Healthcare inequities and resultant disparities in health outcomes can be influenced by clinical guidelines and organization policies. This guidance may be implicitly or explicitly embedded with bias, discrimination, and racist ideologies which have the potential to cause harm, not only for historically marginalized and minoritized communities, but also at a broader population health-level. The American Academy of Pediatrics (AAP) is a professional society responsible for the creation and dissemination of many clinical practice guidelines (CPGs) and clinical reports (CRs) to promote child health. Recognizing the importance of ensuring that these CPGs and CRs promote health equity, the AAP convened a group of health services researchers to develop and pilot an evidence-informed instrument to assess for the inappropriate use of race and/or ethnicity. This article describes the methodological approach to developing and applying the evidence-informed instrument to the compendium of active AAP CPGs and CRs. We also present an approach for prioritizing CPGs and CRs most urgently in need of revision and describe a process to achieve buy-in within AAP leadership, and among the authoring groups and other partners. The process described here may be utilized by other professional societies and healthcare organizations to assess their own clinical guidelines.

Pediatric clinical guidelines and algorithms have frequently included race as a risk factor to be considered in clinical decision-making. This practice, commonly known as "race-based medicine" or "race correction," substitutes race as a flawed proxy for socioeconomic status and genetic ancestry. The American Academy of Pediatrics has called for the elimination of race-based medicine and endorsed "race-conscious medicine" as a preferable alternative. Race-conscious medicine embraces race-neutral clinical tools and supports efforts to tackle the structural barriers to health that cause racial disparities. We aimed to assess recent progress and identify ongoing barriers in the implementation of race-conscious medicine in pediatrics. First, we review the role of medical societies and the research community in generating race-conscious alternatives to race correction, while noting that many pediatric tools continue to include race in ways that may negatively impact equity. Second, we discuss the role of health care organizations in implementing race-conscious guidance locally, drawing upon specific local and regional efforts to reveal organizational, cultural, technical, and financial factors that may facilitate or impede success. Third, we identify medical education governing bodies as essential in integrating the principles of race-conscious medicine into every stage of medical education. Fourth, we highlight the need for third-party clinical algorithm platforms and biomedical device manufacturers to provide access to race-conscious tools through their products. Finally, we address the role of the policy and regulatory landscape in accelerating or slowing the rate of progress, and the importance of patient engagement and redress of historical harms.

The last several years have seen increased scholarly attention paid to the use of race in clinical algorithms and practice guidelines.1 Whether it be attempts at race correction, race norming or race adjustment the inappropriate use of race as independent proxy for biologic variables is being vigorously challenged.2 Several organized medicine bodies have issued policy and/or positions declaring opposition to race-based medicine and commitment to critically examining the role of race and racism as structural contributors to outcome disparities.3,4,5 In terms of the investigative underpinnings that support the development of clinical algorithms, in a 2024 study entitled Rethinking the Use of Race in Biomedical Research, the National Academies of Science Medicine and Engineering panel encouraged researchers to “refrain from making unsupported inferences from the analysis, such as relying on race and ethnicity as causal attributes that drive biomedical research outcomes”.6 The scientific literature is replete with examples beyond the scope of risk determining algorithms and equations where race is embedded as a variable that can deleteriously influence clinical decision-making.

This article summarizes how pediatricians may be uniquely positioned to mitigate the long-term trajectory of COVID-19 on the health and wellness of pediatric patients especially with regard to screening for social determinants of health that are recognized drivers of disparate health outcomes. Health inequities, that is, disproportionately deleterious health outcomes that affect marginalized populations, have been a major source of vulnerability in past public health emergencies and natural disasters. Recommendations are provided for pediatricians to collaborate with disaster planning networks and lead strategies for public health communication and community engagement in pediatric pandemic and disaster planning, response, and recovery efforts.

BACKGROUND:Although socioeconomic disparities in outcomes of peripheral artery disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship. METHODS:Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005-2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses. RESULTS:There were 765,175 patients identified; 34% in the first MHI quartile and 18% in the fourth MHI quartile. Compared to patients in the first quartile, those in the fourth quartile were more likely White (69% vs. 42%, P < 0.001), more likely ≥65 years old (75% vs. 62%, P < 0.001), and were less likely to undergo amputations (25% vs. 34%, P < 0.001). After adjusting for patient characteristics, the fourth quartile was associated with more severe disease [Odds ratio: 1.19, 95% confidence interval (CI): 1.11-1.27] compared to the first quartile. CONCLUSIONS:While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.

The last several years have seen accelerated activity and discourse directed at antiracism. Specifically following the 2020 murder of George Floyd, institutions across the country engaged in a range of introspective exercises and transparent reckonings examining their practices, policies, and history insofar as equity and racism is concerned. The authors of this article, both active protagonists in this domain, have been, and continue to be, part of ongoing national efforts and have learned much about the strategies and tactics necessary to initiate, engage, and sustain traction on the path to antiracism.

The last several years have seen accelerated activity and discourse directed at antiracism. Specifically following the 2020 murder of George Floyd, institutions across the country engaged in a range of introspective exercises and transparent reckonings examining their practices, policies, and history insofar as equity and racism is concerned. The authors of this article, both active protagonists in this domain, have been, and continue to be, part of ongoing national efforts and have learned much about the strategies and tactics necessary to initiate, engage, and sustain traction on the path to antiracism.

Race-based medicine has been pervasively interwoven into the fabric of health care delivery in the United States for more than 400 years. Race is a historically derived social construct that has no place as a biologic proxy. In addition to valid measures of social determinants of health, the effects of racism require consideration in clinical decision-making tools in ways that are evidence informed and not inappropriately conflated with the limiting phenotype of race categorization. This policy statement addresses the elimination of race-based medicine as part of a broader commitment to dismantle the structural and systemic inequities that lead to racial health disparities.

Over the last several years, academic pediatrics has made a concerted effort to address diversity and inclusion, certainly accelerated by the heightened national discourse and activism in the wake of the May 2020 murder of George Floyd.1 The Academic Pediatric Association (APA), the American Academy of Pediatrics, the American Pediatric Society (APS), and the Society for Pediatric Research, the partner organizations that comprise the Pediatric Academic Societies, have taken notable steps in promoting diverse and inclusive environments as part of strategic commitments to address equity and health equity broadly.2–5In this issue of Pediatrics, Omoruyi et al6 detail the trends of pediatric faculty underrepresented in medicine (URiM) over the last 2 decades. Despite overall growth in URiM pediatric faculty at all academic ranks, these increases have notably failed to keep pace with the rapidly diversifying population of children <18 years old in the United States. Dramatically discordant with the percentage of people of color in the general population at baseline, the authors point out the importance of growing a diverse and culturally competent physician workforce to effectively address the systemic inequities and health disparities that disproportionately impact vulnerable and historically marginalized communities. Structural barriers that contribute to noninclusive professional environments, including feelings of isolation, perceived lack of academic opportunity, and microaggressions and outright racism, have all been cited by URiM faculty as contributing factors to negative and less than satisfactory experiences.7,8 Additionally, the authors specifically highlight stagnation of African American male representation among pediatric faculty, reflective of the overall decline of this demographic among medical school matriculants since 1978.9 Complicating the multifactorial challenges at the entry point, the career pipeline for African American men in academic medicine is particularly leaky, beset by retention challenges including lack of scholarly advancement and relatively higher rates of attrition.6The value of exposure of early career URiM trainees and junior faculty to programs that emphasize academic scholarship and focus on successful navigation of the academic landscape has been recognized and supported by academic pediatric organizations.10,11 Specifically included as part of the curricular content of one such program (the APA’s “New Century Scholars”) is concordant alignment of participants with both a junior and a senior faculty mentor. This triad model is designed to not only support the participants’ scholarship, but also to promote career and leadership development through the important experiential lens of “if I can see it, I can be it.” URiM trainees have identified the opportunity to develop such relationships as a positive influence in choosing academic pediatrics.12 Therefore, the task of aligning, supporting, and ultimately growing the relatively small pool of URiM pediatric faculty to serve in mentorship or sponsorship capacities is a key element of diverse and inclusive workforce development.The American Academy of Pediatrics policy statement Enhancing Pediatric Workforce Diversity and Providing Culturally Effective Pediatric Care: Implications for Practice, Education, and Policy Making emphasizes the need to advance diversity in leadership roles.13 The current constellation of leadership across the Pediatric Academic Societies serves as a perfect example. The APA and Society for Pediatric Research presidents-elect are both from URiM groups as are both the current APS president and president-elect.14–17 Additionally, 2 of the leaders in this cohort are men of color. The intra- and interorganizational energy across the Pediatric Academic Societies is palpable as these leaders chart the course for advancing diversity, equity and inclusion in their respective organizations. The collective talent and unique lived experience perspectives of these individuals will provide valuable synergy and “see it to be it” visibility for members as all pediatric providers engage in this necessary work. Transformative change in any profession, sector, or domain starts with leadership at the top; addressing diversity and inclusion in academic pediatrics is no different.To be clear, the work of diversifying the pediatric workforce should not be limited to URiM leaders and practitioners. In a 2020 commentary,18 Reddick analogizes the onerous labor of African American leaders in dismantling workplace racism to the work of the folklore hero John Henry. Henry, an African American “steel-driving man” ultimately defeats a machine in a race to bore an underground coal mining tunnel. However, he dies at the end of the narrative tale of heart failure. The so-called “minority tax”19,20 borne by URiM physicians in addressing issues of bias and racism in patient care, policy, and faculty development is deleterious to personal physical and mental health, clinical performance, and professional advancement. URiM and non-URIM practitioners must evenly disseminate diversity, equity, and inclusion work to ensure that all academic pediatricians positively contribute to the reframing of our institutional and professional environments.

In theory, clinical practice guidelines (CPGs) are designed to reduce cognitive load, standardize care delivery, improve clinical outcomes, and mitigate disparities through equitable practice.1However, pediatric CPGs have recently come under scrutiny for being outdated and methodologically challenged in keeping up with emerging evidence.2 In addition, a systematic review found that, although there were some positive effects of the use of race or ethnicity in pediatric CPGs, there was a potential for negative effect almost half of the time.3In this issue of Pediatrics, Kemper et al offer a revision of the CPG on Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.4 Initially published in 2004 and updated with clarifications and modifications in 2009,5,6 this CPG has been among the most frequently cited of the American Academy of Pediatrics’ practice guidelines, as well as, a highly referenced resource by practitioners commensurate with the almost universal incidence of jaundice in the newborn period. This CPG is the first published, following the American Academy of Pediatrics’ concerted commitment to applying an equity lens in developing its policy statements, practice guidelines, and clinical and technical reports as outlined in the Eliminating Race-Based Medicine policy statement.7 The policy statement defines race-based medicine as the inappropriate use of race or ethnicity as an independent or dichotomizing risk-adjusting variable in clinical algorithms, practice guidelines, or policy statements. This new policy is relevant to the revised Management of Hyperbilirubinemia CPG in that the 2004 version of the practice guideline identified race and ethnicity assignment of the newborn as a risk-adjusting variable in clinical decision-making. Specifically, an infant race-assigned as Black received a downgraded quantitative score for risk of severe hyperbilirubinemia, thus obviating the urgency for aggressive diagnostic work-up. However, a more recent and nuanced analysis of the incidence of hazardous hyperbilirubinemia, ie, the risk for encephalopathy and neurotoxicity, reveals that Black babies are disproportionately represented in kernicterus databases at 25% as compared with their 14% representation in the overall population of newborns.8 Missed or delayed recognition of the acute hemolysis associated with glucose- 6-phosphate dehydrogenase (G6PD) deficiency has been implicated among the root causes of this irreversible condition. Persistence of this dangerous disparity potentially related to algorithmic minimization of risk for Black infants warranted attention and reconciliation. The authors have addressed this in the revision by: (1) striking the race and ethnicity terms from among the independent variables included in assessing risk for severe hyperbilirubinemia, and (2) emphasizing the critical importance of probing ancestry as a critical component of the decision-making process in the assessment of jaundice. As an x-linked recessive enzymopathy that renders children with G6PD deficiency highly susceptible to rapid onset hemolysis in the setting of oxidative stress, pediatricians need to understand the underlying biology of G6PD deficiency and its relevance to geographic distribution around the world.The linkage of race, ancestry, and genetics is inextricable, particularly in the face of conditions that result from a defined polymorphism.9 However, race assignment is a social construct and should not necessarily be conflated with genetic ancestry. For instance, in the case of the 2004 Management of Hyperbilirubinemia CPG, the decision-making risk assessment was predicated on the mother’s assignment of the newborn’s race. This approach is problematic, particularly with increasing genetic admixture worldwide and families who may identify themselves as mixed-race or defer racial definitions altogether. Determination of care delivery based on capricious, subjective stratification as judged by the phenotypic physical characteristic of skin color is fraught with uncertainty. Whereas we must surely be cognizant of the significance of assigned race along the causal pathway of disease or condition manifestation, we cannot independently substitute race alone as a proxy for underlying biologic mechanisms. Therefore, we must be conscious of the role that race plays as a driver of systemic inequities and disparate outcomes, especially as relates to the influences of the social determinants of health.10 However, we cannot be dependent on race as a substitute for contributory factors either known and not measured, or unknown and in need of discovery. An excellent example of progress in this area is the Urinary Tract Infection (UTI) Risk Calculator,11 which was recently revised by incorporating 2 new clinical factors and dropping race as a risk-adjusting variable. The UTI Calc version 3.0 with race now removed and the clinical variables, history of prior UTI, and fever for ≥48 hours, added performs comparably to prior versions.12 The observed epidemiologic difference initially identified by the investigators that prompted the inclusion of race as a dichotomizing variable remains unexplained. Still, the decision-making pathway is clinically efficient and no longer race-based.13From an epidemiologic perspective, we cannot completely ignore race, especially in the context of biomedical research given the sustained impacts of bias and discrimination in healthcare and society over time.14 However, we must responsibly incorporate it into the complex milieu of interdisciplinary factors that constitute adversity, define differential lived experiences, and ultimately confer resilience to our patients and their families, especially those from historically vulnerable and minoritized communities.

Police violence in the United States represents a pressing public health crisis impacting youth, particularly youth of color. This article reviews the recent epidemiology of police executions and conflicts involving children, adolescents, and young adults. The roles of social determinants of health and centuries-long history of white supremacy and racism as root causes of adverse policing are emphasized. The article summarizes the evidence as to how direct and vicarious experiences of police violence impact youth academic, behavioral, and health outcomes. Recommendations are provided for pediatricians to address this public health crisis through clinical practice, education, advocacy, and research.

Department of Health Policy and Management, School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD 20742, United States. Department of Surgery, Howard University College of Medicine, 2041 Georgia Ave NW, Washington, DC 20060, United States. Louis Stokes Health Sciences Library, College of Medicine, Howard University, 501 W Street NW, Washington, DC 20060, United States. Department of Behavioral and Community Health, School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD 20742, United States. University of Maryland Capital Region Health, 3001 Hospital Dr, Cheverly, MD 20785, United States.

It has been more than a year since Immediate Past President of the American Academy of Pediatrics (AAP), Sally Goza, MD, FAAP, warned against the threat severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) posed to children and families, including the harm coronavirus disease 2019 (COVID-19)–fueled racism and xenophobia could cause the Asian American community. Sadly, as the COVID-19 pandemic spread, racism and violent attacks on Asian Americans spread along with it.

ObjectiveAlthough it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction.MethodsPatients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses.ResultsOf the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups.ConclusionsLower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.