English-primary-language households more often had no usual source of medical care (38% vs 13%), made no medical (27% vs 12%) or preventive dental (14% vs 6%) visits in the previous year, and had problems obtaining specialty care (40% vs 23%). Latino and Asian children in non-English-primary-language households had several unique disparities compared with white children in non-English-primary-language households. Almost all disparities persisted in multivariable analyses. CONCLUSIONS: Compared with children in English-primary-language households, children in non-English-primary-language households experienced multiple disparities in medical and oral health, access to care, and use of services.

Access to hospital interpreter services for limited English proficient patients in New Jersey: a statewide evaluation.

CONTEXT/OBJECTIVES: We surveyed New Jersey (NJ) hospitals to assess current language services and identify policy recommendations on meeting limited English proficiency (LEP) patients' needs. METHODS: Survey with 37 questions regarding hospital/patient features, interpreter services, and resources/policies needed to provide quality interpreter services. RESULTS: Sixty-seven hospitals responded (55% response rate). Most NJ hospitals have no interpreter services department, 80% provide no staff training on working with interpreters, 31% lack multilingual signs, and 19% offer no written translation services. Only 3% of hospitals have full-time interpreters, a ratio of 1 interpreter:240,748 LEP NJ residents. Most hospitals stated third-party reimbursement for interpreters would be beneficial, by reducing costs, adding interpreters, meeting population growth, and improving communication. CONCLUSIONS: Most NJ hospitals have no full-time interpreters, interpreter services department, or staff training on working with interpreters, and deficiencies exist in hospital signage and translation services. Most NJ hospitals stated third-party reimbursement for interpreter services would be beneficial.

Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children.

BACKGROUND: Not enough is known about the national prevalence of racial/ethnic disparities in children's medical and dental care. OBJECTIVE: The purpose of this work was to examine racial/ethnic disparities in medical and oral health, access to care, and use of services in a national sample. METHODS: The National Survey of Children's Health was a telephone survey in 2003-2004 of a national random sample of parents and guardians of 102,353 children 0 to 17 years old. Disparities in selected medical and oral health and health care measures were examined for white, African American, Latino, Asian/Pacific Islander, Native American, and multiracial children. Multivariate analyses were performed to adjust for primary language at home, age, insurance coverage, income, parental education and employment, and number of children and adults in the household. Forty measures of medical and oral health status, access to care, and use of services were analyzed. RESULTS: Many significant disparities were noted; for example, uninsurance rates were 6% for whites, 21% for Latinos, 15% for Native Americans, 7% for African Americans, and 4% for Asians or Pacific Islanders, and the proportions with a usual source of care were as follows: whites, 90%; Native Americans, 61%; Latinos, 68%; African Americans, 77%; and Asians or Pacific Islanders, 87%. Many disparities persisted for > or = 1 minority group in multivariate analyses, including increased odds of suboptimal health status, overweight, asthma, activity limitations, behavioral and speech problems, emotional difficulties, uninsurance, suboptimal dental health, no usual source of care, unmet medical and dental needs, transportation barriers to care, problems getting specialty care, no medical or dental visit in the past year, emergency department visits, not receiving mental health care, and not receiving prescription medications. Certain disparities were particularly marked for specific racial/ethnic groups: for Latinos, suboptimal health status and teeth condition, uninsurance, and problems getting specialty care; for African Americans, asthma, behavior problems, skin allergies, speech problems, and unmet prescription needs; for Native Americans, hearing or vision problems, no usual source of care, emergency department visits, and unmet medical and dental needs; and for Asians or Pacific Islanders, problems getting specialty care and not seeing a doctor in the past year. Multiracial children also experienced many disparities. CONCLUSIONS; Minority children experience multiple disparities in medical and oral health, access to care, and use of services. Certain disparities are particularly marked for specific racial/ethnic groups, and multiracial children experience many disparities.

Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies.

BACKGROUND: Twenty-three million Americans have limited English proficiency. Language barriers can have major adverse consequences in health care, but little is known about whether pharmacies provide adequate care to patients with limited English proficiency. OBJECTIVES: We sought to evaluate pharmacies' ability to provide non-English-language prescription labels, information packets, and verbal communication, and assess pharmacies' satisfaction with communication with patients who have limited English proficiency. METHODS: We used a cross-sectional, mixed-methods survey of Milwaukee County, Wisconsin, pharmacies. Survey questions addressed sociodemographic and language-service characteristics of pharmacies. A pharmacist or technician at each pharmacy was asked 45 questions by telephone, fax, or mail. The main outcome measures were the ability of pharmacies to provide non-English-language prescription labels, information packets, and verbal communication; and pharmacy satisfaction with communication with patients who have limited English proficiency. RESULTS: Of 175 pharmacies, 73% responded. Forty-seven percent of the pharmacies never/only sometimes can print non-English-language prescription labels, 54% never/only sometimes can prepare non-English-language information packets, and 64% never/only sometimes can verbally communicate in non-English languages. Eleven percent use patients' family members/friends to interpret. Only 55% were satisfied with their communication with patients who have limited English proficiency. In multivariate analyses, community pharmacies had significantly lower odds of being able to verbally communicate in non-English languages, whereas pharmacies using telephone interpreting services had significantly higher odds. Pharmacies' suggestions for improving patient communication included continuing education, producing a chain-wide list of resources, hiring bilingual staff, using telephone interpreters, analyzing translation quality/accuracy of labels and information packets, and adding more languages to pharmacy software. CONCLUSIONS: Approximately half of Milwaukee pharmacies never/only sometimes can provide non-English-language prescription labels or information packets, and approximately two thirds never/only sometimes can verbally communicate in non-English languages. One in 9 pharmacies that verbally communicate in non-English languages use patients' family members/friends to interpret. Almost half of the pharmacies are dissatisfied with their communication with patients who have limited English proficiency. Community pharmacies are less likely and pharmacies using telephone interpreting services are more likely to be able to verbally communicate in non-English languages. Study findings indicate that improvements in pharmacies' communication with patients who have limited English proficiency may result by increasing the quality and number of non-English languages in existing computer programs, hiring bilingual staff, and using telephone interpreting services when in-person interpreters are unavailable.

Why are Latinos the most uninsured racial/ethnic group of US children? A community-based study of risk factors for and consequences of being an uninsured Latino child.

BACKGROUND: Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children. OBJECTIVE: [corrected] The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children. METHODS: A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance. RESULTS: Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. CONCLUSIONS: After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

How Medicaid and the State Children's Health Insurance Program can do a better job of insuring uninsured children: the perspectives of parents of uninsured Latino children.

BACKGROUND: Eight and a half million US children are uninsured, despite the 1997 enactment of the State Children's Health Insurance Program (SCHIP) with $39 billion in funding, and Latinos continue to be the most uninsured racial/ ethnic group, with 24% (3 million) uninsured. Why SCHIP and Medicaid have not been more successful insuring uninsured children is unclear. OBJECTIVE: To identify reasons why parents are unable to insure uninsured Latino children in a state where all low-income children are eligible for insurance. METHODS: Bilingual focus groups of parents of uninsured Latino children from Boston communities with the highest proportion of uninsured Latino children. RESULTS: The 30 parents interviewed in 6 focus groups had a mean age of 39 years; 63% never graduated high school and 33% were US citizens. The mean age of their children was 12 years, and the median annual family income was $9120. Parents reported 52 barriers to insuring children. Major obstacles included lack of knowledge about the application process and eligibility (especially misconceptions about work, welfare, and immigration), language barriers, immigration issues, income, hassles, pending decisions, family mobility, misinformation from insurance representatives (being told insurance is too expensive and parents must work), and system problems (including lost applications, discrimination, and excessive waits). Parents universally agreed case managers would be helpful in insuring uninsured children. CONCLUSIONS: Even in a state where all low-income children are eligible for health insurance, current SCHIP and Medicaid outreach and enrollment are not effectively reaching uninsured Latino children. Parents need better information about programs, eligibility, and the application process, and a more efficient, user-friendly system.

Keeping children with asthma out of hospitals: parents' and physicians' perspectives on how pediatric asthma hospitalizations can be prevented.

BACKGROUND: A total of 196,000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations. OBJECTIVES: To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma. METHODS: A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period. RESULTS: The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income: 13,356 dollars), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care-sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their child's admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age > or =11 years and no physician contact before the hospitalization were associated with approximately 2 times the odds of a preventable asthma hospitalization. CONCLUSIONS: The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.

Limited english proficiency, primary language at home, and disparities in children's health care: how language barriers are measured matters.

BACKGROUND: Approximately 3.5 million U.S. schoolchildren are limited in English proficiency (LEP). Disparities in children's health and health care are associated with both LEP and speaking a language other than English at home, but prior research has not examined which of these two measures of language barriers is most useful in examining health care disparities. OBJECTIVES: Our objectives were to compare primary language spoken at home vs. parental LEP and their associations with health status, access to care, and use of health services in children. METHODS: We surveyed parents at urban community sites in Boston, asking 74 questions on children's health status, access to health care, and use of health services. RESULTS: Some 98% of the 1,100 participating children and families were of non-white race/ethnicity, 72% of parents were LEP, and 13 different primary languages were spoken at home. "Dose-response" relationships were observed between parental English proficiency and several child and parental sociodemographic features, including children's insurance coverage, parental educational attainment, citizenship and employment, and family income. Similar "dose-response" relationships were noted between the primary language spoken at home and many but not all of the same sociodemographic features. In multivariate analyses, LEP parents were associated with triple the odds of a child having fair/poor health status, double the odds of the child spending at least one day in bed for illness in the past year, and significantly greater odds of children not being brought in for needed medical care for six of nine access barriers to care. None of these findings were observed in analyses of the primary language spoken at home. Individual parental LEP categories were associated with different risks of adverse health status and outcomes. CONCLUSIONS: Parental LEP is superior to the primary language spoken at home as a measure of the impact of language barriers on children's health and health care. Individual parental LEP categories are associated with different risks of adverse outcomes in children's health and health care. Consistent data collection on parental English proficiency and referral of LEP parents to English classes by pediatric providers have the potential to contribute toward reduction and elimination of health care disparities for children of LEP parents.

Racial and ethnic disparities in early childhood health and health care.

BACKGROUND: Racial/ethnic disparities in health care have received much national attention recently, but few studies have focused on disparities among children. We studied disparities in early childhood health and health care. METHODS: We analyzed data for 2608 children, 4 to 35 months of age, from the 2000 National Survey of Early Childhood Health, a nationwide household survey. The overall response rate was 65.6%. Survey questions addressed health, health care, and interactions with health care providers. RESULTS: Hispanic and black children were significantly less likely than whites to be in excellent/very good health (72%, 79%, and 90%, respectively) and were more likely to be uninsured (31%, 18%, and 9%, respectively). Only 60% of Hispanic and 77% of black parents would recommend their child's provider to others, compared with 84% of white parents. Minority parents more often reported that providers never or only sometimes understood their child-rearing preferences, and Hispanic parents most often reported that providers never or only sometimes understood their child's needs. Minority parents more often were asked about violence, smoking, drinking, and drug use. Hispanic and black parents averaged significantly fewer telephone calls to doctors' offices than did whites (2.0, 3.1, and 4.3 calls, respectively). Providers significantly less often referred Hispanic and black children to specialists (11% and 17%, respectively, compared with 22% for whites). Most disparities persisted in multivariate analyses, and several disparities were found between children with parents who completed surveys in Spanish and those with parents who completed surveys in English. CONCLUSION: Young minority children experience multiple disparities in health status, insurance coverage, topics discussed during pediatric visits, parents feeling understood by providers, parental satisfaction, and referrals to specialists.

Does disadvantage start at home? Racial and ethnic disparities in health-related early childhood home routines and safety practices.

BACKGROUND: Little is known about whether racial/ethnic differences exist in household family activities, safety practices, and educational opportunities known to impact young children's healthy development and school success. OBJECTIVE: To examine whether racial/ethnic disparities exist in early childhood home routines, safety measures, and educational practices/resources. METHODS: The 2000 National Survey of Early Childhood Health is a telephone survey of a nationwide sample of parents of 2608 children aged 4 to 35 months. Differences in family activities, safety measures, and educational practices/resources were examined for white, black, and Hispanic children. RESULTS: Minority children are less likely than white children to have consistent daily mealtimes and bedtimes, and more frequently never eat lunch or dinner with their family. Minority parents are less likely to install stair gates or cabinet safety locks and to turn down hot water settings. Minority parents less often read daily to their child, Hispanic parents more often never read to their child, and minority households average fewer children's books. Black children average more hours watching television daily. Disparities persisting in multivariate analyses included: minority children having increased odds of never eating lunch or dinner with their family, black children not having regular mealtimes (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) and watching 1 more hour of television daily, black parents not installing cabinet locks, minority parents having twice the odds of not installing stair gates and not reading to their child daily, and minority homes having fewer children's books (black homes, -30; and Hispanic homes, -20). Children whose parents completed surveys in Spanish also experienced several disparities. CONCLUSIONS: Young minority children experience multiple disparities in home routines, safety measures, and educational practices/resources that have the potential to impede their healthy development and future school success. Such disparities might be reduced or eliminated through targeted education and intervention by pediatric providers.