A lifecourse approach to health development: implications for the maternal and child health research agenda

Using the life course health development model to address pediatric mental health disparities

TOPIC

Early-life experiences, the transmission of health and disease within families, and the influence of cumulative risks as well as protective factors throughout life shape the trajectory of health, including mental health. Long-term health trajectories established early in life are influenced by biologic, social, and environmental factors. Negative trajectories may be more salient if exposures to adversity occur during critical developmental periods.

PURPOSE

The purpose of this brief is to (a) review pediatric health disparities related to depression and the intergenerational transmission of pediatric depression using a Life Course Health Development (LCHD) model and (b) provide recommendations for pediatric mental health research.

SOURCES

Peer-reviewed papers available for PubMed, CINAL, and Medline. Other sources include published books, papers, and gray materials.

CONCLUSIONS

The LCHD model is a perspective to guide and foster new scientific inquiry about the development of mental health outcomes over the life course. The model enables synthesis of mental health, nursing, and public health, linking mental health prevention, risk reduction, and treatment in children.

Integrated growth assessment in the first 1000 d of life: an interdisciplinary conceptual framework

OBJECTIVES

Prenatal growth affects short- and long-term morbidity, mortality and growth, yet communication between prenatal and postnatal healthcare teams is often minimal. This paper aims to develop an integrated, interdisciplinary framework for foetal/infant growth assessment, contributing to the continuity of care across the first 1000 d of life.

DESIGN

A multidisciplinary think-tank met regularly over many months to share and debate their practice and research experience related to foetal/infant growth assessment. Participants’ personal practice and knowledge were verified against and supplemented by published research.

SETTING

Online and in-person brainstorming sessions of growth assessment practices that are feasible and valuable in resource-limited, low- and middle-income country (LMIC) settings.

PARTICIPANTS

A group of obstetricians, paediatricians, dietitians/nutritionists and a statistician.

RESULTS

Numerous measurements, indices and indicators were identified for growth assessment in the first 1000 d. Relationships between foetal, neonatal and infant measurements were elucidated and integrated into an interdisciplinary framework. Practices relevant to LMIC were then highlighted: antenatal Doppler screening, comprehensive and accurate birth anthropometry (including proportionality of weight, length and head circumference), placenta weighing and incorporation of length-for-age, weight-for-length and mid-upper arm circumference in routine growth monitoring. The need for appropriate, standardised clinical records and corresponding policies to guide clinical practice and facilitate interdisciplinary communication over time became apparent.

CONCLUSIONS

Clearer communication between prenatal, perinatal and postnatal health care providers, within the framework of a common understanding of growth assessment and a supportive policy environment, is a prerequisite to continuity of care and optimal health and development outcomes.

Holistic antenatal education class interventions: a systematic review of the prioritisation and involvement of Indigenous Peoples' of Aotearoa New Zealand, Australia, Canada and the United States over a 10-year period 2008 to 2018

BACKGROUND

Research into the effectiveness of antenatal education classes is crucial for Indigenous Peoples from Aotearoa New Zealand, Australia, Canada and the United States who experience poorer maternal and infant health outcomes compared to non-Indigenous populations. Our systematic review questions were intended to determine the extent of Indigenous Peoples prioritisation and involvement in antenatal education classes, and to understand the experience of Indigenous Peoples from these countries in antenatal education classes.

METHODS

Using a standardised protocol, we systematically searched five electronic databases for primary research papers on antenatal education classes within the four countries noted and identified 17 papers that met the criteria. We undertook a qualitative meta-synthesis using a socio-critical lens.

RESULTS

Systematic review of the academic literature demonstrates that Indigenous Peoples of Aotearoa New Zealand, Australia, Canada and the United States are not prioritised in antenatal education classes with only two of 17 studies identifying Indigenous participants. Within these two studies, Indigenous Peoples were underrepresented. As a result of poor engagement and low participation numbers of Indigenous Peoples in these antenatal education classes, it was not possible to understand the experiences of Indigenous Peoples.

CONCLUSION

Given that Indigenous Peoples were absent from the majority of studies examined in this review, it is clear little consideration is afforded to the antenatal health needs and aspirations of Indigenous Peoples of Aotearoa New Zealand, Australia, Canada and the United States. To address the stark antenatal health inequities of Indigenous Peoples, targeted Indigenous interventions that consider culture, language, and wider aspects of holistic health must be privileged.

TRIAL REGISTRATION

PROSPERO Registration ID: CRD4202017658.

What Makes an Intervention a Life Course Intervention?

OBJECTIVES

To develop an initial list of characteristics of life course interventions to inform the emerging discipline of life course intervention research.

METHODS

The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives, and thought leaders, considered the principles, characteristics, and utility of life course interventions. After an in-person launch meeting in 2019, the steering committee collaboratively and iteratively developed a list of life course intervention characteristics, incorporating a modified Delphi review process.

RESULTS

The Life Course Intervention Research Network identified 12 characteristics of life course interventions. These interventions (1) are aimed at optimizing health trajectories; (2) are developmentally focused, (3) longitudinally focused, and (4) strategically timed; and are (5) designed to address multiple levels of the ecosystem where children are born, live, learn, and grow and (6) vertically, horizontally, and longitudinally integrated to produce a seamless, forward-leaning, health optimizing system. Interventions are designed to (7) support emerging health development capabilities; are (8) collaboratively codesigned by transdisciplinary research teams, including stakeholders; and incorporate (9) family-centered, (10) strengths-based, and (11) antiracist approaches with (12) a focus on health equity.

CONCLUSIONS

The intention for this list of characteristics of life course interventions is to provide a starting point for wider discussion and to guide research development. Incorporation of these characteristics into intervention designs may improve emerging health trajectories and move critical developmental processes and pathways back on track, even optimizing them to prevent or reduce adverse outcomes.

Exposome and Social Vulnerability: An Overview of the Literature Review

Background-The exposome concept refers to the totality of exposures from internal and external sources, including chemical and biological agents from conception throughout the lifetime. Exposome is also made up of psychosocial components such as socio-economic status (SES), which will focus on in this review. Despite exposures to the same environmental nuisances, individuals and groups are impacted differently. According to the literature, health inequalities exist among different socioeconomic groups, and SES may influence the association between environmental nuisances and health outcomes. However, the variation of this interaction across ages has rarely been studied. There is a need to adopt a life course approach to understand the history of diseases better. Objective-The main objective of this review is to document how SES could modify the association between environmental nuisances and health outcomes, across different ages, as a first crucial step introducing the emerged concept of social exposome. Methods-The PubMed database was searched from January 2010 to August 2021 for systematic reviews published in English addressing the interaction between SES, environmental nuisances, and health outcomes. Socio-economic indicators considered include education, level of income, neighborhood environment. Environmental nuisances considered many environment nuisances, mainly air pollution and noise. Results-Among 242 literature reviews identified, 11 of them address the question of the effect modification. Overall, our work reveals that environmental nuisances were mostly associated with poorer health outcomes and that SES modified this association, increasing the health risk among the poorest. Very interestingly, our work reports the existence of this interaction across different ages, including pregnancy, childhood, and adulthood, and for various environmental nuisances. Conclusion-In conclusion, our work confirms that we are not all equal to face environmental nuisances. The poorest are more vulnerable to the health effect of environmental nuisances. Policy decisions and interventions should target this high-risk population as a priority. Further investigations are needed to formalize the concept of social exposome more precisely and then communicate about it.

Inequality and child health: dynamic population health interventions

PURPOSE OF REVIEW

Established social gradients across a wide range of child health issues including obesity, anxiety, infectious diseases, injuries, prematurity and low birth weight suggest that much illness is avoidable and there is an imperative to intervene in this whole of society issue. This review examines recent advances in understanding of the pathways to health and health inequalities and their application to interventions to improve health equity.

RECENT FINDINGS

Children's health develops over the life course in ways that are profoundly influenced by their entire developmental ecosystem including individual, family, community and system-level factors. Interventions to address child health inequalities must include action on the structural determinants of health, a greater focus on family and community health development, and attention to the acquisition of developmental capabilities. Nascent dynamic population health initiatives that address whole developmental ecosystems such as All Children Thrive, Better Start Bradford and Generation V, hold real promise for achieving child health equity.

SUMMARY

Pathways to health inequalities are driven by social and structural determinants of health. Interventions to address inequalities need to be driven less by older biomedical models, and more by prevailing ecological and complex systems models incorporating a life course health development approach.

Preeclampsia Across Pregnancies and Associated Risk Factors: Findings From a High-Risk US Birth Cohort

Background

Preeclampsia increases women's risks for maternal morbidity and future cardiovascular disease. The aim of this study was to identify opportunities for prevention by examining the association between cardiometabolic risk factors and preeclampsia across 2 pregnancies among women in a high‐risk US birth cohort.

Methods and Results

Our sample included 618 women in the Boston Birth Cohort with index and subsequent pregnancy data collected using standard protocols. We conducted log‐binomial univariate regression models to examine the association between preeclampsia in the subsequent pregnancy (defined as incident or recurrent preeclampsia) and cardiometabolic risk factors (ie, obesity, hypertension, diabetes mellitus, preterm birth, low birth weight, and gestational diabetes mellitus) diagnosed before and during the index pregnancy, and between index and subsequent pregnancies. At the subsequent pregnancy, 7% (36/540) had incident preeclampsia and 42% (33/78) had recurrent preeclampsia. Compared with women without obesity, women with obesity had greater risk of incident preeclampsia (unadjusted risk ratio [RR], 2.2 [95% CI, 1.1–4.5]) and recurrent preeclampsia (unadjusted RR, 3.1 [95% CI, 1.5–6.7]). Preindex pregnancy chronic hypertension and diabetes mellitus were associated with incident, but not recurrent, preeclampsia (hypertension unadjusted RR, 7.9 [95% CI, 4.1–15.3]; diabetes mellitus unadjusted RR, 5.2 [95% CI, 2.5–11.1]. Women with new interpregnancy hypertension versus those without had a higher risk of incident and recurrent preeclampsia (incident preeclampsia unadjusted RR, 6.1 [95% CI, 2.9–13]); recurrent preeclampsia unadjusted RR, 2.4 [95% CI, 1.5–3.9]).

Conclusions

In this diverse sample of high‐risk US women, we identified modifiable and treatable risk factors, including obesity and hypertension for the prevention of preeclampsia.

Moving Health Literacy Research and Practice towards a Vision of Equity, Precision and Transparency

Over the past two decades, health literacy research has gained increasing attention in global health initiatives to reduce health disparities. While it is well-documented that health literacy is associated with health outcomes, most findings are generated from cross-sectional data. Along with the increasing importance of health literacy in policy, there is a lack of specificity and transparency about how to improve health literacy in practice. In this study, we are calling for a shift of current research paradigms from judging health literacy levels towards observing how health literacy skills are developed over the life course and practised in the real world. This includes using a life-course approach, integrating the rationale of precision public health, applying open science practice, and promoting actionable knowledge translation strategies. We show how a greater appreciation for these paradigms promises to advance health literacy research and practice towards an equitable, precise, transparent, and actionable vision.

Understanding Policy Influences on Health and Occupation Through the Use of the Life Course Health Development (LCHD) Framework

Life course health development (LCHD) is a framework that considers the transactional nature of risks and protective factors along the life trajectory and how this context influences health. Public policies, from health care to education to social services to labor laws, have many goals, including lessening and eliminating health disparities, yet inequities in health services and outcomes remain. Policy is a contextual factor that may be overlooked when examining influences on health and occupation. As such, the LCHD framework may assist occupational therapy practitioners in understanding the influences of policy-both successes and failures-on occupation. In this article, we introduce the principles of LCHD and use this framework to illustrate analysis of a policy example of paid family leave, demonstrating how gaps in or unintended consequences of policy may contribute to disparities in health and occupation for certain populations.

Linking a History of Childhood Abuse to Adult Health among Canadians: A Structural Equation Modelling Analysis

A history of childhood abuse has been linked to serious and long-lasting problems in adulthood. We developed two theoretical models concerning how early adverse experiences affect health in adulthood, and we tested the empirical fit of the two models in a population-based representative sample of Canadian adults (N = 25,113) using a structural equation modelling (SEM) technique, path analysis. The first model included direct pathways by which a history of three types of childhood abuse-exposure to intimate partner violence, physical abuse, and sexual abuse-affected adult physical and mental health, as well as indirect pathways by which perceived social support and everyday life stress acted as mediators of these associations. The second model included only indirect pathways and tested mediating effects. Global statistics indicated that both models were a good fit to the data, and local statistics supported the hypothesized associations between independent, dependent, and mediator variables.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

'Telling our story... Creating our own history': caregivers' reasons for participating in an Australian longitudinal study of Indigenous children

BACKGROUND

Improving the wellbeing of Indigenous populations is an international priority. Robust research conducted with Aboriginal and Torres Strait Islander peoples is key to developing programs and policies to improve health and wellbeing. This paper aims to quantify the extent of participation in a national longitudinal study of Aboriginal and Torres Strait Islander (Indigenous Australian) children, and to understand the reasons why caregivers participate in the study.

METHODS

This mixed methods study uses data from Wave 6 of Footprints in Time, the Longitudinal Study of Indigenous Children. We conducted descriptive analysis of quantitative variables to characterise the sample and retention rates. We applied conventional content analysis to 160 caregivers' open-ended responses to the question, 'Why do you stay in the study?', identifying themes and overarching meta-themes.

RESULTS

The study has maintained a high retention rate, with 70.4% (n = 1239/1671) of the baseline sample participating in the study's 6th wave. We identified seven themes related to why participants stay in the study: telling our story, community benefit, satisfaction, tracking Study Child's progress, study processes, receiving study gifts, and valuing what the study stands for. These related to two meta-themes: reciprocity, and trust and connection. Caregivers reported that participation was associated with benefits for their family and community as well as for the study. They identified specific features of the Footprints in Time study design that built and maintained trust and connection between participants and the study.

CONCLUSIONS

Our findings support the assertion that Aboriginal and Torres Strait Islander people want to be involved in research when it is done 'the right way'. Footprints in Time has successfully recruited and retained the current-largest cohort of Aboriginal and Torres Strait Islander children in Australia through the use of participatory research methodologies, suggesting effective study implementation and processes. Participants indicated ongoing commitment to the study resulting from perceptions of reciprocity and development of trust in the study. Footprints in Time can serve as a successful model of Aboriginal and Torres Strait Islander health research, to promote good research practice and provides lessons for research with other Indigenous populations.

Altitude and Variable Effects on Infant Mortality in the United States

Levine, Robert S., Jason L. Salemi, Maria C. Mejia de Grubb, Sarah K. Wood, Lisa Gittner, Hafiz Khan, Michael A. Langston, Baqar A. Husaini, George Rust, and Charles H. Hennekens. Altitude and variable effects on infant mortality in the United States. High Alt Med Biol. 19:265-271, 2018.

AIMS

To explore whether altitude has different effects on infant mortality from newborn respiratory distress, nontraumatic intracranial hemorrhage, and necrotizing enterocolitis.

RESULTS

Infants born in the US Mountain Census Division (AR, CO, ID, NV, NM, UT, and WY) had lower mortality from newborn respiratory distress (p < 0.001, mortality rate ratios [MRR] = 0.5 for non-Hispanic blacks and non-Hispanic whites and 0.6 for Hispanic whites) relative to infants born elsewhere in the United States, while Mountain Division non-Hispanic white infants had significantly higher mortality from nontraumatic intracranial hemorrhage (MRR = 1.3 [1.1, 1.6] p < 0.001). After adjustment for state average birth weight, gestational age, and income inequality, a statistically significant, inverse association remained between state average altitude and non-Hispanic white infant mortality from newborn respiratory distress. County altitude (3058 counties in 9 categories from ≤0 to ≥7000 feet) was negatively correlated with newborn respiratory distress (r = -0.91, p < 0.001) and necrotizing enterocolitis (r = -0.81, p = 0.006) at ≤0 to ≥7000 feet and positively correlated with nontraumatic intracranial hemorrhage at ≤0 to 6000-6999 feet (r = 0.78, p = 0.02).

CONCLUSIONS

These data show variable cause-specific effects of altitude on infant mortality. Analytic epidemiologic research is needed to confirm or refute the hypotheses generated by these descriptive data.

Should I stay or should I go?: consistency and switching of delivery locations among new mothers in 39 Sub-Saharan African and South/Southeast Asian countries

The objective of this article is to assess the extent and determinants of switching delivery location between women’s first and second deliveries. We used Demographic and Health Survey data from 39 low- and middle-income countries on delivery locations from >30 000 women who had their first two deliveries in the 5-year survey recall period. Each delivery was characterized as occurring at home or in a health facility, facilities were classified as public- or private-sector. The extent of switching was estimated for each country, region and overall. Multivariable logistic regression models assessed determinants of switching (home to facility or facility to home), using four dimensions (perceived/biological need, socioeconomic characteristics, utilization of care and availability of care). Overall, 49.0% of first and 44.5% of second deliveries occurred in health facilities. Among women who had their first delivery at home, 11.8% used a facility for their second (7.0% public-sector and 4.8% private-sector). Among women who had their first delivery in a facility, 21.6% switched to a home location for their second. The extent of switching varied by country; but the overall net effect was either non-existent (n = 20) or away from facilities (n = 17) in all but two countries—Cambodia and Burkina Faso. Four factors were associated with switching to a facility after a home delivery: higher education, urban residence, non-poor household status and multiple gestation. Majority of women consistently used the same delivery location for their first two deliveries. We found some evidence that where switching occurred, women were being lost from facility care during this important transition, and that all four included dimensions were important determinants of women’s pattern of delivery care use. The relative importance of these factors should be understood in each specific context to improve retention in and provision of quality intrapartum care for women and their newborns.

Predictors and outcomes of excess gestational weight gain among low-income pregnant women

Low-income women were interviewed and their post-natal records were retrieved (n = 160) to assess prevalence of excess gestational weight gain and its socio-demographic predictors. More than half of the women (64%) gained excess weight during pregnancy, with an average of 10 lbs in excess of Institute of Medicine guidelines. Logistic regression indicated that women that started pregnancy at an obese body mass index; who were African American or having an unplanned pregnancy were at significant risk of gaining excess weight in pregnancy. Intervention to prevent excess weight gain during pregnancy is critical in addressing obesity epidemic in the United States and worldwide.

Placing Health Trajectories in Family and Historical Context: A Proposed Enrichment of the Life Course Health and Development Model

Purpose This article offers constructive commentary on The Life Course Health and Development Model (LCHD) as an organizing framework for MCH research. Description The LCHD has recently been proposed as an organizing framework for MCH research. This model integrates biomedical, biopsychosocial, and life course frameworks, to explain how "individual health trajectories" develop over time. In this article, we propose that the LCHD can improve its relevance to MCH policy and practice by: (1) placing individual health trajectories within the context of family health trajectories, which unfold within communities and societies, over historical and generational time; and (2) placing greater weight on the social determinants that shape health development trajectories of individuals and families to produce greater or lesser health equity. Assessment We argue that emphasizing these nested, historically specific social contexts in life course models will enrich study design and data analysis for future developmental science research, will make the LCHD model more relevant in shaping MCH policy and interventions, and will guard against its application as a deterministic framework. Specific ways to measure these and examples of how they can be integrated into the LCHD model are articulated. Conclusion Research applying the LCHD should incorporate the specific family and socio-historical contexts in which development occurs to serve as a useful basis for policy and interventions. Future longitudinal studies of maternal and child health should include collection of time-dependent data related to family environment and other social determinants of health, and analyze the impact of historical events and trends on specific cohorts.

Theoretical Insights into Preconception Social Conditions and Perinatal Health: The Role of Place and Social Relationships

Recent efforts to explain the stark social and racial disparities in adverse birth outcomes that have persisted for decades in the U.S. have looked beyond prenatal factors, to explore preconception social conditions that may influence perinatal health via dysregulation of physiologic processes. The extant evidence supporting this link however remains limited, both due to a lack of data and theory. To address the latter, this manuscript generates a structured set of theoretical insights that further develop the link between two preconception social conditions - place and social relationships - and perinatal health. The insights propose the following.

PLACE

necessarily encompasses all social contexts to which females are exposed from infancy through young adulthood; encompasses a variety of related exposures that, when possible, should be jointly considered; and may compound the effect of poverty-in childhood, adolescence, or young adulthood-on perinatal health. Social relationships: span relationships from early life through adulthood, and extend to intergenerational associations; often involve (or induce) major changes in the lives of individuals and should be examined with an emphasis on the developmental stage in which the change occurred; and necessarily encompass a lack of social integration, or, social isolation. We also identify potential biological and social-structural mechanisms linking these preconception social conditions to perinatal health, and conclude by identifying promising directions for future research.

Latent growth models matched to research questions to answer questions about dynamics of change in multiple processes

OBJECTIVES

Given theoretical and methodological advances that propose hypothesis about change in one or multiple processes, analytical methods for longitudinal data have been developed that provide researchers with various options for analyzing change over time. In this paper, we revisited several latent growth curve models that may be considered to answer questions about repeated measures of continuous variables, which may be operationalized as time-varying covariates or outcomes.

STUDY DESIGN AND SETTING

To illustrate each of the models discussed and how to interpret parameter estimates, we present examples of each method discussed using cognitive and blood pressure measures from a longitudinal study of aging, the Origins of Variance in the Old-Old study.

RESULTS AND CONCLUSION

Although statistical models are helpful tools to test theoretical hypotheses about the dynamics between multiple processes, the choice of model and its specification will influence results and conclusions made.

From Theory to Measurement: Recommended State MCH Life Course Indicators

Purpose

In May 2012, the Association of Maternal and Child Health (MCH) Programs initiated a project to develop indicators for use at a state or community level to assess, monitor, and evaluate the application of life course principles to public health.

Description

Using a developmental framework established by a national expert panel, teams of program leaders, epidemiologists, and academicians from seven states proposed indicators for initial consideration. More than 400 indicators were initially proposed, 102 were selected for full assessment and review, and 59 were selected for final recommendation as Maternal and Child Health (MCH) life course indicators.

Assessment

Each indicator was assessed on five core features of a life course approach: equity, resource realignment, impact, intergenerational wellness, and life course evidence. Indicators were also assessed on three data criteria: quality, availability, and simplicity.

Conclusion

These indicators represent a major step toward the translation of the life course perspective from theory to application. MCH programs implementing program and policy changes guided by the life course framework can use these initial measures to assess and influence their approaches.

Bioactive factors in milk across lactation: Maternal effects and influence on infant growth in rhesus macaques (Macaca mulatta)

Among mammals, numerous bioactive factors in milk vary across mothers and influence offspring outcomes. This emerging area of research has primarily investigated such dynamics within rodent biomedical models, domesticated dairy breeds, and among humans in clinical contexts. Less understood are signaling factors in the milk of non-human primates. Here, we report on multiple bioactive components in rhesus macaque (Macaca mulatta) milk and their associations with maternal and infant characteristics. Milk samples were collected from 59 macaques at multiple time points across lactation in conjunction with maternal and infant morphometrics and life-history animal records. Milk was assayed for adiponectin (APN), epidermal growth factor (EGF) and its receptor (EGF-R), and transforming growth factor beta 2 (TGF-β2 ). Regression models were constructed to assess the contributions of maternal factors on variation in milk bioactives, and on the relationship of this variation to infant body mass and growth. Maternal body mass, parity, social rank, and infant sex were all predictive of concentrations of milk bioactives. Primiparous mothers produced milk with higher adiponectin, but lower EGF, than multiparous mothers. Heavier mothers produced milk with lower EGF and EGF-R, but higher TGF-β2 . Mothers of daughters produced milk with higher TGF-β2 . Mid-ranking mothers produced milk with higher mean EGF and adiponectin concentrations than low-ranking mothers. Milk EGF and EGF-R were positively associated with infant body mass and growth rate. Importantly, these signaling bioactives (APN, EGF, EGF-R, and TGF-β2 ) were significantly correlated with nutritional values of milk. The effects of milk signals remained after controlling for the available energy in milk revealing the added physiological role of non-nutritive milk bioactives in the developing infant. Integrating analyses of energetic and other bioactive components of milk yields an important perspective for interpreting the magnitude, sources, and consequences of inter-individual variation in milk synthesis. Am. J. Primatol. 78:838-850, 2016. © 2016 Wiley Periodicals, Inc.

Determinants of Health and Pediatric Primary Care Practices

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Maternal and pediatric health and disease: integrating biopsychosocial models and epigenetics

The concepts of allostasis (stability through adaptation) and accumulated life stress (McEwen's allostatic load) aim to understand childhood and adult outcomes. Chronic malnutrition, changes in social condition, and adverse early-life experiences may program phenotypes and contribute to long-lasting disease risk. However, integration of life course approaches, social and economic contexts, and comparison among different biopsychosocial models has not generally been explored. This review critically examines the literature and evaluates recent insights into how environmental stress can alter lifelong hypothalamic-pituitary-adrenal axis and immune system responsiveness and induce metabolic and neurodevelopmental maladaptation. Models of biopsychosocial stress overlap but may consider different conditions. Concepts include allostasis, which incorporates hormonal responses to predictable environmental changes, and Geronimus's "weathering," which aims to explain how socially structured, repeated stress can accumulate and increase disease vulnerability. Weathering emphasizes roles of internalized/interpersonal racism in outcomes disparities. For Mexican immigrants and Mexican Americans, the "acculturation" framework has proven especially useful to explore disparities, including preterm birth and neuropsychiatric risks in childhood. Complexities of stress assessments and recent research into epigenetic mechanisms mediating effects of physical, nutritional, psychological, and social stress are reviewed.

A Road Map to Address the Social Determinants of Health Through Community Collaboration

Economic, environmental, and psychosocial needs are common and wide-ranging among families cared for in primary care settings. Still, pediatric care delivery models are not set up to systematically address these fundamental risks to health. We offer a roadmap to help structure primary care approaches to these needs through the development of comprehensive and effective collaborations between the primary care setting and community partners. We use Maslow's Hierarchy of Needs as a well-recognized conceptual model to organize, prioritize, and determine appropriate interventions that can be adapted to both small and large practices. Specifically, collaborations with community organizations expert in addressing issues commonly encountered in primary care centers can be designed and executed in a phased manner: (1) build the case for action through a family-centered risk assessment, (2) organize and prioritize risks and interventions, (3) develop and sustain interventions, and (4) operationalize interventions in the clinical setting. This phased approach to collaboration also includes shared vision, codeveloped plans for implementation and evaluation, resource alignment, joint reflection and adaptation, and shared decisions regarding next steps. Training, electronic health record integration, refinement by using quality improvement methods, and innovative use of clinical space are important components that may be useful in a variety of clinical settings. Successful examples highlight how clinical-community partnerships can help to systematically address a hierarchy of needs for children and families. Pediatricians and community partners can collaborate to improve the well-being of at-risk children by leveraging their respective strengths and shared vision for healthy families.

Diversity of Pediatric Workforce and Education in 2012 in Europe: A Need for Unifying Concepts or Accepting Enjoyable Differences?

OBJECTIVE

To evaluate differences in child health care service delivery in Europe based on comparisons across health care systems active in European nations.

STUDY DESIGN

A survey involved experts in child health care of 40 national pediatric societies belonging both to European Union and non-European Union member countries. The study investigated which type of health care provider cared for children in 3 different age groups and the pediatric training and education of this workforce.

RESULTS

In 24 of 36 countries 70%-100% of children (0-5 years) were cared for by primary care pediatricians. In 12 of 36 of countries, general practitioners (GPs) provided health care to more than 60% of young children. The median percentage of children receiving primary health care by pediatricians was 80% in age group 0-5 years, 50% in age group 6-11, and 25% in children >11 years of age. Postgraduate training in pediatrics ranged from 2 to 6 years. A special primary pediatric care track during general training was offered in 52% of the countries. One-quarter (9/40) of the countries reported a steady state of the numbers of pediatricians, and in one-quarter (11/40) the number of pediatricians was increasing; one-half (20/40) of the countries reported a decreasing number of pediatricians, mostly in those where public health was changing from pediatric to GP systems for primary care.

CONCLUSIONS

An assessment on the variations in workforce and pediatric training systems is needed in all European nations, using the best possible evidence to determine the ideal skill mix between pediatricians and GPs.

Cumulative social risk exposure, infant birth weight, and cognitive delay in infancy

OBJECTIVE

To determine the effect of exposure to multiple social risks on cognitive delay at 9 months of age; and whether obstetric factors mediate the relationship between cumulative social risk and cognitive delay.

METHODS

Data were from 8950 mother-child dyads participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort. Cognitive delay was defined as falling in the lowest 10% of mental scale scores from the Bayley Short Form-Research Edition. Five social risk factors were combined and categorized into a social risk index. Staged multivariable logistic regressions were used to investigate whether obstetric factors mediated the impact of social risk on the odds of cognitive delay.

RESULTS

Infants with cognitive delay were more likely to live with social risks than infants without cognitive delay. The percentage of infants with cognitive delay increased with the number of social risks. In adjusted analyses, exposure to multiple social risk factors was associated with higher odds of cognitive delay at 9 months of age (adjusted odds ratio 2.11; 95% confidence interval 1.18-3.78 for 4 or more risks vs no risks). Accounting for birth weight attenuated this relationship (P < .001).

CONCLUSIONS

This population-based study investigated the independent and cumulative effects of social risk factors on cognitive delay in infancy. Findings revealed a significant cumulative relationship between exposure to social risk and cognitive delay, which was partly mediated by birth weight. Programs that address the social context of US infants are needed to improve their developmental trajectories.