Lately, I have been struck by the increasing volumes of research on disparities in medicine. A recent issue from the Journal of Pediatrics had at least 4 articles touching on this subject. Most of these articles view these disparities as being due to structural racism.

1. J Smith et al. J Pediatr 2023; 260: 113522. Racial Disparities in Pediatric Inflammatory Bowel Disease Care: Differences in Outcomes and Health Service Utilization Between Black and White Children

In this article, the authors show that among 519 children with newly diagnosed IBD, black patients were less likely to achieve CSFR (corticosteroid-free remission) 1-year post diagnosis (OR: 0.52, 95% CI:0.3-0.9) and less likely to achieve sustained CSFR (OR: 0.48, 95% CI: 0.25-0.92). This was despite a similar phenotype. Black patients had much higher rate of public insurance (58% vs 30%) and were less likely to be seen for routine follow-up visits.

While the authors attribute the response to therapy as likely to be related mainly to social determinants of health, there may be biologic factors at work as well. In a recent study (R Greywoode et al. Inflamm Bowel Dis 2023; 29: 843-849. Open Access! Racial Difference in Efficacy of Golimumab in Ulcerative Colitis), there were disparate racial response rate differences among patients receiving the same therapy.

2. AP Srinivasan et al. J Pediatr 2023; 260: 113485. Open access! Disparities in Pediatric Specialty Referral Scheduling and Completion

In this retrospective review of 38,334 specialty referrals (2019-2021), of all referrals, 62% were scheduled and 54% were completed. Referral completion rates were lower for patients with Black race (45%), Native Hawaiian/Pacific Islander race (48%), Spanish language (49%), and public insurance (47%). Since the report focused on primary clinics within 5 miles of the hospital, the authors indicate that the lower referral completion is due to nongeographic structural barriers, including problems with arranging visits as some families have less flexible jobs. The authors conclude that the fact that specialty care is inaccessible is due to ” the effects of racism and discrimination on the scheduling process.” The authors recommend that the referral workflows should not “place the administrative onus of scheduling exclusively on families.”

3. SS Hwang et al. J Pediatr 2023; 260: 113498. Racial and Ethnic Disparities in Sudden Unexpected Infant Death Among US Infants Born Preterm

This was a retrospective cohort analysis of linked birth and death certificates from 50 states from 2005 to 2014 to investigate among US infants born at <37 weeks gestation (a) racial and ethnic disparities in sudden unexpected infant death (SUID).  Key findings:

• Among 4,086,504 preterm infants born during the study period, 8096 infants (0.2% or 2.0 per 1000 live births) experienced SUID. State variation in SUID ranged from the lowest rate of 0.82 per 1000 live births in Vermont to the highest rate of 3.87 per 1000 live births in Mississippi
• In the adjusted analysis (for sociodemographic and clinical factors), compared with Non-Hispanic white infants, Non-Hispanic black infants and Alaska Native/American Indian preterm infants had greater odds of SUID (aOR, 1.5)and aOR, 1.44) 
• The authors attribute the adjusted differences to “structural racism [that] creates and perpetuates health inequities.”

4. KL Karvonen et al. J Pediatr 2023; 260: 113499. Open access! Structural Racism Operationalized via Adverse Social Events in a Single-Center Neonatal Intensive Care Unit

This was a retrospective cohort study of 3290 infants hospitalized in a single center NICU between 2017 and 2019 in the Racial and Ethnic Justice in Outcomes in Neonatal Intensive Care (REJOICE) study. Key findings:

• 205 families (6.2%) that experienced an adverse social event. Black families were more likely to have experienced a CPS referral and a urine toxicology screen (OR, 3.6). American Indian and Alaskan Native families were also more likely to experience CPS referrals and urine toxicology screens (OR, 15.8 and OR, 7.6)
• Black families were more likely to experience behavioral contracts and security emergency response calls

My take: These articles offer more proof that racial disparities are highly prevalent in healthcare. While we should strive to help improve access/equitable care in medicine, the approach needs to start well before the clinic/hospital. To make the greatest impact, policies are needed to address education outcomes and poverty (eg. expanded child income tax credit) which overall impact health more than anything that happens in our clinics.

Related blog posts:

On Disparities:

• Understanding Racial Differences in Response to IBD Treatment — Golimumab in Ulcerative Colitis
• Zip Code vs. Genetic Code
• Zip Code or Genetic Code -which is more important for longevity?
• U.S. Health System: ‘World Leader in Amputations’
• Unfortunate or Unfair Disparities in Liver Transplantation
• Disparity in the Care of Black Inflammatory Bowel Disease Patients
• Images Only: Health Disparity for Maternal Deaths and HCV Treatment
• Why Telehealth Will Not Solve Health Care Disparities: Liver Care Experience
• Getting a Seat at the Liver Counter
• Equitable Access to Liver Transplant
• “Health Insurance Is Broken”

On SUID:

• Safe Sleep Recommendations
• Safe Sleep A terrific website that focuses on this crucial issue: Charlieskids.org; it has videos, do’s and don’ts as well as a link to Cribs for Kids (discounted safe crib website). In addition, this website has a book called “Sleep Baby Safe and Snug” which incorporates updated recommendations on safe sleep practices.
• The High Toll of Sudden Infant Death From 2013-2015, there was an average of 3523 US infants each year who died from SUID (sudden unexpected infant death), peaking at 1-2 months of life.  More black infants died of SUID in the first year than black children who died from firearm homicides in all of childhood through age 19 years. SUID deaths from 2013-2015 (10,568) was similar to the total number of motor vehicle-traffic deaths in all of childhood (10,714) and greater than the total number of any of the other causes.
• Are We Making Progress on Infant Sleep-Related Deaths? (not anymore) 
• Safe Sleep (AAP 2017) 

J Gaillard et al. J Pediatr 2023; 260: 113493. Necrotizing Enterocolitis following Onasemnogene Abeparvovec for Spinal Muscular Atrophy: A Case Series

Background: Onasemnogene abeparvovec treats spinal muscular atrophy by delivering a functional SMN1 gene.

Key finding: This case report documents two cases of medically-treated necrotizing enterocolitis (NEC) that developed shortly after Onasemnogen Abeparvovec which was administered at ~3 weeks of life in two full term infants (born at 40 and 41 weeks).

My take: Consider the diagnosis of NEC in full term infants with SMA who have received gene therapy.

Related blog posts:

• Gene Replacement Therapy for Spinal Muscular Atrophy and Subacute Liver Failure
• Understanding the New Therapies for Spinal Muscular Atrophy

VB Stoody et al. J Pediatr 2023; 260: 113482. Advancements in Inpatient Medical Management of Malnutrition in Children and Adolescents with Restrictive Eating Disorders

This article is a good review detailing the management of restrictive eating disorders, including anorexia nervosa, atypical anorexia nervosa (weight in normal range despite significant loss) and avoidant/restrictive food intake disorder. The tables provide diagnostic criteria, medical complications, and clinical factors supporting admission.

The authors also delve into the topic of refeeding syndrome. Key points:

• “Contrary to prior belief, HCR [high calorie restriction] does not carry a significant risk of RS [refeeding syndrome] when close electrolyte surveillance and supplementations are implemented. Furthermore, LCR is associated with poor inpatient weight gain…and longer hospital admissions.”
• “The evidence in our progress report supports an HCR strategy of initiating inpatient refeeding at 2000-2400 kcal/day…and increasing by 200 kcal/day in patients with an admission BMI of >60% mBMI.”
• The authors recommend daily electrolyte assessment for first 7 days, followed by every other day for duration of admission.
• Daily caloric requirements “often exceed 3000 kcal/day in the initial weeks of refeeding”

My take: While the authors focus on restrictive eating disorders, their approach to refeeding implies consideration in other disorders associated with moderate malnutrition.

Related blog posts:

• Prevalence of Avoidant/Restrictive Food Intake Disorders in Pediatric Neurogastroenterology
• Mel Heyman: Past, Present and Future of ARFID
• Avoidant/Restrictive Food Intake Disorder (ARFID) with Irritable Bowel Syndrome and with Inflammatory Bowel Disease
• Afraid to Eat -Could be “Avoidant Restrictive Food Intake Disorder”

Dog walks into a bar jokes:

A dog walks into the bar, jumps up on the stool and says to the bartender, “Hey barkeep, it’s my birthday today. How ’bout a free drink?” The bartender turns, looks at the dog and nods his head, “Sure pal, toilet’s right down the hall.”

And

A dog walks into a bar. Bartender nods and says, “Hey dog, haven’t seen you in a while, how are things going?” Dog looks at him sadly and replies, “Ruff.”

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