Health Care for Unaccompanied Immigrant Children in US Communities: A Guide for Pediatric Practitioners.

Children who arrived at the United States border without a parent or legal guardian (ie, unaccompanied children) are present in communities throughout the country in growing numbers. For them to receive the highest-quality medical and mental services available, pediatric practitioners should have a foundational understanding of their unique set of circumstances and experiences. However, formal education on how to care for this specific immigrant subpopulation is not routinely incorporated into pediatric training programs, and limited clinical guidance is available in the published literature. This article provides best-practice recommendations for pediatric practitioners caring for unaccompanied children after their release from government custody, incorporating guidance for clinical encounters as well as suggestions of processes to meet their health-related social needs and advocacy actions to improve their well-being. [Pediatr Ann. 2024;53(5):e178-e182.].

Immigrant Mothers' Perspectives on Pediatric Primary Care: Challenges and Solutions to Improve Medical Home Use.

Children in immigrant families (CIF) constitute 25% of all children in the United States. Known barriers to accessing and navigating the health care system for immigrants (i.e., poverty, fear, limited English proficiency, lack of insurance) lead to decreased medical home establishment among CIF, although the ways in which these obstacles affect medical home access are less studied. With a focus on Congolese, Afghan, Syrian/Iraqi, and Central American immigrants, key informant interviews and focus groups were conducted to identify mothers' perceptions of and experiences with pediatric primary health care. Five common themes emerged: mothers' critical role in children's health, uniqueness of the U.S. health care system, logistical challenges, influence of prior clinical experiences, and importance of culturally appropriate communication. Few, but distinct, differences among the groups revealed specific obstacles for individual populations. Improving rates of medical home use among CIF requires targeted, immigrant-informed approaches that involve population outreach as well as systems-level changes.

Qualitative Study of Barriers and Facilitators to Care Among Children in Immigrant Families.

OBJECTIVES: Children in immigrant families comprise ∼25% of US children and live in families with high levels of poverty and food insecurity. Studies suggest a decline in public benefit enrollment among children in immigrant families. We aimed to explore perspectives on barriers and facilitators in accessing care among immigrant caregivers of hospitalized children. METHODS: With a general qualitative descriptive design, we developed a semistructured interview guide using an iterative process informed by literature and content expertise. Using purposive sampling, we recruited immigrant caregivers of hospitalized children in March 2020 and conducted interviews in English or Spanish. Interviews were recorded, transcribed, and translated to English. Three authors coded transcripts using Dedoose and identified themes via thematic analysis. RESULTS: Analysis of 12 caregiver interviews revealed barriers and facilitators in accessing healthcare and public benefit use. Barriers included healthcare system barriers, immigration-related fear, and racism and discrimination. Within healthcare system barriers, subthemes included language barriers, cost, complexity of resource application, and lack of guidance on available benefits. Within immigration-related fear, subthemes included fear of familial separation, fear of deportation, fear that benefit use affects immigration status, and provider distrust. Healthcare system facilitators of resource use included recruiting diverse workforces, utilizing language interpretation, guidance on benefit enrollment, legal services, and mental health services. Participants also recommended hospital partnership with trusted information sources, including media stations and low-cost clinics. CONCLUSIONS: Immigrant caregivers of hospitalized children identified barriers and facilitators in access to care. Further research is needed to assess the efficacy of caregiver-suggested interventions.

State-Specific Medicaid/CHIP Eligibility Criteria and Their Impact on Health Care Access for Foreign-born Children Living in the United States.

INTRODUCTION: Foreign-born children are subject to discrepant state policies in determining eligibility for Medicaid/Children's Health Insurance Program (CHIP) coverage. The objective of this study was to determine the effect of these policies on health care access. METHODS: Data from the National Survey of Children's Health (NSCH) were used to assess associations between health care access outcomes and three categories of state health insurance eligibility: restrictive (only U.S. citizens plus immigrants who "qualified" after five-year waiting period), semi-restrictive (same as restrictive except no waiting period), and inclusive (all children). RESULTS: When compared with restrictive states, foreign-born children in inclusive states were significantly more likely to have current insurance, consistent coverage, recent preventive exams, and fewer problems paying medical bills. DISCUSSION: Extending health care eligibility to all children, regardless of immigration status, improves health care coverage and access for foreign-born children. Expansion of eligibility criteria in all states is necessary to reduce health disparities in the immigrant population.

Driving to Reduce Socioeconomic Barriers to Latent Tuberculosis Infection Care: A Mobile Pediatric Treatment Program.

CONTEXT: Tuberculosis (TB) disease causes significant morbidity, mortality, and public health impacts. Prevention of latent tuberculosis infection (LTBI) in children reduces the burden of disease. PROGRAM: The Texas Children's Mobile Clinic Program's (TC-MCP's) mission is to provide high-quality health care to underresourced children within the community setting. The TC-MCP serves a large foreign-born pediatric population. The need for an LTBI treatment program arose when caring for this high-risk population. IMPLEMENTATION: The TC-MCP providers collaborated with nationally recognized pediatric TB experts as well as local health departments that provide medications free of cost. The TC-MCP placed tuberculin skin tests (TSTs) on patients with risk factors for TB. TST-positive patients had an interferon-γ release assay (IGRA) performed. IGRA-positive patients had a chest radiograph (CXR) obtained. Children with positive IGRA and normal CXR were included in the LTBI program, which consisted of TC-MCP outpatient visits and 12 once-weekly doses of isoniazid/rifapentine (3HP) provided by local health departments. RESULTS: From January 2018 to March 2020, 785 TC-MCP patients received TSTs, of which 38 (4.8%) were positive. An additional 7 positive TSTs were identified from outside facilities. In addition to the 45 positive TSTs, 4 TC-MCP patients with follow-up difficulties had IGRAs done as the initial test. Of these 49 IGRAs done, 13 patients had a positive IGRA. An additional 6 patients with positive IGRAs from outside facilities were identified. Nineteen patients (36.5%) were diagnosed with LTBI; of whom, 18 completed 3HP therapy through the TC-MCP. Eighty-three percent (15/18) completed at least 2 in-person visits. DISCUSSION: Underresourced children at higher risk for TB benefit from a mobile clinic's unique reach. By utilizing community partnerships, mobile clinics can successfully fill gaps in the health care system where marginalized populations may be missed.

Pediatric Hospitalizations from Immigration Detention in Texas, 2015-2018.

Although there are concerns regarding children's health in immigration detention, there are little data regarding hospitalizations in this population. Using 2015-2018 Texas inpatient data, we identified 95 hospitalizations of children in detention and found that most (60%) were driven by infectious causes, and that 37% of these children were admitted to an intensive care unit (ICU) or intermediate ICU.

Adult hospitalizations from immigration detention in Louisiana and Texas, 2015-2018.

Poor health conditions within immigration detention facilities have attracted significant concerns from policymakers and activists alike. There is no systematic data on the causes of hospitalizations from immigration detention facilities or their relative morbidity. The objective of this study, therefore, was to analyze the causes of hospitalizations from immigration detention facilities, as well as the percentage of hospitalizations necessitating ICU or intermediate-ICU (i.e, "step-down") admission and the types of surgical and interventional procedures conducted during these hospitalizations. We conducted a cross-sectional study of statewide adult (age 18 and greater) hospitalization data, with hospitalizations attributed to immigration facilities via payor designations (from Immigration and Customs Enforcement) and geospatial data in Texas and Louisiana from 2015-2018. Our analysis identified 5,215 hospitalizations of which 887 met inclusion criteria for analysis. Average age was 36 (standard deviation, 13.7), and 23.6% were female. The most common causes of hospitalization were related to infectious diseases (207, 23.3%) and psychiatric illness (147, 16.6%). 340 (38.3%) hospitalizations required a surgical or interventional procedure. Seventy-two (8.1%) hospitalizations required ICU admission and 175 (19.5%) required intermediate ICU. In this relatively young cohort, hospitalizations from immigration detention were accompanied with significant morbidity. Policymakers should mitigate the medical risks of immigration detention by improving access to medical and psychiatric care in facilities.

Public Benefit Use and Social Needs in Hospitalized Children With Undocumented Parents.

BACKGROUND AND OBJECTIVES: Studies supporta recent decline in public benefit enrollment among immigrant families. We aimed to describe health and resource use, barriers to use, and immigration-related fear in families with undocumented parents compared with families without undocumented parents. We also aimed to assess associations with discontinuation of public benefits and fear of deportation. METHODS: We assessed immigration concerns and enrollment in Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with an 89-item anonymous, cross-sectional survey of English- and Spanish-speaking caregivers of hospitalized children. Multivariable logistic regression was used to assess associations with discontinuation of public benefits and fear of deportation. RESULTS: Of 527 families approached, 399 enrolled (105 with 1 or more undocumented parent, 275 with no undocumented parent, and 19 with undisclosed immigration status). Compared with families without undocumented parents, families with undocumented parents had higher levels of poverty and food insecurity. Controlling for perceived eligibility, public benefit use was similar across groups. Of families with undocumented parents, 29% reported public benefit discontinuation because of immigration concerns, and 71% reported fear of deportation. Having an undocumented parent was associated with public benefit disenrollment (odds ratio: 46.7; 95% confidence interval: 5.9-370.4) and fear of deportation (odds ratio: 24.3; 95% confidence interval: 9.6-61.9). CONCLUSIONS: Although families with undocumented parents had higher levels of poverty and food insecurity compared with families without undocumented parents, public benefit use was similar between groups. Immigration-related fear may be a barrier to public benefit use in this population.

Hyaluronidase-Assisted Resuscitation in Kenya for Severely Dehydrated Children.

BACKGROUND: Dehydration, mainly due to diarrheal illnesses, is a leading cause of childhood mortality worldwide. Intravenous (IV) therapy is the standard of care for patients who were unable to tolerate oral rehydration; however, placing IVs in fragile, dehydrated veins can be challenging. Studies in resource-rich settings comparing hyaluronidase-assisted subcutaneous rehydration with standard IV rehydration in children have demonstrated several benefits of subcutaneous rehydration, including time and success of line placement, ease of use, satisfaction, and cost-effectiveness. METHODS: A single-arm trial assessing the feasibility of hyaluronidase-assisted subcutaneous resuscitation for the treatment of moderately to severely dehydrated individuals in western Kenya was conducted. Children aged 2 months or older who presented with moderately to severely dehydration clinically warranting parenteral rehydration and had at least 2 failed IV attempts were eligible. Study staff received training on standard dehydration management and hyaluronidase infusion processes. Children received all other standards of care. They were monitored from presentation and through discharge, with a 1-week phone follow-up. Predischarge surveys were completed by caregivers, and semistructured interviews with providers were performed. RESULTS: A total of 51 children were enrolled (median age, 13.0 months; interquartile range of 18 months). Fifty-one patients (100%) had severe dehydration. The median length of subcutaneous infusion was 3.0 hours (interquartile range [IQR], 2.95). The median total subcutaneous infusion was 700.0 mL (IQR, 420 mL). Median time to resolution of moderate to severe dehydration symptoms was 3.0 hours (IQR, 2.95 hours). There were no significant complications. CONCLUSIONS: Hyaluronidase-assisted subcutaneous resuscitation is a feasible alternative to IV hydration in moderately to severely dehydrated children with difficult to obtain IV access in resource-limited areas.

Improving peace and well-being among Syrian refugee youth through a higher education initiative in Jordan.

Forced migration affects overall health, especially when it happens at a young age. Focus group discussions and the Peace Evaluation Across Cultures and Environments (PEACE) survey were used to compare the effects of the programme on two groups: refugee university students who received full tuition support and a monthly living stipend (intervention group) and unsponsored Syrian students who were preparing for the end of high school examination (control group). The overall mean PEACE score among the intervention group was 152.0 (95% confidence interval [CI]: 147.4-156.5), while the control group mean score was 134.1 (95% CI: 129.1-139.1), p < 0.01. In addition to significantly higher mean total PEACE scores, the intervention group demonstrated better results for each of the seven constructs in the scale (t-test p < 0.05), with the largest differences seen in personal safety, group cohesion and agency. This effect was further elucidated in the focus group discussions, highlighting the psychosocial benefits of the scholarship programme due to improvements in their academic and financial status. This combined education and economic intervention for Syrian refugee youth has measurable positive effects on feelings of peace, security and well-being and can be used as a framework from which to design similar initiatives in other contexts of displacement.

Developing Equitable Primary Health Care in Conflict-Affected Settings: Expert Perspectives From the Frontlines.

Health systems are frequently among the casualties of conflict. Within these settings, increased knowledge is needed on how to rebuild and strengthen health infrastructure resilience, such as primary health care (PHC) systems, in context-specific ways that promote health equity. Therefore, this study aimed to explore perspectives of experts with experience working on frontlines of social crises to contribute to understandings of pathways toward equitable PHC in conflict-affected settings. Semistructured qualitative interviews with 18 expert participants were completed. Through engaging elements of grounded theory situational analysis, three themes emerged iteratively, including (a) Building Blocks, (b) Intermediating Factors, and (c) a Roadmap. These emergent themes contribute to conceptual frameworks explaining key contextually specific priorities, challenges, and facilitating factors for developing resilient health infrastructures under social crises. Findings inform policy and practical guidelines that address complexities of conflict conditions and underscore the importance of PHC development toward promoting health as a human right.

Community Health Workers and Disasters: Lessons Learned from the 2015 Earthquake in Nepal.

Introduction The Nepal earthquake of 2015 was a major disaster that exacted an enormous toll on human lives and caused extensive damage to the infrastructure of the region. Similar to other developing countries, Nepal has a network of community health workers (CHWs; known as female community health volunteers [FCHVs]) that was in place prior to the earthquake and continues to function to improve maternal and child health. These FCHVs and other community members were responsible, by default, for providing the first wave of assistance after the earthquake. Hypothesis/Problem Community health workers such as FCHVs could be used to provide formal relief services in the event of an emergency, but there is a paucity of evidence-based literature on how to best utilize them in disaster risk reduction, preparedness, and response. Data are needed to further characterize the roles that this cadre has played in past disasters and what strategies can be implemented to better incorporate them into future emergency management. METHODS: In March 2016, key-informant interviews, FCHV interviews, and focus group discussions (FGDs) were conducted in Nepali health facilities using semi-structured guides. The audio-recorded data were obtained with the assistance of a translator (Nepali-English), transcribed verbatim in English, and coded by two independent researchers (manually and with NVivo 11 Pro software [QSR International; Melbourne, Australia]). RESULTS: Across seven different regions, 14 interviews with FCHVs, two FGDs with community women, and three key-informant interviews were conducted. Four major themes emerged around the topic of FCHVs and the 2015 earthquake: (1) community care and rapport between FCHVs and local residents; (2) emergency response of FCHVs in the immediate aftermath of the earthquake; (3) training requested to improve the FCHVs' ability to manage disasters; and (4) interaction with relief organizations and how to create collaborations that provide aid relief more effectively. CONCLUSIONS: The FCHVs in Nepal provided multiple services to their communities in the aftermath of the earthquake, largely without any specific training or instruction. Proper preparation, in addition to improved collaboration with aid agencies, could increase the capacity of FCHVs to respond in the event of a future disaster. The information gained from this study of the FCHV experience in the Nepal earthquake could be used to inform risk reduction and emergency management policies for CHWs in various settings worldwide. Fredricks K , Dinh H , Kusi M , Yogal C , Karmacharya BM , Burke TF , Nelson BD . Community health workers and disasters: lessons learned from the 2015 earthquake in Nepal. Prehosp Disaster Med. 2017;32(6):604-609.

Developing and Implementing a Pediatric Emergency Care Curriculum for Providers at District Level Hospitals in Sub-Saharan Africa: A Case Study in Kenya.

INTRODUCTION: Emergency medicine is a relatively new field in sub-Saharan Africa and dedicated training in pediatric emergency care is limited. While guidelines from the African Federation of Emergency Medicine (AFEM) regarding emergency training exist, a core curriculum in pediatric emergency care has not yet been established for providers at the district hospital level. METHODS: The objective of the project was to develop a curriculum for providers with limited training in pediatric emergencies, and contain didactic and simulation components with emphasis on treatment and resuscitation using available resources. A core curriculum for pediatric emergency care was developed using a validated model of medical education curriculum development and through review of existing guidelines and literature. Based on literature review, as well as a review of existent guidelines in pediatric and emergency care, 10 core topics were chosen and agreed upon by experts in the field, including pediatric and emergency care providers in Kenya and the United States. These topics were confirmed to be consistent with the principles of emergency care endorsed by AFEM as well as complimentary to existing Kenyan medical school syllabi. A curriculum based on these 10 core topics was created and subsequently piloted with a group of medical residents and clinical officers at a community hospital in western Kenya. RESULTS: The 10 core pediatric topics prioritized were airway management, respiratory distress, thoracic and abdominal trauma, head trauma and cervical spine management, sepsis and shock, endocrine emergencies, altered mental status/toxicology, orthopedic emergencies, burn and wound management, and pediatric advanced life support. The topics were incorporated into a curriculum comprised of ten 1.5-h combined didactic plus low-fidelity simulation modules. Feedback from trainers and participating providers gave high ratings to the ease of information delivery, relevance, and appropriateness of the curriculum. CONCLUSION: We present here a core curriculum in pediatric emergency care for district hospital level providers in Kenya which can be used as a framework for further development and implementation of training programs throughout sub-Saharan Africa.

An innovative safe anesthesia and analgesia package for emergency pediatric procedures and surgeries when no anesthetist is available.

BACKGROUND: Adequate pain control through sedation and anesthesia for emergency procedures is a crucial aspect of pediatric emergency care. Resources for administering such anesthesia are extremely limited in many low-income settings. METHODS: Non-anesthetist providers in Western Kenya were trained in the use of a ketamine-based sedation and anesthesia package for non-anesthetists, Every Second Matters for Mothers and Babies-Ketamine™ (ESM-Ketamine). Data on use and safety of this package for emergent and urgent pediatric procedures was collected. Providers were surveyed as to what they would have done for similar procedures if the ESM-Ketamine package were unavailable. RESULTS: Ninety procedures were completed for 77 pediatric patients utilizing the ESM-Ketamine package. Of these, 29 (32.2 %) cases were orthopedic reductions, 19 (21.1 %) were incision and drainage, and 19 (21.1 %) were debridement and irrigation of burns. Remaining cases included cesarean section, repair of perineal tear, foreign body removal, arthrocentesis, laceration repair, exploratory laparotomy, excision of mass, paracentesis, and circumcision. There were no serious adverse events in any of the cases, 17 % experienced minor adverse events including hypersalivation, hallucinations, or brief, self-resolving, oxygen desaturations. Providers were surveyed for 80 of the 90 cases as to what they would have done in the absence of the ESM-Ketamine package: in 26 cases (32.5 %), they reported they would proceed with the procedure without any anesthesia or analgesia; in 15 (18.75 %), they reported they would significantly delay the procedure while waiting for an anesthetist; in 13 (16.25 %), they reported they would attempt referral to another facility; and in 26 (32.5 %), they reported they would try using an alternate form of analgesia, primarily acetaminophen, ibuprofen, diclofenac, and/or diazepam. All surveyed providers reported they would use the ESM-Ketamine package again in similar cases. CONCLUSIONS: The ESM-Ketamine package, through the use of a simplified protocol and checklist, allows for safe analgesia and anesthesia in children by non-anesthetists in a resource-limited setting for selected emergent and urgent procedures. This package addresses a significant gap in the availability of anesthesia services in low-income settings that would otherwise result in significant delays to procedures or proceeding with painful procedures with inadequate analgesia.