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This article is a report of a 2-day workshop, entitled "Social determinants of health and obstetric outcomes," held during the Society for Maternal-Fetal Medicine 2022 Annual Pregnancy Meeting. Participants' fields of expertise included obstetrics, pediatrics, epidemiology, health services, health equity, community-based research, and systems biology. The Commonwealth Foundation and the Alliance of Innovation on Maternal Health cosponsored the workshop and the Society for Women's Health Research provided additional support. The workshop included presentations and small group discussions, and its goals were to accomplish the following: 1. Review the current evidence on the relationship between social determinants of health and obstetrical outcomes 2. Discuss approaches to and research opportunities for the epidemiologic analysis of social determinants of health in obstetrical settings 3. Discuss approaches to and research opportunities for measuring how social determinants get biologically embedded to influence health and disease risk 4. Discuss approaches to and research opportunities for interventions and strategies to mitigate the detrimental effects of social determinants of health and improve obstetrical outcomes [ABSTRACT FROM AUTHOR]

Poverty affects child health and well-being in short- and long-term ways, directly and indirectly influencing a range of health outcomes through linked social and environmental challenges. Given these links, pediatricians have long advocated for poverty reduction in both clinical settings and society. Pediatricians and others who work in pediatric settings are well-suited to address poverty given frequent touchpoints with children and families and the trust that develops over repeated encounters. Many pediatricians also recognize the need for cross-sector engagement, mobilization, and innovation in building larger collaborative efforts to combat the harmful effects of poverty. A range of methods, like co-design, community organizing, and community-engaged quality improvement, are necessary to achieve measurable progress. Moreover, advancing meaningful representation and inclusion of those from underrepresented racial and ethnic minority groups will augment efforts to address poverty within and equity across communities. Such methods promote and strengthen key clinical-community partnerships poised to address poverty's upstream root causes and its harmful consequences downstream. This article focuses on those clinical-community intersections and cross-sector, multi-disciplinary programs like Medical-Legal Partnerships, Medical-Financial Partnerships, clinic-based food pantries, and embedded behavioral health services. Such programs and partnerships increase access to services difficult for children living in poverty to obtain. Partnerships can also broaden to include community-wide learning networks and asset-building coalitions, poised to accelerate meaningful change. Pediatricians and allied professionals can play an active role; they can convene, catalyze, partner, and mobilize to create solutions designed to mitigate the harmful effects of poverty on child health. [ABSTRACT FROM AUTHOR]

Civic engagement, including voting, has been linked to health outcomes for adults. Here, we found that census tract-level voter participation rates are significantly associated with pediatric inpatient bed-day rates even after adjustment for socioeconomic deprivation. Such links suggest that promotion of voting participation could be warranted in healthcare settings. [ABSTRACT FROM AUTHOR]

Study Objective: We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma.Methods: This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit.Results: A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit.Conclusion: Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort. [ABSTRACT FROM AUTHOR]

Objectives: To design and implement a collaborative medication therapy management (MTM) program targeting pediatric patients with high-risk asthma in a community pharmacy.Setting: Underserved inner city of Cincinnati, OH.Practice Description: A large national grocery store chain pharmacy and an academic hospital developed a partnership aimed at improving asthma care for shared patients. An interdisciplinary project team was formed, including 2 clinical pharmacists, 1 pharmacy district clinical coordinator, 1 pharmacy division clinical coordinator, 1 associate professor at a college of pharmacy, 1 pharmacy resident, and 3 pediatric physicians. This pilot project involved 2 Kroger Pharmacy sites and Cincinnati Children's Hospital Medical Center's (CCHMC) 3 pediatric primary care centers.Practice Innovation: Kroger and CCHMC staff identified shared high-risk asthma patients (those cared for at the included primary care centers who used Kroger for their medication fills) with the use of information from validated symptom assessments (Asthma Control Test), refill history, and recent health care utilization. Community pharmacists recruited jointly identified patients and provided a targeted MTM intervention. Education focused on asthma diagnosis, types of asthma medications, appropriate medication administration, and environmental triggers. Pharmacists suggested medication changes to prescribers via facsimile. Pharmacists followed up with patients in 30 days to assess asthma control, provide additional education, and propose further recommendations.Evaluation: Outcomes evaluated included the average number of recommendations made to patients and prescribers and acceptance rates for each of those measures.Results: Six patients completed the project. Pharmacists provided an average of 3.7 recommendations to each patient and 1.5 to prescribers for each patient; 77.3% and 100% recommendations were accepted, respectively.Conclusion: This pilot project describes the design and implementation of a pharmacist-physician collaborative program for high-risk pediatric asthma patients. The greatest outcome of this project was the formation of a collaborative team between pharmacists and physicians that continues to work together on additional family-centered initiatives. [ABSTRACT FROM AUTHOR]

Racial disparities in childhood asthma outcomes result from a complex interplay of individual- and neighborhood-level factors. We sought to examine racial disparities in asthma-related emergency department (ED) visits between African American (AA) and European American (EA) children. This is a retrospective study of patients younger than 18 years who visited the ED at Cincinnati Children's for asthma from 2009 to 2018. The outcome was number of ED visits during a year. We assessed 11 social, economic, and environmental variables. Mediation and mixed-effects analyses were used to assess relationships between race, mediators, and number of ED visits. A total of 31,114 children (46.1% AA, 53.9% EA) had 186,779 asthma-related ED visits. AA children had more visits per year than EA children (2.23 vs 2.15; P <.001). Medicaid insurance was associated with a 7% increase in rate of ED visits compared with commercial insurance (1.07; 95% CI, 1.03-1.1). Neighborhood socioeconomic deprivation was associated with an increased rate of ED visits in AA but not in EA children. Area-level particulate matter with diameter less than 2.5 μm, pollen, and outdoor mold were associated with an increased rate of ED visits for both AA and EA children (all P <.001). Associations between race and number of ED visits were mediated by insurance, area-level deprivation, particulate matter with diameter less than 2.5 μm, and outdoor mold (all P <.001), altogether accounting for 55% of the effect of race on ED visits. Race was not associated with number of ED visits (P =.796) after accounting for mediators. Racial disparities in asthma-related ED visits are mediated by social, economic, and environmental factors, which may be amenable to interventions aimed at improving outcomes and eliminating inequities. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective: To identify the optimal measure of active and passive prenatal tobacco exposure to predict wheeze in early life. Study design: We conducted a birth cohort study of 398 mother-infant dyads enrolled during the second trimester of pregnancy and followed through age 2 years. We measured tobacco exposure with maternal report, serum cotinine level, and meconium cotinine level. We assessed wheeze with parent report every 6 months. We used a repeated measures logistic regression model. Results: Of 367 children with respiratory data, 26% percent had parent reported active or passive prenatal maternal tobacco exposure, but cotinine was detected in 61% of mothers during pregnancy. Compared with children of mothers in the fifth percentile of tobacco exposure, children of mothers in the 95th percentile had increased odds of wheeze when exposure was measured with maternal serum cotinine level (adjusted OR, 2.6; 95% CI, 1.3-5.2; P < .006) versus meconium cotinine level (adjusted OR, 2.0; 95% CI, 1.0-4.0; P = .04) and total parent-reported exposure (adjusted OR, 1.7; 95% CI, 1.1-2.7; P = .01). Conclusions: Serum cotinine, a biomarker of tobacco exposure, was more strongly associated with wheeze than parent-reported exposure. Studies that rely on parent report of prenatal tobacco exposure may underestimate risk of wheeze. [ABSTRACT FROM AUTHOR]

Objective.—To determine the relative contribution of maternal psychological distress, maternal restraint use, and sociodemographic characteristics to the likelihood that a child would not be restrained in a motor vehicle. Methods.—We examined data on 6251 children aged 0–17 years from the 1998 National Health Interview Survey. The level of children's motor vehicle restraint use (low vs high) was examined by maternal psychological distress and motor vehicle restraint use. Multivariate regression analyses were used to model the odds of children's low use of motor vehicle restraints, controlling for potential confounders. Results.—According to maternal reports, more than 10% of children and nearly 13% of mothers reported low use of motor vehicle restraints. Multivariate analyses revealed that maternal use of restraints and psychological distress were both independently related to children's use of restraints, with maternal low use as the stronger correlate. Older children were more likely than younger children to be low users of motor vehicle restraints if the mother reported that she was a low user of restraints. Families with male children, black and Hispanic mothers, and 4 or more members reported lower use of restraints for their children. Conclusions.—Children's low use of motor vehicle restraints was associated with low levels of maternal motor vehicle restraint use and maternal psychological distress. Moreover, maternal motor vehicle restraint practices become increasingly important as children age. Health care providers should consider maternal motor vehicle restraint use, maternal psychological distress, and child age in addition to sociodemographics when assessing children's motor vehicle safety. [ABSTRACT FROM AUTHOR]

Social and financial hardships, combined with disease managment and environmental factors explain approximately 80% of the observed disparity in asthma-related readmissions between Black and White children. We sought to determine whether asthma-related readmissions differed by degree of African ancestry and the extent to which such an association would also be explained by socioenvironmental risk factors. This study used data from a prospective cohort study of 695 Black and White children aged 1 to 16 years with an asthma-related admission. The primary outcome was a similar readmission within 12 months. Each subject's African ancestry was determined by single nucleotide polymorphisms on a continuous scale ranging from 0 to 1 (0 = no African ancestry; 1 = 100% African ancestry). We also assessed 37 social, environmental, and clinical variables that we clustered into 6 domains (for example, hardship, disease management). Survival and mediation analyses were conducted. A total of 134 children (19.3%) were readmitted within 12 months. Higher African ancestry was associated with asthma readmission (odds ratio 1.11, 95% confidence interval 1.05-1.18 for every 10% increase in African ancestry) with adjustment for age and gender. The association between African ancestry and readmission was mediated by hardship (sβ = 3.42, P <.001) and disease management (sβ = 0.046, P =.001), accounting for >50% of African ancestry's effect on readmission. African ancestry was no longer significantly associated with readmission (sβ = 0.035, P =.388) after accounting for these mediators. African ancestry was strongly associated with readmission, and the association was mediated by family hardship and disease management. These results are consistent with the notion that asthma-related racial disparities are driven by factors like structural racism and social adversity. [Display omitted] [ABSTRACT FROM AUTHOR]

Objectives: To determine whether the Child Opportunity Index (COI), a nationally available measure of relative educational, health/environmental, and social/economic opportunity across census tracts within metropolitan areas, is associated with population- and patient-level asthma morbidity.Study Design: This population-based retrospective cohort study was conducted between 2011 and 2013 in a southwest Ohio county. Participants included all children aged 1-16 years with hospitalizations or emergency department visits for asthma or wheezing at a major pediatric hospital. Patients were identified using discharge diagnosis codes and geocoded to their home census tract. The primary population-level outcome was census tract asthma hospitalization rate. The primary patient-level outcome was rehospitalization within 12 months of the index hospitalization. Census tract opportunity was characterized using the COI and its educational, health/environmental, and social/economic domains.Results: Across 222 in-county census tracts, there were 2539 geocoded hospitalizations. The median asthma-related hospitalization rate was 5.0 per 1000 children per year (IQR, 1.9-8.9). Median hospitalization rates in very low, low, moderate, high, and very high opportunity tracts were 9.1, 7.6, 4.6, 2.1, and 1.8 per 1000, respectively (P < .0001). The social/economic domain had the most variables significantly associated with the outcome at the population level. The adjusted patient-level analyses showed that the COI was not significantly associated with a patient's risk of rehospitalization within 12 months.Conclusions: The COI was associated with population-level asthma morbidity. The details provided by the COI may inform interventions aimed at increasing opportunity and reducing morbidity across regions. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether population-level violent (and all) crime rates were associated with population-level child asthma utilization rates and predictive of patient-level risk of asthma reutilization after a hospitalization.Study Design: A retrospective cohort study of 4638 pediatric asthma-related emergency department visits and hospitalizations between 2011 and 2013 was completed. For population-level analyses, census tract asthma utilization rates were calculated by dividing the number of utilization events within a tract by the child population. For patient-level analyses, hospitalized patients (n = 981) were followed until time of first asthma-related reutilization. The primary predictor was the census tract rate of violent crime as recorded by the police; the all crime (violent plus nonviolent) rate was also assessed.Results: Census tract-level violent and all crime rates were significantly correlated with asthma utilization rates (both P < .0001). The violent crime rate explained 35% of the population-level asthma utilization variance and remained associated with increased utilization after adjustment for census tract poverty, unemployment, substandard housing, and traffic exposure (P = .002). The all crime rate explained 28% of the variance and was similarly associated with increased utilization after adjustment (P = .02). Hospitalized children trended toward being more likely to reutilize if they lived in higher violent (P = .1) and all crime areas (P = .01). After adjustment, neither relationship was significant.Conclusions: Crime data could help facilitate early identification of potentially toxic stressors relevant to the control of asthma for populations and patients. [ABSTRACT FROM AUTHOR]

Objective: To describe hardships experienced by families of children with medical complexity (CMC) and compare them with those experienced by families of children with asthma.Study Design: We assessed hardships in a cohort of 167 families of CMC. Surveys assessed sociodemographics and hardships (eg, financial: inability to pay bills; social: limited help from family/friends). CMC cohort hardships were compared with those of an established cohort of children hospitalized with asthma using multivariable logistic regression.Results: CMC had diagnoses in a median of 5 different complex chronic condition categories (most common neurologic/neuromuscular), and the majority (74%) were dependent on technology. Over 80% of families of CMC reported experiencing ≥1 hardship; 68% with financial and 46% with social hardship. Despite higher socioeconomic status than families with asthma, families of CMC often experienced more hardships. For example, families of CMC were significantly more likely to report failure to pay rent/mortgage (aOR 2.6, 95% CI 1.6, 4.3) and the expectation of little to no help from family/friends (aOR 2.9, 95% CI 1.9, 4.7).Conclusions: Families of CMC frequently report financial and social hardships, often at rates higher than families with asthma who were generally of lower socioeconomic status. Identifying and acting upon hardships may be an important addition to the care of CMC. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between exposure to traffic-related air pollution (TRAP) and hospital readmission for asthma or bronchodilator-responsive wheezing. Study design: A population-based cohort of 758 children aged 1-16 years admitted for asthma or bronchodilator-responsive wheezing was assessed for asthma readmission within 12 months. TRAP exposure was estimated with a land use regression model using the home address at index admission, with TRAP dichotomized at the sample median (0.37 μg/m3). Covariates included allergen-specific IgE, tobacco smoke exposure, and social factors obtained at enrollment. Associations between TRAP exposure and readmission were assessed using logistic regression and Cox proportional hazards models. Results: The study cohort was 58% African American and 32% white; 19% of the patients were readmitted within 12 months of the original admission. Higher TRAP exposure was associated with a higher readmission rate (21% vs 16%; P = .05); this association was not significant after adjusting for covariates (aOR, 1.4; 95% CI, 0.9-2.2). Race modified the observed association; white children with high TRAP exposure had 3-fold higher odds of asthma readmission (OR, 3.0; 95% CI, 1.1-8.1), compared with white children with low TRAP exposure. In African American children, TRAP exposure was not associated with increased readmission (OR, 1.1; 95% CI, 0.6-1.8). In children with high TRAP exposure, TRAP exposure was associated with decreased time to readmission in white children (hazard ratio, 3.2; 95% CI, 1.5-6.7) compared with African American children (hazard ratio, 1.0; 95% CI, 0.7-1.4). African American children had a higher readmission rate overall. Conclusion: TRAP exposure is associated with increased odds of hospital readmission in white children, but not in African American children. [Copyright &y& Elsevier]

Objectives: To characterize variation and inequalities in neighborhood child asthma admission rates and to identify associated community factors within one US county. Study design: This population-based prospective, observational cohort study consisted of 862 sequential child asthma admissions among 167 653 eligible children ages 1-16 years in Hamilton County, Ohio. Admissions occurred at a tertiary-care pediatric hospital and accounted for nearly 95% of in-county asthma admissions. Neighborhood admission rates were assessed by geocoding addresses to city- and county-defined neighborhoods. The 2010 US Census provided denominator data. Neighborhood admission distribution inequality was assessed by the use of Gini and Robin Hood indices. Associations between neighborhood rates and socioeconomic and environmental factors were assessed using ANOVA and linear regression. Results: The county admission rate was 5.1 per 1000 children. Neighborhood rates varied significantly by quintile: 17.6, 7.7, 4.9, 2.2, and 0.2 admissions per 1000 children (P < .0001). Fifteen neighborhoods containing 8% of the population had zero admissions. The Gini index of 0.52 and Robin Hood index of 0.38 indicated significant inequality. Neighborhood-level educational attainment, car access, and population density best explained variation in neighborhood admission rates (R2 = 0.55). Conclusion: In a single year, asthma admission rates varied 88-fold across neighborhood quintiles in one county; a reduction of the county-wide admission rate to that of the bottom quintile would decrease annual admissions from 862 to 34. A rate of zero was present in 15 neighborhoods, which is evidence of what may be attainable. [Copyright &y& Elsevier]

Objective: Because of significant individual variability in attention-deficit/hyperactivity disorder (ADHD) medication response, there is increasing interest in identifying genetic predictors of treatment effects. This study examined the role of four catecholamine-related candidate genes in moderating methylphenidate (MPH) dose-response.Method: Eighty-nine stimulant-naive children with ADHD 7 to 11 years old participated in a randomized, double-blind, crossover trial of long-acting MPH. Parents and teachers assessed each child's response on placebo and three MPH dosage levels using the Vanderbilt ADHD rating scales. Children were genotyped for polymorphisms in the 3' untranslated region of dopamine transporter (DAT), exon 3 on dopamine receptor D(4) (DRD4), codon 158 on catechol-O-methyltransferase, and the adrenergic α(2A)-receptor promoter. Linear mixed models evaluated gene, dose (milligrams per kilogram per day), and gene-by-dose effects on inattentive and hyperactive-impulsive domain outcomes.Results: The most statistically significant gene-by-dose interactions were observed on hyperactive-impulsive symptoms for DRD4 and DAT polymorphisms, with participants lacking the DAT 10-repeat allele showing greater improvements in symptoms with increasing dose compared with 10-repeat carriers (p = .008) and those lacking the DRD4 4-repeat allele showing less improvement across MPH doses compared with 4-repeat carriers (p = 0.02).Conclusions: This study suggests that DAT and DRD4 polymorphisms may be associated with individual variability in MPH dose-response, although further research in larger samples is required to confirm these findings and their clinical utility.Clinical Trial Registration Information: Response Variability in Children with Attention-Deficit/Hyperactivity Disorder (ADHD); http://www.clinicaltrials.gov; NCT01238822. [ABSTRACT FROM AUTHOR]

Background: Prior studies have examined independent effects of a dopamine receptor D4 polymorphism (DRD4-7) and lead exposure on executive functions but not their interaction or the role of sex as a modifier of their effects. Methods: Multivariable analyses were used to examine effects of DRD4-7 genotype, 60-month blood lead level, and sex on spatial working memory, rule learning and reversal, spatial span, and planning for 174 children. Results: DRD4-7 was associated with poorer spatial working memory, and increasing blood lead levels were associated with impaired rule learning and reversal, spatial span, and planning. Adverse effects of lead on planning and rule learning and reversal were seen primarily for boys. In addition, the effect of lead on rule learning and reversal was evident predominately for those lacking DRD4-7. Conclusions: We observed independent effects of DRD4-7 and lead on various executive functions and modifications of lead effects by DRD4 genotype and sex. [Copyright &y& Elsevier]