Pediatric Support for Children Eligible for Legal Humanitarian Relief.

Many children in immigrant families may qualify for legal protection-for themselves if unaccompanied, or as a derivative on parents' claims-on humanitarian grounds related to persecution or forced migration. Pediatric providers can offer a spectrum of multidirectional medical-legal supports to increase access to medical-legal services and support children who are undocumented or in mixed-status families. These activities can include providing trusted information, incorporating screening for health-related social needs, establishing networks for multidirectional referrals, and providing letters of support for legal protection. To expand workforce capacity for medical-legal services related to immigration, pediatric providers can also receive training to conduct specialized, trauma-informed forensic evaluations and can advocate at individual, local, state, federal, and global levels to address factors leading to persecution and forced migration while supporting individuals who may be eligible for legal protection. [Pediatr Ann. 2024;53(5):e183-e188.].

State paid family leave policies and breastfeeding duration: cross-sectional analysis of 2021 national immunization survey-child.

BACKGROUND: Paid parental leave policies may promote breastfeeding, which can have short- and long-term health benefits for both members of the birthing person-infant dyad. In the United States, where 56% of the workforce qualifies for unpaid federal medical leave, certain states have recently enacted paid parental and family leave policies. We aimed to assess the extent to which living in states with versus without paid family leave was associated with feeding regimens that included breastfeeding. METHODS: In this cross-sectional analysis of the 2021 National Immunization Survey-Child, we assessed feeding outcomes: (1) exclusively breastfed (only fed breastmilk-never infant formula-both before and after six months of age), (2) late mixed breastfeeding (formula after six months), (3) early mixed breastfeeding (breastfed, formula before six months), and (4) never breastfed. We conducted Pearson χ2 to compare social-demographic characteristics and multivariable nominal regression to assess extent to paid family leave was associated with breastfeeding regimens, compared with never breastfeeding. RESULTS: Of the 35,995 respondents, 5,806 (25% of weighted respondents) were from states with paid family leave policies. Compared with never breastfeeding, all feeding that incorporated breastfeeding-exclusive breastfeeding, late mixed feeding (breastfed, formula introduced after six months), and early mixed feeding (breastfed, formula introduced before six months)-were more prevalent in states with paid family leave policies. The adjusted prevalence ratio (aPR) and differences in adjusted prevalence compared with never breastfeeding in states with versus without paid family leave policies were: aPR 1.41 (95% CI 1.15, 1.73), 5.36% difference for exclusive breastfeeding; aPR 1.25 (95% CI 1.01, 1.53), 3.19% difference for late mixed feeding, aPR 1.32 (95% CI 1.32, 1.97), 5.42% difference for early mixed feeding. CONCLUSION: States with paid family leave policies have higher rates of any breastfeeding and of exclusive breastfeeding than states without such policies. Because all feeding types that incorporate breastfeeding were higher in states with paid family leave policies, expansion of paid family leave may improve breastfeeding rates.

Dyadic care to improve postnatal outcomes of birthing people and their infants: A scoping review protocol.

INTRODUCTION: Dyadic care, which is the concurrent provision of care for a birthing person and their infant, is an approach that may improve disparities in postnatal health outcomes, but no synthesis of existing dyadic care studies has been conducted. This scoping review seeks to identify and summarize: 1) dyadic care studies globally, in which the birthing person-infant dyad are cared for together, 2) postnatal health outcomes that have been evaluated following dyadic care interventions, and 3) research and practice gaps in the implementation, dissemination, and effectiveness of dyadic care to reduce healthcare disparities. MATERIALS AND METHODS: Eligible studies will (1) include dyadic care instances for the birthing person and infant, and 2) report clinical outcomes for at least one member of the dyad or intervention outcomes. Studies will be excluded if they pertain to routine obstetric care, do not present original data, and/or are not available in English or Spanish. We will search CINAHL, Ovid (both Embase and Medline), Scopus, Cochrane Library, PubMed, Google Scholar, Global Health, Web of Science Core Collection, gray literature, and WHO regional databases. Screening will be conducted via Covidence and data will be extracted to capture the study design, dyad characteristics, clinical outcomes, and implementation outcomes. The risk of bias will be assessed using the Joanna Briggs Institute Critical Appraisal Tool. A narrative synthesis of the study findings will be presented. DISCUSSION: This scoping review will summarize birthing person-infant dyadic care interventions that have been studied and the evidence for their effectiveness. This aggregation of existing data can be used by healthcare systems working to improve healthcare delivery to their patients with the aim of reducing postnatal morbidity and mortality. Areas for future research will also be highlighted. TRAIL REGISTRATION: This review has been registered at Open Science Framework (OSF, https://osf.io/5fs6e/).

Exploring the determinants of successful implementation of a preventive mental health and wellness intervention for Afghan refugee families: a qualitative analysis.

Many refugee children experience trauma in early childhood. Effective, tailored interventions are needed to improve refugee children's access to preventive mental health. We interviewed refugee-serving stakeholders and parents participating in an evidence-based preventive mental health and wellness intervention adapted for Afghan refugee children and families who may have experienced trauma. Interview guide development was informed by two implementation science frameworks: the Consolidated Framework for Implementation Research and the Model for Adaptation Design and Impact. A three-person team coded transcripts via rapid qualitative analysis, and the study team reached consensus on themes. Six refugee-serving facilitators and five refugee parents discussed key determinants of successful implementation. Themes included: (i) modeling cultural humility to promote communication about emotions; (ii) needed linguistic support and referral networks to avoid miscommunications and missed communications; (iii) bridging connections between children, families and schools; (iv) different takeaways, or differing goals and expectations between facilitators and participants; and (v) timely, specific cultural considerations to overcome participation barriers. Overall, we found key determinants of successful implementation of a preventive mental health and wellness intervention for refugee children and families included adaptations to enhance cultural humility and sensitivity to cultural context while strengthening communication among facilitators, children and families.

Medical Certification for Utility Shut-Off Protection and Health-Related Social Needs.

BACKGROUND AND OBJECTIVES: Children in families facing energy insecurity have greater odds of poor health and developmental problems. In this study of families who requested and received medical certification for utility shut-off protection and were contacted by our Medical Legal Partnership (MLP), we aimed to assess concurrent health-related social needs related to utilities, housing, finances, and nutrition. METHODS: After medical certificates were completed at our academic pediatric center, our MLP office contacted families and assessed utility concerns as well as other health, social, and legal needs. In this observational study, we present descriptive analyses of patients who received certificates from September 2019 to May 2020 via data collected through the MLP survey during the coronavirus disease 2019 pandemic (June 2020-December 2021). RESULTS: Of 167 families who received utility shut-off protection from September 2019 to May 2020, 84 (50.3%) parents and guardians were successfully contacted. Most (93%) found the medical certificate helpful. Additionally, 68% had applied for Energy Assistance, and 69% reported they were on utility company payment plans. Most (78%) owed arrearages, ranging from under $500 to over $20 000, for gas, electric, and/or water bills. Food, housing, and financial insecurity screening positivity rates were 65%, 85%, and 74%, respectively. CONCLUSIONS: Patients who were contacted by an MLP after receiving medical certification for utility shutoff protection were found to have challenges paying for utilities and faced multiple food, housing, and financial stressors. Through consultation and completion of medical forms for utility shutoff protection, pediatricians and MLPs can provide resources and advocacy to support families' physical, emotional, and psychosocial needs.

Food Insecurity Screening and Intervention in United States Children's Hospitals.

OBJECTIVES: Food insecurity (FI) affects many United States families and negatively impacts the health of children. We assessed patterns of FI screening for United States children's hospitals, characterized screening protocols, and assessed how hospitals addressed general and inpatient-specific caregiver FI, including provision of food or meals for caregivers of admitted children. METHODS: We conducted a cross-sectional, confidential survey of clinical team members at United States children's hospitals. We evaluated FI screening practices and responses, including which team members conduct FI screening, the types of screeners used, and interventions including social work consultations, referrals to community resources, and provision of food or meals. RESULTS: Of the 76 children's hospital representatives (40% response rate) who participated in the survey, 67.1% reported at least some screening, and 34.2% performed universal screening for FI. Screening was conducted most frequently on the inpatient units (58.8%), with social workers (35.5%) and nurses (34.2%) administering screeners most frequently. Responses to positive screens included social work consultation (51.3%), referral to community resources (47.4%), and offering food or meals (43.4%). Eighty-four percent of hospitals provided food or meals to at least some caregivers for admitted pediatric patients. Conditional qualifications for food/meals included need-based (31.6%) and presence of breastfeeding mothers (30.3%). CONCLUSIONS: Many United States children's hospitals screen for FI, but most survey respondents reported that their hospital did not conduct universal screening. Screening protocols and interventions varied among institutions. Children's hospitals could consider improving screening protocols and interventions to ensure that needs are identified and addressed.

Insurance and Health Care Outcomes in Regions Where Undocumented Children Are Medicaid-Eligible.

OBJECTIVES: Expansion of insurance eligibility is associated with positive health outcomes. We compared uninsurance and health care utilization for (1) all children, and (2) children in immigrant families (CIF) and non-CIF who resided inside and outside of the seven US states/territories offering public health insurance to children regardless of documentation status ("extended-eligibility states/territories"). METHODS: Using the cross-sectional, nationally representative National Survey of Children's Health-2019, we used survey-weighted, multivariable Poisson regression to assess the association of residence in nonextended- versus extended-eligibility states/territories with uninsurance and with health care utilization measures for (1) all children, and (2) CIF versus non-CIF, adjusting for demographic covariates. RESULTS: Of the 29 433 respondents, the 4035 (weighted 27.2%) children in extended- versus nonextended-eligibility states/territories were more likely to be CIF (27.4% vs 20.5%, P < .001), 12 to 17 years old (37.2% vs 33.2%, P = .048), non-White (60.1% vs 45.9%, P < .001), and have a non-English primary language (20.6% vs 11.1%, P < .001).The relative risk of uninsurance for children in nonextended- versus extended-eligibility states/territories was 2.0 (95% confidence interval 1.4-3.0), after adjusting for covariates. Fewer children in extended- versus nonextended-eligibility states/territories were uninsured (adjusted prevalence 3.7% vs 7.5%, P < .001), had forgone medical (2.2% vs 3.1%, P = .07) or dental care (17.1% vs 20.5%, P = .02), and had no preventive visit (14.3% vs 17.0%, P = .04). More CIF than non-CIF were uninsured, regardless of residence in nonextended- versus extended-eligibility states/territories: CIF 11.2% vs 5.7%, P < .001; non-CIF 6.1% vs 3.1% P < .001. CONCLUSIONS: Residence in nonextended-eligibility states/territories, compared with in extended-eligibility states/territories, was associated with higher uninsurance and less preventive health care utilization.

Rapid Deployment of a Mobile Medical Clinic During the COVID-19 Pandemic: Assessment of Dyadic Maternal-Child Care.

OBJECTIVES: To describe demographic characteristics and health-related social needs of families who accessed maternal-infant care through a mobile medical clinic (MMC) during the COVID-19 pandemic and to explore feasibility, acceptability, perceived benefits, and barriers to care. METHODS: In this mixed-methods observational study, chart reviews, telephone surveys, and qualitative interviews in English and Spanish were conducted with caregivers who accessed the MMC between April and November 2020. Qualitative interviews were analyzed with the constant comparative method alongside descriptive chart and survey data analyses. RESULTS: Of 139 caregiver-infant dyads contacted, 68 (48.9%) completed the survey; 27 also completed the qualitative interview. The survey participants did not differ from the larger sample; most (86.7%) were people of color (52.9% identified as Latino and 33.8% as Black). Health-related social needs were high, including food insecurity (52.9%), diaper insecurity (44.1%), and anxiety (32%). Four women (6.1%) were diagnosed with hypertension requiring urgent evaluation. Nearly all (98.5%) reported being very satisfied with the services. Major themes from qualitative interviews included (1) perceived patient- and family-centered care, (2) perceived safety, and (3) perceived benefits of dyadic mother-infant care. CONCLUSIONS FOR PRACTICE: In this assessment of caregivers who accessed the MMC-a rapidly-developed COVID-19 pandemic response-insights from caregivers, predominantly people of color, provided considerations for future postpartum/postnatal service delivery. Perceptions that the MMC addressed health-related social needs and barriers to traditional office-based visits and the identification of maternal hypertension requiring urgent intervention suggest that innovative models for postpartum mother-infant care may have long-lasting benefits.

Pilot Wellness Program With Adapted Social-Emotional Learning and COVID-19 Curriculum for Refugee Youth.

Refugee children are less likely than their non-refugee peers to receive timely diagnoses and treatment for mental and/or behavioral health problems, despite facing multiple risk factors including potential exposure to trauma during premigration, migration, and postmigration experiences. Social-Emotional Learning offers preventive mental health education for children through well-established, evidenced-based curricula. Although there are clear benefits of Social-Emotional Learning curricula, which can help children achieve long-term success emotionally and academically, Social-Emotional Learning curricula are not easily accessible for refugee children, often because of language and socioeconomic barriers. In this pilot study, we evaluated the feasibility and acceptability of an adapted Social-Emotional Learning program that included culturally specific, multilingual, trauma-informed wellness, and physical education during the COVID-19 pandemic: EMPOWER (Emotions Program Outside the Clinic With Wellness Education for Refugees). We used the Intervention Mapping framework which guided the (1) planning, (2) program development, and (3) mixed-method evaluation of the feasibility and acceptability of the EMPOWER pilot. We found that this adaptation was well-received by Afghan refugee families and that COVID-19 safety measures were well-understood after participation. Challenges emerged around videoconferencing connectivity and around finding a common language for discussing emotions. Future iterations of the program and evaluations will require continued partnerships with community members and organizations. As we continue and expand EMPOWER, we aim to evaluate short-term improvement in Social-Emotional Learning competence as well as long-term mental and behavioral health outcomes for children and their families.

Recently-Arrived Afghan Refugee Parents' Perspectives About Parenting, Education and Pediatric Medical and Mental Health Care Services.

Refugee children are at risk for mental/behavioral health problems but may not receive timely diagnosis or care. Parental experiences and perspectives about resources in the US may help guide interventions to improve mental/behavioral health care. In a community-academic partnership, we performed a qualitative study of recently-arrived Afghan refugee parents, using in-depth, semi-structured interviews to characterize experiences with parenting, education, and health care services. A four-person coding team identified, described, and refined themes. We interviewed 19 parents from ten families, with a median residence in the US of 24 months. Four themes emerged; parents described: (1) shifting focus as safety needs changed, (2) acculturation stress, (3) adjustment to an emerging US support system, and (4) appreciation of an engaged health care system. Health and educational providers' appreciation for the process of acculturation among newly-arrived refugee Afghan families may facilitate screening, diagnostic, and intervention strategies to improve care.

Clinicians as advocates amid refugee resettlement agency closures.

As ongoing war and violence forcibly displace people worldwide, resettlement remains a critical response to the unprecedented global refugee crisis. In recent years, however, the USA (US) has diminished admissions, forcing agencies to shutter offices and resettlement programs across the nation-posing a silent threat to the refugee resettlement system. We provide historical context of refugee resettlement, discuss challenges, and offer recommendations for healthcare providers to become more effective advocates for refugee health in the USA. The need is urgent for healthcare providers and institutions-particularly in regions of high resettlement-to advocate for expanding and assuring sustainable capacity to care for refugees. Key elements include promotion of trauma-informed care, integration of social services in primary care settings, partnership with community-based organizations to promote continuation of care, advocacy for resources and services, and opposition to policies detrimental to the health of refugees and immigrants.

Characteristics and scope of humanitarian relief forensic medical evaluations for immigrant children in the US.

According to US Customs and Border Protection, over 473,000 family units and 76,000 unaccompanied children were apprehended in 2019, a multi-fold increase from previous years. Thus, the number of children who may be eligible for humanitarian relief has increased significantly. For those claiming humanitarian relief, forensic medical evaluations performed by health professionals can provide critical evidence to bolster claims. In this cross-sectional, nationwide survey-in which we sought to characterize specialties, forensic training, capacity, and scope of humanitarian relief evaluations for immigrant children under eighteen-years-old-only 28 providers, half of whom were Child Abuse Pediatricians, reported performing humanitarian relief evaluations. The most common reported type of humanitarian relief evaluation conducted was for asylum. We found that the current training for forensic medical evaluations for humanitarian relief in pediatrics is likely varied not well-defined, and not pediatric-specific. In order to protect the rights of children who are eligible for humanitarian relief, pediatric and family medicine forensic medical evaluation training standards and curricula need to be developed; validated humanitarian relief screening tools need to be tested and utilized; and residents and attending physicians, including specialists with expertise in forensic evaluations, need to be actively recruited to perform these evaluations in collaboration with legal aid organizations.

National Study of Youth Opinions on Vaccination for COVID-19 in the U.S.

PURPOSE: This study aimed to understand the potential barriers and facilitators to COVID-19 vaccination among youth. METHODS: Open-ended questions regarding COVID-19 vaccination were posed to a national cohort of 14- to 24-year-olds (October 30, 2020). Responses were coded through qualitative thematic analysis. Multivariable logistic regression tested the association of demographic characteristics with vaccination unwillingness. RESULTS: Among 911 respondents (response rate = 79.4%), 75.9% reported willingness to receive a COVID-19 vaccine, 42.7% had unconditional willingness, and 33.3% were conditionally willing, of which the majority (80.7%) were willing if experts deemed vaccination safe and recommended. Preferred vaccine information sources were medical organizations (42.3%; CDC, WHO) and health care professionals (31.7%). Frequent concerns with vaccination included side effects (36.2%) and efficacy (20.1%). Race predicted vaccination unwillingness (Black: odds ratio = 3.31; and Asian: odds ratio = .46, compared with white, p < .001). CONCLUSION: Most youth in our national sample were willing to receive a COVID-19 vaccine when they believe it is safe and recommended. Public health experts and organizations must generate youth-centered materials that directly address their vaccination concerns.

Youth Perceptions of Vaccination for COVID-19 in the United States.

This survey study examines opinions from a diverse sample of US youth after the initiation of mass immunization campaigns regarding COVID-19 vaccine acceptability, perceived barriers to vaccination, and anticipated changes in behavior.

Disparities in Mental and Behavioral Health Treatment for Children and Youth in Immigrant Families.

BACKGROUND AND OBJECTIVE: Children and youth in immigrant families (CIF)-children and youth with at least 1 foreign-born parent-face unique psychosocial stressors. Yet little is known about access to mental and behavioral health (MBH) services for CIF. Among US CIF and non-CIF with MBH problems, we assessed access to MBH treatment. METHODS: We used the National Survey of Children's Health-2016, a nationally representative survey of predominantly English- or Spanish-speaking US parents. The sample included 2- to 17-year-olds whose parent reported at least 1 MBH problem. The primary outcome was prior-year receipt of MBH treatment (counseling, medication, or both). RESULTS: Of 50,212 survey respondents, 7164 reported a current MBH problem (809 CIF and 6355 non-CIF). The majority of CIF were Hispanic/Latinx (56% CIF vs 13% non-CIF, P < .001). CIF were less likely than non-CIF to have an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis (35% vs 59%, P < .001) and less likely to have received MBH medication and/or counseling (61% vs 71%, P = .02). This difference was pronounced for receiving medication (32% vs 50%, P < .001). When controlling for multiple covariates, differences in any MBH treatment were no longer statistically significant (adjusted odds ratios 0.76, 95% confidence interval 0.52-1.11), while the odds of receipt of medication remained significantly lower for CIF (adjusted odds ratios 0.61, 95% confidence interval 0.42-0.88). CONCLUSIONS: Among children and youth with at least 1 parent-reported MBH problem, CIF, compared with non-CIF, were less likely to receive MBH treatment, specifically medication. This may be explained, in part, by differences in the proportion of CIF and non-CIF diagnosed with ADHD.

Translating Discharge Instructions for Limited English-Proficient Families: Strategies and Barriers.

BACKGROUND: Access to written hospital discharge instructions improves caregiver understanding and patient outcomes. However, nearly half of hospitals do not translate discharge instructions, and little is known about why. OBJECTIVES: To identify barriers to and potential strategies for translating children's hospital discharge instructions. METHODS: We conducted a mixed-methods, multimodal analysis. Data comprised closed- and open-ended responses to an online survey sent to Children's Hospital Association language services contacts (n = 31), an online environmental scan of Children's Hospital Association translation policies (n = 22), and county-level census data. We examined quantitative data using descriptive statistics and analyzed open-ended survey responses and written policies using inductive qualitative content analysis. RESULTS: Most survey respondents (81%) reported having a written translation policy at their hospital, and all reported translating a subset of hospital documents, for example, consent forms. Most but not all reported translating discharge instructions (74%). When asked how inpatient staff typically provide translated discharge instructions, most reported use of pretranslated documents (87%) or staff interpreters (81%). Reported barriers included difficulty translating uncommon languages, mismatched discharge and translation time frames, and inconsistent clinical staff use of translation services. Strategies to address barriers included document libraries, pretranslated electronic health record templates, staff-edited machine translations, and sight translation. Institutional policies differed regarding the appropriateness of allowing interpreters to assist with translation. Respondents agreed that machine translation should not be used alone. CONCLUSIONS: Children's hospitals experience similar operational and organizational barriers in providing language-concordant discharge instructions. Current strategies focus on translating standardized documents; collaboration and innovation may encourage provision of personalized documents.