BACKGROUND:Household food insecurity (FI) and caregiver inpatient FI (ie, limited or uncertain access to adequate food during hospitalization) negatively affect children. We aimed to describe outcomes of a hospital-based intervention bundle for household/inpatient FI. METHODS:A single-arm prospective clinical trial conducted at a large children's hospital from March 2021 to March 2022 screened English- and Spanish-speaking caregivers. Caregivers with household and/or inpatient FI received the intervention bundle (complimentary hospital meals, active referral to a community-based organization [CBO] for assistance applying for public benefits and accessing food pantries). Two-week postdischarge follow-up calls were completed with caregivers enrolled in the intervention bundle, and the CBO provided 12-month post-referral outcomes. Statistical analysis described the intervention bundle feasibility (% participants who received interventions), acceptability (participant-rated comfort, helpfulness, and satisfaction), and referral outcomes. RESULTS:Of 1000 enrolled caregivers (English-speaking, 75%, Spanish-speaking, 25%), 54% screened positive for household and/or inpatient FI (48% household FI and 46% inpatient FI). 70% of caregivers completed the 2-week follow-up, with median scores of 10/10 comfort with FI screening, 9/10 satisfaction with complimentary trays, and 10/10 satisfaction with CBO. Twelve-month follow-up data demonstrated that the CBO had successfully connected with 62% of referred caregivers. A total of 51% of those who connected applied for Supplemental Nutrition Assistance Program (SNAP), and 86% of those who applied received SNAP benefits within 3 months. CONCLUSIONS:FI was highly prevalent in caregivers of hospitalized children. Hospital-based interventions with a CBO successfully reached caregivers and was rated favorably. This work can inform intervention efforts as hospital FI screening programs grow.

Improving self-management skills for adolescents and emerging adults (AEA) with chronic health conditions is critical for successful transition to adult-based care. Peer-mentoring has been effective in improving the self-management skills of AEA. However, the components of training a successful young adult peer mentors (YAPM), especially interpersonal aspects of the role, such as communication skills and navigating mentee ambivalence are not well understood. This descriptive study created and pilot-tested a training curriculum for YAPM as part of a larger study to build self-management skills in the context of healthcare transition from pediatric to adult care. Five YAPM completed the training curriculum. The curriculum included four components: 1) organizational policies and research ethics, 2) healthcare transition content and knowledge, 3) interpersonal training for the YAPM role with a focus on using Motivational Interviewing, and 4) ongoing support. Trainings included didactic, group activities, and formal simulation. YAPM rated the training components as useful, especially interpersonal training. Skill development during simulation was measured with a standardized observational coding system. Each YAPM improved in unique ways during simulation. Simulation materials are provided to allow for further development and application in future YAPM training development. This formal mentor training curriculum has the potential to clarify expectations, provide support, and help navigate the challenging interpersonal components of the YAPM role, thereby potentially increasing the effectiveness of YAPM communication with AEA to improve self-management skills.

This technical report on Medicaid and the Children's Health Insurance Program (CHIP), the cornerstones of the entire children's health care delivery system, complements the 2023 American Academy of Pediatrics policy statement "Medicaid and the Children's Health Insurance Program: Optimization to Promote Equity in Child and Young Adult Health." The origin and intent of both the Medicaid and CHIP programs are outlined, and a current summary of issues related to enrollment, eligibility, funding, benefits, payments, quality assurance, and reporting in these programs that pertain to all children, including children with special health care needs (CYSHCN), is provided. Opportunities and drawbacks associated with states contracting with Medicaid managed care organizations are highlighted. This report also details mechanisms by which Medicaid can be modified through executive and legislative actions and summarizes past proposals (many recently resurrected) that would have degraded Medicaid's ability to provide quality care for children. Special issues of interest for specific populations are explored, including children with special health care needs, adolescents, immigrant children, children in foster care, and adopted children, and the role of Medicaid and CHIP in addressing specific health care needs in the arenas of mental and behavioral health and dental care are discussed. Finally, the following 3 themes are emphasized: (1) the criticality of these programs to the current needs of children and the necessity to resolve operational factors that cause inequities; (2) the strategic importance of these programs to the well-being of the country's future; and (3) the crisis with attracting, training, and retaining pediatric generalists and subspecialty physicians to lead the care of children in future generations.

Community-based participatory research (CBPR) is essential for addressing health care inequities; however, it is unclear to what extent articles published in high-impact medical journals use CPBR. We reviewed original research articles in nine journals across 4 years to determine how frequently CBPR was used and, for articles using CBPR, details about partnerships. Of 5,624 articles, only 6 (0.1%) used CBPR. Five identified community partners and whether partners were involved in research planning/implementation, one reported that partners were involved in dissemination, and none reported adherence to CBPR principles. Improving integration of CBPR is an urgent priority for funders, institutions, journals, and researchers.

OBJECTIVE:We aimed to describe social stressors and health care access in children with special health care needs (CSHCN) from low-income households by immigrant generation and determine the association between immigrant generation and health care utilization. METHODS:This was a retrospective cross-sectional study of CSHCN living at or below 200% of the federal poverty level using the National Survey of Children's Health from 2018 to 2022. Exposures were demographics, immigrant generation (first-generation, second-generation, or nonimmigrant), social stressors, and health care factors. Outcomes were 1) one or more emergency room (ER) visits and 2) one or more hospitalizations in the past year. We compared variables across generations using chi-square testing and assessed factors associated with our outcomes using logistic regression. RESULTS:We included 16,679 CSHCN (293 first-generation, 2203 second-generation, 14,183 nonimmigrants). Compared to second-generation and nonimmigrants, more parents of first-generation CSHCN identified as Hispanic, lived in non-English speaking households, reduced work hours due to their child's health, reported poor child health, lacked insurance for their child, and lacked a medical home for their child. ER visits and hospitalization rates were similar across all 3 generation groups. When controlling for covariates, immigrant generation was not associated with ER visits or hospitalizations. CONCLUSIONS:Despite having poorer health status and less access to medical homes compared to nonimmigrants, CSHCN from immigrant families do not utilize the ER more often, which is potentially concerning for underutilization. Addressing social drivers of health in immigrant families and expanding public health insurance eligibility to all low-income CSHCN, regardless of immigration status, may ensure appropriate ER use.

Background Few children in food insecure (FI) households meet dietary recommendations for fruit and vegetables (“produce”). Barriers include affordability, accessibility, and desirability. Home produce delivery may reduce FI, increase produce consumption, and decrease budget tradeoffs. Objective Evaluate the acceptability and potential impact of delivering produce through home visiting programs on FI, diet, and budget tradeoffs. Methods In this prospective pre/post mixed methods study, 51 parents engaged in home visiting programs were enrolled. Participants completed pre- and post-program surveys on FI (18-item Food Security Scale), produce consumption, and budget tradeoffs. Pre- and post-surveys were compared using McNemar’s test and weighted kappas. Interview guides were based on Social Cognitive Theory and a previously published framework. Interviews were conducted in English or Spanish; thematic analysis was completed. Results Twenty-nine (56.9%) participants completed both surveys. Most were female (96.3%) and Hispanic (79.3%) (Table 1). Food security improved in the post-period, with more participants reporting high food security (pre: 6.9%, post: 31.0%) and fewer reporting very low food security (pre: 20.7%, post: 6.9%, p<0.01) (Table 2). Budgetary tradeoffs decreased in the post-program period (pre: 71.4%, post: 48.1%, p=0.03). Fifteen participants were interviewed. Themes included 1) saved money, 2) increased fruit and vegetable consumption, and 3) interest in future participation. Conclusion This pilot study found that an intervention for delivery of produce through home visiting programs was acceptable to participants and resulted in potential improvements in FI and household budgets. This supports future studies to further explore the impact of this novel intervention. What’s New In this prospective mixed-methods pilot, home delivered produce was acceptable and feasible with potentially improved food security and household budgets; evidence of potential change in produce consumption was mixed. Changes in budget tradeoffs is a novel outcome in food programs.

BACKGROUND:Guidelines recommend that hydroxyurea be offered to children with sickle cell disease (SCD) as early as 9 months of age using shared decision-making. To help clinicians implement shared decision-making with parents, we developed the Hydroxyurea Shared Decision-Making (H-SDM) toolkit. We evaluated its effectiveness on parent decisional uncertainty, perceptions of shared decision-making, hydroxyurea knowledge, and the likelihood of being offered and prescribed hydroxyurea. PROCEDURE:Sites began in the usual care condition (clinician pocket guide) before crossing over to the H-SDM toolkit condition between 2018 and 2022. Caregivers of children with SCD (birth to 5 years) eligible for hydroxyurea completed assessments at baseline, immediately after discussing hydroxyurea with their clinician, and 3-7 months later. RESULTS:Participants included 176 caregivers (93.2% female, 89% Black); most toolkit participants were enrolled during the pandemic (n = 81). There were no statistically significant differences between conditions on parent decisional uncertainty, perceptions of shared decision-making, or hydroxyurea knowledge (p-values >0.05). However, there was a clinically important difference in certainty, with higher decisional uncertainty in the usual care group. A greater proportion of participants enrolled during usual care were offered (80.7%) and prescribed hydroxyurea (48.2%), compared to 58.7% offered and 39.7% prescribed during the toolkit condition (p-values ≤0.01). CONCLUSIONS:Findings suggest the toolkit may help parents feel more confident in deciding about hydroxyurea. Given the significant impacts of the COVID-19 pandemic on study implementation, the impact on hydroxyurea uptake requires additional exploration. Ultimately, the H-SDM toolkit may be most beneficial for clinics that do not routinely use a shared decision-making process for those considering hydroxyurea.

Understanding the economics of pediatric liver transplantation (LT) is central to high-value care initiatives. We examined cost and resource utilization in pediatric LT nationally to identify drivers of cost and hospital factors associated with greater total cost of care. We reviewed 3295 children (<21 y) receiving an LT from 2010 to 2020 in the Pediatric Health Information System to study cost, both per LT and service line, and associated mortality, complications, and resource utilization. To facilitate comparisons, patients were stratified into high-cost, intermediate-cost, or low-cost tertiles based on LT cost. The median cost per LT was $150,836 [IQR $104,481-$250,129], with marked variance in cost within and between hospital tertiles. High-cost hospitals (HCHs) cared for more patients with the highest severity of illness and mortality risk levels (67% and 29%, respectively), compared to intermediate-cost (60%, 21%; p <0.001) and low-cost (51%, 16%; p <0.001) hospitals. Patients at HCHs experienced a higher prevalence of mechanical ventilation, total parental nutrition use, renal comorbidities, and surgical complications than other tertiles. Clinical (27.5%), laboratory (15.1%), and pharmacy (11.9%) service lines contributed most to the total cost. Renal comorbidities ($69,563) and total parental nutrition use ($33,192) were large, independent contributors to total cost, irrespective of the cost tertile ( p <0.001). There exists a significant variation in pediatric LT cost, with HCHs caring for more patients with higher illness acuity and resource needs. Studies are needed to examine drivers of cost and associated outcomes more granularly, with the goal of defining value and standardizing care. Such efforts may uniquely benefit the sicker patients requiring the strategic resources located within HCHs to achieve the best outcomes.

Equitable social determinants of health (SDOH) screening has been recommended by the Centers for Medicare & Medicaid Services and the Joint Commission; however, little is known about Spanish-speaking caregiver preferences on how they would like to be screened. We conducted a cross-sectional study at 3 pediatric clinics (October-December 2019). Caregivers completed (in English or Spanish) an SDOH screening preferences survey. Three hundred eighty-two of 443 caregivers approached (response rate = 86.2%) completed the survey. Most were female, preferred Spanish, and completed only high school. Spanish-speaking caregivers had greater odds of preferring verbal SDOH screening (odds ratio: 4.1; 95% confidence interval, 1.8-9.2) than English-speaking caregivers. Verbal SDOH screening should be a consideration in families who speak Spanish. Future studies should utilize qualitative methods to further explore Spanish-speaking caregiver preferences for SDOH screening.

BACKGROUND AND OBJECTIVE:National guidelines recommend that children with sickle cell anemia (SCA) be seen regularly by primary care providers (PCPs) as well as hematologists to receive comprehensive, multidisciplinary care. The objective is to characterize the patterns of primary and hematology care for children with SCA in Michigan.METHODS:Using validated claims definitions, children ages 1-17 years with SCA were identified using Michigan Medicaid administrative claims from 2010 to 2018. We calculated the number of outpatient PCP and hematologist visits per person-year, as well as the proportion of children with at least one visit to a PCP, hematologist, or both a PCP and hematologist annually. Negative binomial regression was used to calculate annual rates of visits for each provider type.RESULTS:A total of 875 children contributed 2889 person-years. Of the total 22,570 outpatient visits, 52% were with a PCP and 34% with a hematologist. Annually, 87%-93% of children had a visit with a PCP, and 63%-85% had a visit with a hematologist. Approximately 66% of total person-years had both visit types within a year. The annual rate ranged from 2.3 to 2.5 for hematologist visits and from 3.7 to 4.1 for PCP visits.CONCLUSIONS:Substantial gaps exist in the receipt of annual hematology care. Given that the majority of children with SCA see a PCP annually, strategies to leverage primary care visits experienced by this population may be needed to increase receipt of SCA-specific services.

The purpose of this review is to examine the impact of the Alma-Ata Declaration on global pediatric health disparities, highlighting the potential value of innovative research approaches such as intersectional quantitative studies in broadening our understanding of how the drivers of marginalization and social privilege intertwine to reinforce (or diminish each other) in the development of pediatric health disparity. Despite the global reach of the Alma-Ata Declaration and decades of its implementation, pediatric health disparities persist, with poorer health outcomes and greater exposure to adverse social contexts borne by children living in low and middle income countries (LMICs). This paper explores degree to which the Alma-Ata Declaration through its proxy pediatric policy, the Integrated Management of Childhood Illnesses (IMCI), has been able to reduce global pediatric health disparities and suggests the use of intersectional analytical approaches as a means of addressing shortfalls in effectiveness of pediatric health policies.

Increasing recognition of racism as a public health crisis has brought a new understanding of the historical context of marginalized communities and the policies (eg, redlining, gentrification, mass incarceration) implemented that have led to racial injustice. As pediatric health professionals embrace the necessary work of dismantling racism in medical education, clinical care, and research, they must adopt new principles and strategies in child health advocacy. This chapter provides an overview of child health advocacy, discusses advocacy as a professional standard, and outlines how to engage in advocacy centered on anti-racism. Keywords: pediatrics, advocacy, anti-racism