In a two-part literature review led by researchers at Harvard University, public health experts from across the United States analyzed the findings of nearly 150 recent studies examining racial disparities in pediatric care quality in the USA. In a damning report, they found that non-White children consistently received worse care than their White counterparts throughout the spectrum of healthcare.
The collection of studies, published over the last five years, demonstrates widespread differences in care quality across numerous pediatric specialties. Researchers could not justify these disparities with differences in health insurance, preference, geographic area, or need.
“There are deeply entrenched racial disparities that span broad sectors of US society and transcend generations,” said series author Dr. Monique Jindal, of University of Illinois Chicago School of Medicine. “These lead to, among other disadvantages, stark inequities in healthcare for children from minoritized racial and ethnic groups.”
Health Inequalities Begin at Birth
Across multiple studies, racialized newborns were shown to have poorer outcomes in hospitals than White neonates. For example, a study of premature infants in 12 different hospitals found that serious blood infections were more common in Black and Hispanic babies. In a study of over 400,000 low-risk newborns in 40 New York hospitals, avoidable neonatal complications were more common among Hispanic and Black babies than White newborns.
The researchers showed that Black and Native American infants with very low birth weights were less likely than White babies to have received any breast milk while they were in the hospital. This was despite healthcare workers being well aware of the benefits of breast milk for low-birth-weight children.
Racial Differences in Primary Care
In the pediatrician’s office, the authors found that healthcare providers communicated less well with parents of children from minority racial and ethnic groups. For example, one study uncovered that prescribers were much less likely to recommend the HPV vaccine for Black children than White children.
Another study of over 37,000 children across 21 states revealed that doctors less frequently recorded a new diagnosis of asthma for Latino kids on the first visit. This omission could delay appropriate care at future visits.
Unequal Care in the Emergency Department
Of all the clinical areas studied, the emergency department was most often reported to show significant differences in the way racialized children were prioritized, diagnosed and treated.
According to the authors, “Disparities in emergency medicine are particularly concerning given the important role of the emergency department as a healthcare safety net, where marginalized populations can access care regardless of insurance status or ability to pay.”
At least one study found that Black and Hispanic children waited significantly longer in the Emergency department. They were also less likely to have their care needs assessed as immediate or emergent.
Inequalities in Emergency care between White and minoritized patients have been documented in studies even outside those included in this review. For example, a 4-year study of over 4,200 children found that non-White children were less likely to be X-rayed when they came to the Emergency department with a painful arm or wrist injury.
Reduced Access to Surgery and Worse Outcomes
The authors found that complications after surgery are higher for non-White children. A study of over 100,000 children who had their appendix removed found that Black children consistently experienced more complications than White children. This difference existed even after controlling for the type of surgery, co-existing medical conditions, and whether the appendix had ruptured. Similarly, in a study of over 66,000 gastrointestinal surgical procedures, non-White children were more likely to have postoperative complications than White children.
Outside of this review, studies point to significant differences in access to certain surgeries for non-White children. For example, kidney transplant is the best treatment for children with end-stage renal disease. Yet, in the United States, Black and Hispanic children are less likely to be placed on a waitlist or proceed to transplant than White children. These differences could not be fully explained by differences in health insurance or the preference of the families. The authors note problems of poverty, such as food insecurity and housing problems, could be factor in the ability of families to coordinate medical care or find a living donor for their child.
Recognition and Treatment of Developmental Disabilities
Data from nearly 8,000 children showed that preschools and kindergartens were less likely to diagnose developmental disabilities in Black and Asian kids than White children. This was true even after controlling for scores on formal developmental assessments.
Among children with Medicaid insurance, non-White children with autism received fewer outpatient services than White children.
These examples represent just a sample of the studies included in the review. The authors also found significant inequalities in care quality between White and racialized children in the areas of mental health, endocrinology, critical care, and end-of-life care.
Systemic Review
The authors summarized the findings of 147 research studies published between January 1, 2017, and July 31, 2022. The researchers only included studies where patient preference or the appropriateness of the intervention did not influence differences in access to care. They also rejected studies that did not control for health insurance status. This ensured that lack of access to health services did not cause the differences in care quality.
The studies included in the review collected data from patients in various medical settings across the USA. The authors did not note any patterns in the care discrepancies based on geography alone. According to the authors, a few studies reported complex patterns, but the majority, “reported patterns of inequitable care that disadvantage children from minoritized racial and ethnic groups,” relative to non-White children for at least one study outcome.
The study designs included in the review were considered strong. Half of the studies included multiple control variables for socioeconomic status and patient characteristics such as co-existing medical conditions and the severity of their illness. Many studies collected data from multiple medical sites, increasing the likelihood that the findings are widely applicable in other settings.
Symptoms of a Wide-Ranging Issue
Many of the studies included in this review suggested that biases and stereotyping might influence clinical decisions. However, the authors point out that little research directly links clinician bias with disparities in treatment choices, patient satisfaction, or outcomes. Rather, the authors state the roots of this problem go far deeper than the biases of individual healthcare providers.
“We now have more evidence than ever that pediatric care in the USA is not only disparate, but inequitable for a large group of children. Policies that advance health justice and reach across institutions, communities, and populations are urgently needed,” said series lead Dr Nia Heard-Garris, of the Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University.
As described in the review, the ecological model of racism emphasizes the role that many systems in society—including healthcare, education, employment, housing, and legal and economic systems—play in shaping a child’s opportunity for healthy development.
“From the very earliest moments of life, there are pervasive inequities in the quality of healthcare received by children in the USA.” said Dr. Natalie Slopen, of Harvard University, who led the research review. “Racism profoundly impacts not only children’s health but also people’s health on into adulthood, emphasizing the vital importance of tackling disparities in the care received by children.”
The authors made wide-ranging recommendations for policy changes to address the problem of two-tier child healthcare in the USA.
“We must fundamentally rethink and redesign systems and policies, not only in healthcare but across the societal spectrum, to promote equitable, excellent health for all children,” said Dr Slopen.
References
Amaral S, Patzer R. Disparities, race/ethnicity and access to pediatric kidney transplantation. Current Opinion in Nephrology and Hypertension. 2013;22(3):336. doi:10.1097/MNH.0b013e32835fe55b
Baughman DJ, Akinpelu T, Waheed A, et al. Racial Disparity in Pediatric Radiography for Forearm Fractures. Cureus. 2022;14(3). doi:10.7759/cureus.22850
Slopen N, Chang AR, Johnson TJ, et al. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence. The Lancet Child & Adolescent Health. 2024;8(2):147-158. doi:10.1016/S2352-4642(23)00251-1
Zhang X, Carabello M, Hill T, He K, Friese CR, Mahajan P. Racial and Ethnic Disparities in Emergency Department Care and Health Outcomes Among Children in the United States. Frontiers in Pediatrics. 2019;7. Accessed February 23, 2024. https://www.frontiersin.org/articles/10.3389/fped.2019.00525
