Lance A. Chilton

Community Pediatrics: Navigating the Intersection of Medicine, Public Health, and Social Determinants of Children’s Health

This policy statement provides a framework for the pediatrician’s role in promoting the health and well-being of all children in the context of their families and communities. It offers pediatricians a definition of community pediatrics, emphasizes the importance of recognizing social determinants of health, and delineates the need to partner with public health to address population-based child health issues. It also recognizes the importance of pediatric involvement in child advocacy at local, state, and federal levels to ensure all children have access to a high-quality medical home and to eliminate child health disparities. This statement provides a set of specific recommendations that underscore the critical nature of this dimension of pediatric practice, teaching, and research.

Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity

Child health and housing security are closely intertwined, and children without homes are more likely to suffer from chronic disease, hunger, and malnutrition than are children with homes. Homeless children and youth often have significant psychosocial development issues, and their education is frequently interrupted. Given the overall effects that homelessness can have on a child’s health and potential, it is important for pediatricians to recognize the factors that lead to homelessness, understand the ways that homelessness and its causes can lead to poor health outcomes, and when possible, help children and families mitigate some of the effects of homelessness. Through practice change, partnership with community resources, awareness, and advocacy, pediatricians can help optimize the health and well-being of children affected by homelessness.

Providing Care for Immigrant, Migrant, and Border Children

This policy statement, which recognizes the large changes in immigrant status since publication of the 2005 statement “Providing Care for Immigrant, Homeless, and Migrant Children,” focuses on strategies to support the health of immigrant children, infants, adolescents, and young adults. Homeless children will be addressed in a forthcoming separate statement (“Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity”). While recognizing the diversity across and within immigrant, migrant, and border populations, this statement provides a basic framework for serving and advocating for all immigrant children, with a particular focus on low-income and vulnerable populations. Recommendations include actions needed within and outside the health care system, including expansion of access to high-quality medical homes with culturally and linguistically effective care as well as education and literacy programs. The statement recognizes the unique and special role that pediatricians can play in the lives of immigrant children and families. Recommendations for policies that support immigrant child health are included.

Primary Care Pediatrics and Public Health: Meeting the Needs of Today’s Children

The proportion of children suffering from chronic illnesses--such as asthma and obesity, which have significant environmental components--is increasing. Chronic disease states previously seen only in adulthood are emerging during childhood, and health inequalities by social class are increasing. Advocacy to ensure environmental health and to protect from the biological embedding of toxic stress has become a fundamental part of pediatrics. We have presented the rationale for addressing environmental and social determinants of childrens health, the epidemiology of issues facing childrens health, recent innovations in pediatric medical education that have incorporated public health principles, and policy opportunities that have arisen with the passage of the 2010 Patient Protection and Affordable Care Act.

Policy statement - Child fatality review

Injury remains the leading cause of pediatric mortality and requires public health approaches to reduce preventable deaths. Child fatality review teams, first established to review suspicious child deaths involving abuse or neglect, have expanded toward a public health model of prevention of child fatality through systematic review of child deaths from birth through adolescence. Approximately half of all states report reviewing child deaths from all causes, and the process of fatality review has identified effective local and state prevention strategies for reducing child deaths. This expanded approach can be a powerful tool in understanding the epidemiology and preventability of child death locally, regionally, and nationally; improving accuracy of vital statistics data; and identifying public health and legislative strategies for reducing preventable child fatalities. The American Academy of Pediatrics supports the development of federal and state legislation to enhance the child fatality review process and recommends that pediatricians become involved in local and state child death reviews.

Forty Years in Partnership: The American Academy of Pediatrics and the Indian Health Service

Fifty years ago, American Indian and Alaska Native children faced an overwhelming burden of disease, especially infectious diseases such as pneumonia, meningitis, tuberculosis, hepatitis A and B, and gastrointestinal disease. Death rates of American Indian/Alaska Native infants between 1 month and 1 year were much higher than in the US population as a whole, largely because of these infectious diseases. The health care of American Indian/Alaska Native patients was transferred to the Department of Health, Education, and Welfare in 1955 and placed under the administration of an agency soon to be known as the Indian Health Service. The few early pediatricians in the Indian Health Service recognized the severity of the challenges facing American Indian/Alaska Native children and asked for help. The American Academy of Pediatrics responded by creating the Committee on Indian Health in 1965. In 1986 the Committee on Native American Child Health replaced the Committee on Indian Health. Through the involved activity of these committees, the American Academy of Pediatrics participated in and influenced Indian Health Service policies and services and, combined with improved transportation, sanitation, and access to vaccines and direct services, led to vast improvements in the health of American Indian/Alaska Native children. In 1965, American Indian/Alaska Native postneonatal mortality was more than 3 times that of the general population of the United States. It is still more than twice as high as in other races but has decreased 89% since 1965. Infectious diseases, which caused almost one fourth of all American Indian/Alaska Native child deaths in 1965, now cause <1%. The Indian Health Service and tribal health programs, authorized by the Indian Self-Determination and Education Assistance Act of 1976 (Pub L. 93-638), continue to seek American Academy of Pediatrics review and assistance through the Committee on Native American Child Health to find and implement interventions for emerging child health problems related to pervasive poverty of many American Indian/Alaska Native communities. Acute infectious diseases that once were responsible for excess morbidity and mortality now are replaced by excess rates resulting from harmful behaviors, substance use, obesity, and injuries (unintentional and intentional). Through strong working partnerships such as that of the American Academy of Pediatrics and the Indian Health Service, progress hopefully will occur to address this “new morbidity.” In this article we document the history of the Indian Health Service and the American Academy of Pediatrics committees that have worked with it and present certain statistics related to American Indian/Alaska Native child health that show the severity of the health-status disparities challenging American Indian/Alaska Native children and youth.

Pediatricians and Public Health: Optimizing the Health and Well-Being of the Nation’s Children

Ensuring optimal health for children requires a population-based approach and collaboration between pediatrics and public health. The prevention of major threats to children’s health (such as behavioral health issues) and the control and management of chronic diseases, obesity, injury, communicable diseases, and other problems cannot be managed solely in the pediatric office. The integration of clinical practice with public health actions is necessary for multiple levels of disease prevention that involve the child, family, and community. Although pediatricians and public health professionals interact frequently to the benefit of children and their families, increased integration of the 2 disciplines is critical to improving child health at the individual and population levels. Effective collaboration is necessary to ensure that population health activities include children and that the child health priorities of the American Academy of Pediatrics (AAP), such as poverty and child health, early brain and child development, obesity, and mental health, can engage federal, state, and local public health initiatives. In this policy statement, we build on the 2013 AAP Policy Statement on community pediatrics by identifying specific opportunities for collaboration between pediatricians and public health professionals that are likely to improve the health of children in communities. In the statement, we provide recommendations for pediatricians, public health professionals, and the AAP and its chapters.

New Advisory Committee on Immunization Practices Guidelines for Rotavirus Vaccine Allow More Children to Receive Vaccine

To the Editor. In the July 2008 Pediatrics Electronic Pages , 3 of us (Drs Daskalaki, Long, and Watson) published the results of our analysis of computerized records of diphtheria-tetanus-acellular pertussis (DTaP) immunization of infants, with reference to prediction of the likelihood of being able to have immunized these children against rotavirus.1 These data were derived from the ages at which infants in Philadelphia, Pennsylvania, received their vaccines. Because of a previous rotavirus vaccine having been associated with intussusception, the guidelines for administration of the current rotavirus vaccines (RotaTeq [Merck & Co Inc, Whitehouse Station, NJ] and Rotarix [GSK Biologicals, Rixensart, Belgium]) are more stringent than …