Health literacy is a foundational component of providing accessible pediatric care, influencing whether families can understand, access, and use health information. As families increasingly rely on online health resources, health literacy skills applied to digital information, or e-health literacy, has become an evolving dimension of pediatric health literacy. The concept of health literacy extends beyond an individual's abilities, intersecting with the demands placed on individuals by healthcare systems. There is a growing focus on organizational health literacy (OHL), which reflects how effectively systems support equitable communication, but this remains infrequently assessed or implemented. Limited parent, child, and adolescent health literacy is common and disproportionately affects families with lower income, minoritized racial/ethnic backgrounds, lower educational attainment, and who use languages other than English for care. Limited health literacy has been associated with decreased disease-specific knowledge, suboptimal health behaviors, and worse clinical outcomes. Although health literacy-informed strategies can improve comprehension and outcomes, best practices, such as teach-back, remain underutilized across pediatric care settings. The rapid expansion of digital tools offers new opportunities to enhance health literacy-informed communication but also introduces challenges related to equity, accuracy, and safety. Advancing pediatric health literacy requires coordinated efforts: embedding health literacy principles into institutional and national policies, integrating universal health literacy precautions into clinical workflows, expanding clinician and patient health literacy education, and advancing health literacy-focused research, including on digital interventions and artificial intelligence (AI)-supported communication. Prioritizing these efforts is essential to creating health literate-systems that enable all families to access, understand and use health information.
How can the United States reduce the number of children in our country who, after growing up in families with incomes below the poverty line, remain poor as adults? This article summarizes key conclusions of a 2024 report issued by the Committee of the National Academies of Sciences, Engineering, and Medicine on Policies and Programs to Reduce Intergenerational Poverty. The committee sought to identify evidence-based policies and programs directed at low-income children, their families, or their neighborhoods that could reduce children's chances of remaining low-income as adults. The committee found direct evidence of success in affecting correlates of adult poverty (e.g., low educational attainment and earnings, poor health) for more than two dozen programs and policies addressing health; education; income and parental employment; housing; and crime. Because we concentrate on interventions focused on child health, we include a brief discussion of the importance of the involvement of health care professionals in implementing policy changes resulting from the passage of the One Big Beautiful Bill Act (OBBB Act).
Extensive, high-quality evidence has demonstrated the importance of housing as a fundamental determinant of child health and development. At the same time, housing has become more unaffordable in the US, such that one in three children lives in unaffordable housing, more children are at risk of eviction and homelessness, housing quality has not improved meaningfully, and wide disparities exist in neighborhood access to socioeconomic opportunity. This narrative review chronicles the impacts of housing on children’s health via four pillars: affordability, stability, quality and safety, and neighborhood conditions. We 1) provide an overview of evidence linking each of these housing pillars to child health outcomes and 2) describe effective interventions to reinforce the housing pillar and promote health. Based on this evidence, we urge pediatricians to intervene and advocate at multiple levels in order to advance housing and health for children and families. This review aims to serve as a reference for pediatricians seeking to implement evidence-based housing interventions, across individual, clinical, systems, and policy levels.
OBJECTIVES:Vaccine hesitancy contributes to under-vaccination and recurring outbreaks of vaccine-preventable diseases in the United States. Rates are particularly low in rural areas. This qualitative study identified informational needs, trust in health information sources, and preferences for vaccine-related messaging to inform the design of a mobile application tailored to improve vaccine confidence and deliberative decision-making among rural caregivers. METHODS:Parents or caregivers of children aged newborn to 3 years from Montana and Nebraska were recruited based on their level of childhood vaccination hesitancy using the Parent Attitudes About Childhood Vaccines (PACV) scale. Overall, 32 caregivers (18 fromF Montana, 14 from Nebraska), grouped by low (31%), medium (19%), and high (44%) hesitancy, participated in focus groups and follow-up individual interviews. Consensus coding and thematic analysis using NVivo software was used to identify key themes and patterns. RESULTS:Participants expressed key informational gaps, including questions about how vaccines work, safety testing, and the rigidity of immunization schedules. Gain-framed messages emphasizing benefits were consistently preferred over loss-framed messages, which were often perceived as judgmental or manipulative. Trust in local healthcare providers was a critical determinant of vaccine acceptance, surpassing trust in national health organizations. Participants advocated for non-judgmental, interactive, and personalized communication tools that mimic the relational trust found in provider interactions. CONCLUSIONS:Findings support vaccination communication strategies that integrate trusted local messengers, transparent and empowering framing, and participatory engagement. Insights directly inform the design of a parent-facing mHealth application customized according to preferences elicited from our diverse participant stakeholders.
BACKGROUND:Pediatric Readiness in U.S. emergency departments (EDs) is associated with improved outcomes for critically-ill children. Most children seek emergency care in general EDs. Pediatric Emergency Care Coordinators (PECCs) have been shown to improve readiness; however, their presence declined following the pandemic. We examined the association between PECC status over time with hospital ED characteristics and Pediatric Readiness in general EDs. METHODS:We conducted a retrospective cohort study using data from the 2013 and 2021 National Pediatric Readiness Project (NPRP) assessments. General EDs completing both assessments were categorized by PECC status as retained, gained, lost, or never had a PECC. The primary outcome was adjusted Weighted Pediatric Readiness Score (aWPRS), calculated by removing PECC-associated points and normalizing to 100. Associations between PECC status and aWPRS, including domain scores, were evaluated using multivariable logistic regression and nonparametric testing. RESULTS:Among 2,533 general EDs, 29.3% retained a PECC, 12.9% gained a PECC, 33.9% lost a PECC, and 23.9% never had a PECC. Lower pediatric visit volume was associated with PECC loss (p<.001). EDs that gained or retained a PECC were more likely to require EM/PEM board certification and pediatric competency evaluations. EDs that lost or never had a PECC demonstrated significantly lower overall aWPRS and lower scores across all readiness domains compared with EDs that gained a PECC. CONCLUSIONS:In general EDs nationwide, absence or loss of a PECC was associated with significantly lower Pediatric Readiness. These findings underscore the critical role of PECCs in sustaining pediatric emergency preparedness and support prioritizing institutional investment for this role.
OBJECTIVE:To describe the timing of Medicaid enrollment during pregnancy among Medicaid-insured women in Texas, examine patterns of healthcare utilization following enrollment, and evaluate associations between enrollment timing and infant outcomes. METHODS:Retrospective cohort study of 913,229 deliveries to women aged 15-44 years enrolled in Texas Medicaid between January 1, 2010, and December 31, 2014. Women were classified into five mutually exclusive groups based on timing of first Medicaid enrollment: before conception, first, second, or third trimester, or delivery hospitalization. We evaluated associations between enrollment timing and cesarean delivery, preterm birth, small-for-gestational-age (SGA), and neonatal mortality using Poisson regression with robust standard errors. RESULTS:Overall, 26.4% (n=238,689) of women enrolled in Medicaid before conception, 40.0% (n=364,905) during the first trimester, 14.3% (n=130,568) during the second trimester, 6.1% (n=56,090) during the third trimester, and 13.5% (n=122,977) at delivery. Later enrollment was more common among Hispanic and foreign-born women and among those with a lower mean obstetric comorbidity index. Most women had their first Medicaid-covered healthcare encounter in the same trimester as enrollment, primarily in ambulatory care settings. In adjusted analyses, enrollment before conception was associated with a higher risk of preterm birth (aRR 1.17; 95% CI,1.15-1.18) relative to first-trimester enrollment. Second- and third-trimester enrollment were associated with higher risks of SGA (aRR 1.15 [95% CI,1.12-1.18] and 1.18 [95% CI,1.13-1.22], respectively). CONCLUSION:Medicaid enrollment timing varied across demographic groups and was associated with differences in healthcare utilization and selected infant outcomes. Improving maternal and infant health may require not only timely coverage but also efforts to address structural barriers to Medicaid enrollment and prenatal care access.
BACKGROUND:Early relational health - the quality of caregiver-child interactions - is foundational for socio-emotional development and long-term wellbeing. The American Academy of Pediatrics has called for a paradigm shift toward relationship-centered care in pediatric primary care, yet a gap remains between this vision and real-world implementation. OBJECTIVES:To map early relational health interventions implemented in pediatric primary care, summarize reported outcomes and identify implementation strategies, barriers, and facilitators. DATA SOURCES:PubMed, CINAHL, and PsycINFO were searched for studies published between 2014 and 2024, supplemented by backward citation searching. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS:A scoping review methodology following PRISMA-ScR guidelines was used. Data were charted and synthesized using descriptive and thematic analysis. RESULTS:Eighteen studies met inclusion criteria. Interventions were delivered in clinic, home, or hybrid settings and were commonly integrated into routine workflows. Reported outcomes included improvements in caregiver responsiveness, parenting self-efficacy, and child language and socio-emotional development. Implementation strategies included staff training, workflow integration, fidelity monitoring, and community partnerships. Key facilitators were contextual responsiveness, strong relational supports, and alignment with clinical processes. Barriers included small or homogeneous samples, reliance on parent-report outcomes, short follow-up periods, and resource constraints. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:Early relational health interventions are feasible and show promise in pediatric primary care when embedded into routine care and adapted to context. Addressing methodological and implementation challenges is essential to advancing relationship-centered pediatric practice. SCOPING REVIEW REGISTRATION:Open Science Framework (OSF) DOI: https://doi.org/10.17605/OSF.IO/ZCGVA.
OBJECTIVE:This study examines whether school-based health center (SBHC) access mitigates insurance-based disparities in preventive care utilization, including well-child visits and influenza (flu) vaccination, among students with primary care visits in a rural region of New York State. METHODS:Using 2024 electronic health records from a regional healthcare network, we analyzed 15,267 students aged 5-18. Students were categorized by SBHC access and insurance type (Medicaid vs. commercial). Logistic regressions estimated preventive care utilization by SBHC access and insurance type, with marginal effects examining their interaction. Among students with SBHC access, visits were stratified by care site to examine the odds of SBHC and non-SBHC visits by insurance type. Models were adjusted for age, sex, community socioeconomic status, and district random effects. RESULTS:Overall, 53% of students had SBHC access, and 56% were Medicaid insured. Students with SBHC access and commercial insurance had the highest preventive care utilization, while Medicaid-insured students without SBHC access had the lowest. Insurance-based disparities were observed in well-child visits, and were not fully mitigated by SBHC access. However, Medicaid-insured students with SBHC access had higher utilization of well-child visits and flu vaccination than those without access, and had similar odds of well-child visits as commercially-insured students without SBHC access. Among students with SBHC access, well-child visits delivered in SBHCs showed no insurance-based disparities. CONCLUSIONS:Among students using primary care, insurance-based disparities were found in well-child visits. Although SBHCs did not fully eliminate insurance-based disparities, they improved preventive care utilization among Medicaid-insured students in rural areas.
OBJECTIVE:Military-connected children with medical complexity (CMC) have multifaceted healthcare needs. This study describes the share of ambulatory care delivered to young military-connected CMC within civilian and military health facilities, identifies the predominant clinician providing care, and identifies factors associated with having a predominant clinician at a civilian health facility. METHODS:This retrospective cohort study analyzed United States military Birth and Infant Health Research program data, 2009-2020. The Complex Chronic Condition and Pediatric Medical Complexity algorithms were used to identify CMC <5 years. The clinician and care setting for each ambulatory care visit were determined, and the clinician providing the plurality of care each year from birth through five years was identified. Generalized estimating equations were used to identify factors associated with having a predominant clinician at a civilian health facility. RESULTS:Among 66,920 CMC, 68.7% (n=46,001) received care at both military and civilian health facilities. The proportion with a predominant clinician at a civilian facility ranged from 45.5% (n=17,953) during infancy to 54.5% (n=28,568) by five years. Child-level factors associated with having a civilian predominant clinician included preterm delivery, older age at diagnosis, multisystem disease, and technology dependence. CONCLUSIONS:Two-thirds of military-connected young CMC received ambulatory care across both military and civilian facilities, with increasing reliance on clinicians at civilian facilities beyond infancy and as complexity increased. These findings highlight the importance of coordinated care across healthcare sectors to address the unique needs of military-connected CMC and their families.
BACKGROUND:There has been an increased focus on addressing health-related social needs (HRSN), with recent regulatory bodies requiring screening in adult populations. Though not yet included in the new requirements, pediatric primary care has been at the forefront. Assessing statewide practices is important to understand if HRSN screening and resource provision occur equitably for patients and families. OBJECTIVE:To characterize HRSN screening and referral processes amongst a representative sample of pediatric primary care practices in Maryland. METHODS:In this cross-sectional study (June-August 2023), Maryland pediatric primary care practices were sampled proportionally by county pediatric population density and surveyed regarding practice characteristics, HRSN screening, and referral mechanisms. Results were summarized descriptively. RESULTS:Surveys were completed by 54 practices from 22 of the 24 Maryland counties approximately proportional to pediatric population density in each county. Of the 85% of practices reporting screening for at least one HRSN, all screen during well child visits. Screening processes varied across clinics, with most occurring in the exam room (52%), verbally (57%), and by a physician or nurse practitioner (54%). Most practices document HRSN in the electronic medical record (84%). Clinics have various cascading interventions including referrals to community resources, social workers, and community health workers. CONCLUSION:In a geographically representative sample of pediatric primary care practices in Maryland, most screen for at least one HRSN though variability exists in the method and timing of screening and subsequent referral processes. Our findings underscore the need for practice-level support to ensure HRSN are optimally and equitably addressed.
OBJECTIVE:Studies have demonstrated that using milliliters (mL)-only in dosing instructions and on dosing devices for oral liquid medications (OLMs) can prevent patient/caregiver dosing errors. While previous studies have assessed the perceptions/practices of primary care providers (PCPs) regarding dosing units for OLMs, perceptions/practices of community-based pharmacists are not well described. METHODS:Data were collected in June 2024, through an online survey of retail pharmacists. Pharmacist perceptions/practices regarding OLMs were calculated overall and stratified by the number of years practicing pharmacy. Logistic regression was used to assess associations between certain characteristics and perceptions on pharmacist dispensing behaviors. RESULTS:A total of 201 pharmacists completed the survey. Pharmacists who had been practicing for <10 years were more likely to think that mL-only was safest to use in dosing instructions for OLMs (88.9%) and that patients/caregivers prefer dosing instructions in mL-only (73.3%) compared to those who had been practicing for ≥10 years (70.5% and 37.2%, respectively). Only one-third (33.8%) of all pharmacists reported that they would convert the dosing units dispensed on a prescription for oral liquid amoxicillin to mL-only if the prescriber wrote the dosing instructions in teaspoons; with pharmacist perception that mL-only was the safest to use in dosing instructions having the most significant impact on this dispensing behavior (adjusted odds ratio 11.37, 95% confidence interval 3.20-40.44). CONCLUSIONS:Educational efforts promoting the importance of using mL-only units on dosing instructions/devices for OLMs for pharmacists and PCPs may be necessary to promote safe dosing practices and reduce pediatric medication errors.
OBJECTIVE:To evaluate the association between asthma documentation at school (asthma diagnosis and asthma action plan [AAP]) and outcomes after stock inhaler use at school. METHODS:This observational study examined respiratory events and outcomes in a statewide program that provided albuterol metered dose inhalers to Illinois public schools. Nurses registered online and reported each inhaler use (event). This report collected individual characteristics, asthma documentation, and event outcomes. Analyses included Pearson's Chi-squared tests, Fisher's exact tests, Wilcoxon rank-sum tests, and logistic regression models. RESULTS:In 2023-2024 school year, 656 events occurred requiring stock inhaler use among students across Illinois schools. Students had an asthma diagnosis on file at school in 63% of events (n=413); among these students, 42% had an AAP on file (42%, n=175). For disposition after stock inhaler use, 76% of students returned to class (n=497). Students with an asthma diagnosis documented at school had 2.6 times higher odds of returning to class after stock inhaler use versus those without documentation (95% CI 1.81-3.75). Similarly, students with asthma who also had AAPs on file at school had 2.41 times higher odds of returning to class after respiratory events versus those without AAPs (95% CI 1.39-4.33). These associations remained significant in adjusted models. CONCLUSIONS:In a statewide stock inhaler program in Illinois, we found students with asthma diagnoses and AAPs documented at school had higher rates of return to class after stock inhaler use for respiratory symptoms compared to students without such documentation.
OBJECTIVES:To examine the association between adverse childhood experiences (ACEs) and prior incarceration and its features in a contemporary, nationally representative sample of US men. METHODS:Data come from the 2022-2023 National Survey on Family Growth (NSFG), a cross-sectional survey of reproductive health, fertility, and family formation among a nationally representative sample of non-institutionalized, male and female household residents in the US (ages 15-49). The present study focuses on the adult male subsample, aged 18-49. RESULTS:Findings indicate that ACEs are associated with prior incarceration in this sample of men, especially as ACEs accumulate (i.e., the adjusted predicted probability of incarceration for men reporting 5 or more ACEs is 0.23, compared to 0.05 for men reporting zero ACEs). While these patterns generally held across incarceration features, high ACEs exposure was particularly relevant for incarcerations of longer (v. shorter) durations (e.g., a year or more), and some of the largest point estimates occurred in the case of multiple (v. single) incarcerations and especially when examining 5 or more ACEs and recent incarcerations (i.e., past 12 months). CONCLUSIONS:The impact of ACEs for formal criminal legal system contact appear to reverberate into adulthood and extend to incarcerations with particularly disadvantageous features (e.g., frequent, longer duration experiences). Considering the well-established implications of both ACEs and incarceration for myriad life domains - from health to education and employment to family life - the findings highlight the importance of early prevention and intervention efforts that disrupt pathways from early adversity to involvement in the criminal legal system.
BACKGROUND:Care coordination is a vital role of the pediatrician and an important part of high-quality, cost-effective healthcare. Studies show healthcare providers and school staff find communication between each other to be beneficial. However, data are limited on the prevalence of and parental preference for healthcare provider and school staff communication (HPSC). STUDY DESIGN:This cross-sectional study utilized data from the Voices of Child Health Parent Panel Survey. The survey was administered in English and Spanish to parents across Illinois between September-October 2024. Questions explored parent-reported prevalence and preferences for HPSC. Data were weighted to match demographic benchmarks of Illinois residents. Analyses included descriptive statistics to estimate prevalence and preferences, chi-square tests to examine demographic differences, and multivariable logistic regression to evaluate independent associations. RESULTS:Of 1078 parents who completed the survey, 944 had at least one school-aged child and were included. Only 19.7% of parents indicated HPSC occurred in the last 12 months, but 35.5% of parents indicated they desired more frequent HPSC. HPSC prevalence differed across parent education level, household income, and school type, while no differences were found based on parent sex, race, or urbanicity. Desire for more frequent HPSC differed significantly across parent race and education. CONCLUSION:Our findings suggest HPSC occurs at low rates, despite the need for school staff to be prepared to address children's health needs. This study suggests that parents support the expansion of HPSC, building on literature showing pediatricians and school staff find HPSC to be beneficial to their practice.
