Improving planetary health is integral to improving children's health-a call to action.

IMPACT: This article summarizes the adverse effects of climate and environmental change on children's health. We call for policy change, education, and advocacy to halt further deterioration of planetary health and for specific measures to prevent the negative effects of climate and environmental change on children's health. We offer an agenda for research, policy change, and healthcare practices to improve the resilience of pediatric populations in the face of climate change.

Enhanced Transitions of Care for Medically Complex Refugees.

BACKGROUND: Between 2015 and 2019, 261,091 refugees were resettled through the U.S. Refugee Admissions Program. Few are chronically ill, but previously these went to emergency rooms upon arrival. We designed a pilot program to anticipate, assess, and safely assume care of chronic health needs and stabilize sick and medically complex refugees upon arrival. CLINICAL OPERATIONS: Academic internal medicine and pediatrics clinics are linked to the Washington State Refugee Health Program and Refugee Resettlement Agencies. Arriving refugees deemed medically complex through overseas medical evaluation or post-arrival were selected for the program. METRICS: We reviewed biodata of 2,947 refugees deemed medically complex. We referred five hundred and sixty one (19%) of these for evaluation, and 257 (46%) of referrals received care. DISCUSSION: Safe transitions of care are standard practice in medical systems. This innovation in Seattle is one example of a system for the safe and cost-effective relocation of refugees with complex illnesses.

Perspectives of Caregivers on the Effects of Migration on the Nutrition, Health and Physical Activity of their Young Children: A Qualitative Study with Immigrant and Refugee Families.

To explore perspectives on nutrition, health and physical activity among immigrant parents with young children before and after migration. We conducted focus groups in five languages (Arabic, Somali, Dari, Burmese and Nepali), then conducted a phenomenological analysis of the transcripts. Fifty caregivers participated; 42% spent time in a refugee camp. Within the domain Change in Environment, four themes emerged: (1) food access; (2) family experiences with weight and growth; (3) differences in physical activity and perceptions of safety; and (4) health care experience. Within the domain of Parenting Behaviors and Experiences, two themes emerged: (1) Sociocultural differences in early feeding behaviors and (2) concern about feeding behaviors. To support health outcomes for refugee and immigrant families with young children, key focus areas for programming would include access to fresh foods, safe places for physical activity, and feeding practices following a family history of food scarcity.

Global Health Education for Pediatric Residents: Trends, Training Experiences, and Career Choices.

: media-1vid110.1542/5849572022001PEDS-VA_2018-1559Video Abstract BACKGROUND AND OBJECTIVES: Knowledge and skills related to global child health are increasingly recognized as important to the practice of pediatrics. However, little is known about the status and trends in global health (GH) education in US pediatric residency programs. Our aim was to measure trends in residents' exposure to GH training, their GH education assessments, and GH career plans. METHODS: We analyzed GH-focused questions from national American Academy of Pediatrics surveys of graduating residents in 2008 and 2016. Logistic regression was used to estimate changes over time by using derived predicted values. RESULTS: A total of 1100 graduating pediatric residents participated; response rates were 58.8% for 2008 and 56.0% for 2016. The percentage of residents reporting that their programs offered GH training grew from 59.1% in 2008 to 73.1% in 2016 (P < .001). The majority were somewhat likely, very likely, or definitely planning to work or volunteer in a low- or middle-income country after their residency (predicted value of 70.3% in 2008 and 69.4% in 2016; P = .76). Fourteen percent of respondents reported having completed an international elective in 2016; of those, 36.5% did not receive formal preparation before the experience, and 24.3% did not participate in debriefing sessions on return. Overall, 27.3% of respondents in 2016 reported excellent (8.8%) or very good (18.5%) GH training. CONCLUSIONS: Although a substantial percentage of pediatric residents participate in international electives and plan to include GH activities in their careers, gaps remain, including suboptimal preparation and debriefing for GH electives.

Training Pediatricians to Address Health Disparities: An Innovative Residency Track Combining Global Health With Community Pediatrics and Advocacy.

PROBLEM: Pediatric residency programs have been tasked to train a workforce of pediatricians with skills in community pediatrics (CP) and advocacy, and knowledge of global child health priorities. APPROACH: In 2009, the University of Washington (UW) Seattle Children's Hospital pediatric residency program developed the Resident Education in Advocacy and Child Health (REACH) program, a combined pathway for global health (GH) and CP training. After participating in a combined curriculum, residents complete a community immersion either in Kisii, Kenya (GH) or rural Washington (CP). This approach provides an efficient use of faculty and administrative resources and delivers a sustainable and ethical strategy for inspiring pediatric residents to address child health problems at a systems level. OUTCOMES: Between 2009 and 2013, the percentage of graduating residents from the UW pediatric residency program who rated GH training as "outstanding/excellent/good" increased from 58.4% to 100%, and the percentage rating community and population health training as "outstanding/excellent/good" increased from 56% to 88.8%. Annual applicant surveys in the period 2011-2014 revealed that the REACH program led a significant percentage of candidates to rank the UW pediatric residency more favorably because of its GH (37%-48%) and CP (55%-74%) training. NEXT STEPS: A mixed-methods assessment will evaluate the impact on resident confidence in core areas of community health and advocacy including collaborating with community groups, setting professional career goals, addressing underlying determinants of health during patient encounters, communicating in cross-cultural settings, and advocating for child health. A survey will assess outcomes on graduates' careers.

Partnerships for Global Child Health.

Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

Growth Trajectories of Refugee and Nonrefugee Children in the United States.

BACKGROUND AND OBJECTIVES: Limited data examine longitudinal nutrition outcomes of refugee children after United States resettlement. Among refugee children, our aims were to (1) assess the changes in weight-based nutritional status between baseline (0-3 months) and 10-24 months after arrival and (2) compare the BMI (BMIz) or weight-for-length z score (WFLz) trajectories to nonrefugee children for up to 36 months after arrival. METHODS: We conducted a retrospective study of refugees aged 0-16 years from Washington and Pennsylvania and compared them with an age and sex-matched nonrefugee low-income sample from Washington. Data included anthropometric measurements from the initial screening medical visit and subsequent primary care visits. Multilevel linear mixed-effects regression models evaluated the change in BMIz or WFLz trajectory. RESULTS: The study included 512 refugee and 1175 nonrefugee children. The unadjusted prevalence of overweight/obesity increased from 8.9% to 20% (P < .001) for 2- to 16-year-old refugees from baseline to 10-24 months. Refugees (2-16 years old) had a steeper increase in their BMIz per 12 months compared with nonrefugees (coefficient 0.18 vs 0.03; P < .001). Refugees <2 years old had a less steep increase in their WFLz per 12 months compared with nonrefugees (coefficient 0.12 vs 0.36, P = .002). CONCLUSIONS: Older refugee children exhibited a higher risk of obesity than nonrefugees, whereas refugees <2 years old exhibited a slower increase in their risk of obesity than nonrefugee children. All age groups experienced increasing obesity prevalence. Targeted and culturally tailored obesity prevention interventions may mitigate health and nutrition inequities among refugee children.

Comparison of the Nutritional Status of Overseas Refugee Children with Low Income Children in Washington State.

INTRODUCTION: The extent that the dual burden of undernutrition and overnutrition affects refugee children before resettlement in the US is not well described. OBJECTIVE: To describe the prevalence of wasting, stunting, overweight, and obesity among refugee children ages 0-10 years at their overseas medical screening examination prior to resettlement in Washington State (WA), and to compare the nutritional status of refugee children with that of low-income children in WA. METHODS: We analyzed anthropometric measurements of 1047 refugee children ages 0-10 years old to assess their nutritional status at the overseas medical screening examination prior to resettlement in WA from July 2012--June 2014. The prevalence estimates of the nutritional status categories were compared by country of origin. In addition, the nutritional status of refugee children age 0-5 years old were compared to that of low-income children in WA from the Center for Disease Control and Prevention's Pediatric Nutrition Surveillance System. RESULTS: A total of 982 children were eligible for the study, with the majority (65%) from Somalia, Iraq and Burma. Overall, nearly one-half of all refugee children had at least one form of malnutrition (44.9%). Refugee children ages 0-10 years were affected by wasting (17.3%), stunting (20.1%), overweight (7.6%) and obesity (5.9%). Among children 0-5 years old, refugee children had a significantly higher prevalence of wasting (14.3% versus 1.9%, p<0.001) and stunting (21.3% versus 5.5%, p<0.001), and a lower prevalence of obesity (6.2% versus 12.9%, p<0.001) than low-income children in WA. CONCLUSION: The dual burden of under- and over-nutrition among incoming refugee children as well as their overall difference in prevalence of nutritional status categories compared to low-income children in WA provides evidence for the importance of tailored interventions to address the nutritional needs of refugee children.

A proposed model curriculum in global child health for pediatric residents.

OBJECTIVE: In response to the increasing engagement in global health (GH) among pediatric residents and faculty, academic GH training opportunities are growing rapidly in scale and number. However, consensus to guide residency programs regarding best practice guidelines or model curricula has not been established. We aimed to highlight critical components of well-established GH tracks and develop a model curriculum in GH for pediatric residency programs. METHODS: We identified 43 existing formal GH curricula offered by U.S. pediatric residency programs in April 2011 and selected 8 programs with GH tracks on the basis of our inclusion criteria. A working group composed of the directors of these GH tracks, medical educators, and trainees and faculty with GH experience collaborated to develop a consensus model curriculum, which included GH core topics, learning modalities, and approaches to evaluation within the framework of the competencies for residency education outlined by the Accreditation Council for Graduate Medical Education. RESULTS: Common curricular components among the identified GH tracks included didactics in various topics of global child health, domestic and international field experiences, completion of a scholarly project, and mentorship. The proposed model curriculum identifies strengths of established pediatric GH tracks and uses competency-based learning objectives. CONCLUSIONS: This proposed pediatric GH curriculum based on lessons learned by directors of established GH residency tracks will support residency programs in creating and sustaining successful programs in GH education. The curriculum can be adapted to fit the needs of various programs, depending on their resources and focus areas. Evaluation outcomes need to be standardized so that the impact of this curriculum can be effectively measured.

Global health education for pediatric residents: a national survey.

OBJECTIVE: To assess exposure to global health (GH) training, future plans to work or volunteer abroad, and the importance of GH training in program selection among graduating pediatric residents. METHODS: A national, random sample of graduating pediatric residents was surveyed in the 2008 American Academy of Pediatrics' Annual Graduating Residents Survey. Questions specific to GH training were included. RESULTS: The adjusted survey response rate was 59% (546 of 927); 534 residents from 170 programs responded to at least 1 GH question. GH training was an essential/very important factor in selecting a residency program for 22% of the respondents, and 21% reported participating in GH training during residency. In multivariate analyses, participation in GH training was associated with being single (adjusted odds ratio [aOR]: 1.90 [95% confidence interval (CI): 1.10-3.27]), graduating from a US medical school (aOR: 2.45 [95% CI: 1.14-5.28]), lower educational debt (aOR: 2.63 [95% CI: 1.54-4.49]), and training at a larger program (aOR: 2.73 [95% CI: 1.47-5.06]). One-third of respondents reported definite/very likely plans to work/volunteer in a developing country after residency; these respondents were more likely to be single (aOR: 1.82 [95% CI: 1.14-2.92]) and international medical school graduates (aOR: 2.10 [95% CI: 1.19-3.73]). Fewer than 50% of respondents received education in the majority of topics considered essential to GH training. CONCLUSIONS: GH-training opportunities are important to pediatric residents when selecting a program, and many are graduating with intentions to volunteer/work in a developing country after residency. The low exposure to GH topics among a broad cross-section of pediatric residents suggests that additional work is needed to adequately prepare pediatricians for work in GH after residency.

Understanding infant feeding beliefs, practices and preferred nutrition education and health provider approaches: an exploratory study with Somali mothers in the USA.

The objective of this study was to explore Somali mothers' beliefs and practices around infant feeding and education, towards developing a culturally informed infant nutrition curriculum for health providers. Four focus groups were conducted to explore: (1) beliefs about infant feeding, hunger and ideal weight; (2) feeding practices; (3) nutrition education approaches; and (4) provider/mother interactions. Thirty-seven Somali mother participants identified the following themes within these topics: (1) strategies for assessing hunger, satiety and when to feed; shared beliefs that plump babies are healthy, leading to worry about infant weight; (2) context of breast milk adequacy, difficulties breastfeeding and environmental and cultural barriers to breastfeeding, leading to nearly universal early supplementation with formula; (3) preferred education approaches include provider visits with interpreters, Somali language educational materials and advice from older, experienced family members; and (4) desired health provider skills include: listening, explaining, empathy, addressing specific concerns, repeating important information, offering preventive advice and sufficient visit time. This study presents knowledge about Somali beliefs and practices that can directly guide discussions with these families. Given that these infants appear on a trajectory towards obesity, influencing infant feeding practices in the Somali community is a good upstream approach to preventing obesity. These findings will underpin a new infant nutrition curriculum for health providers.