COVID-19: Widening Health Disparities Among Pediatric Populations

General pediatricians specialize in preventive medicine—we vaccinate, provide anticipatory guidance, support parenting, perform developmental screening, and connect families with needed services. Our constant goal is to ensure that all children achieve their fullest potential and live healthy, productive lives regardless of income, race, or immigration status. In these unprecedented times, the focus across all medical specialties has shifted from preventive to reactive medicine. In the field of pediatrics, we have restructured all of our primary care services to prevent further spread of COVID-19 among our patients and their families. Although children are not sickened by COVID-19 at the same rate as adults, the long-term impact of the pandemic will be all-encompassing and will have detrimental effects on children’s health and development, especially for at-risk populations such as immigrant and minority families, children with developmental delays, and children who live below the poverty line.

Before COVID-19, there were already prevalent health disparities throughout the United States, leaving children from high-risk populations without preventative services ranging from vaccinations to physical therapy. The pandemic is having a disproportionate impact on minority patients, with nationwide data showing high rates of COVID-19 in Black, Hispanic, and immigrant communities.¹ These populations will continue to be affected after the pandemic because of our fractured social and economic support systems. We must be prepared for the downstream effects of social distancing on families and advocate expanded services to assist these marginalized populations.

Discrepancies in immunization rates across the United States highlight existing health care disparities that may worsen during and after the COVID-19 pandemic. Nationwide vaccination rates for children younger than 24 months are consistently lower for uninsured children or children who are on Medicaid, live in rural areas, or live below the poverty line.² Clinic regulations that promote social distancing during the pandemic are likely to reduce vaccination coverage for all populations. Many pediatric clinics have set age cutoffs to allow the youngest children to complete their primary vaccine series, but many parents are afraid to bring children to these appointments. Since the 2014–2015 Ebola epidemic, which similarly overwhelmed hospital capacity and paused routine health services, low immunization rates have been sustained in the postepidemic years.³ Children in the United States who already lack adequate access to health care because of socioeconomic status, insurance, or geographic location are at risk for similar long-lasting declines in vaccine coverage.

To respond to this decline in vaccinations, pediatricians and public health officials can partner together to target outreach toward these at-risk populations. Some clinics have implemented drive-through vaccinations, which is an elegant solution yet alienates large populations of people who do not have cars. We can implement mobile vaccination campaigns to bring immunizations into geographically isolated populations and neighborhoods with high proportions of patients who are on Medicaid or are uninsured. We should also advocate appropriate regulation ensuring up-to-date vaccination status before children reenter schools and should consider on-site vaccinations at schools to prevent delays in education.

Children with developmental delays and special needs are uniquely in danger of falling behind their peers during this time because of prolonged school closures and interrupted therapies. As the pandemic is raging on, children’s brains and bodies are continuing to mature, but many are doing so without needed support to reach their fullest neurodevelopmental potential. The Early Intervention Program (EIP) in New York City provides home speech, physical, and occupational therapy for children aged zero to three years with developmental delays, but at-home services have been paused. Prior to COVID-19, lack of program funding and bilingual therapists caused stark disparities in access to resources across the city. Children referred to the EIP are entitled to an evaluation within 30 days of referral; however, children in low-income and primarily Spanish-speaking neighborhoods are significantly less likely to be evaluated within this time period and ultimately receive services.⁴ Once routine well child care resumes, there will likely be a significant influx of referrals to services such as the EIP, as we will be catching up from months of lower detection rates for developmental delays. Children in these low-income neighborhoods and bilingual households will continue to have extreme difficulty accessing these services when the system is flooded with referrals. As pediatricians, we must advocate increased funding for services such as the EIP around the country so that these programs can employ more therapists and accommodate higher patient loads.

Pediatricians have vastly expanded telemedicine services in the place of routine well child visits to monitor developmental delays. Although telemedicine is an imperfect solution for detecting delays and abnormalities on examination and is difficult for families with limited access to the internet and other technology, it is currently our best tool, and it will help families engage in their children’s health care to mitigate loss to follow-up. Medicaid has recently updated its policies on telemedicine to expand coverage to include virtual well child visits and behavioral therapies, though specific regulations vary by state. Pediatricians should stay up to date on these policies and endorse continued expansion of telemedicine coverage at the state level to reach as many children as possible during and after the pandemic.

Low-income and minority families who are impacted heavily by COVID-19 are not only struggling with disease, but also loss of jobs, housing, and stable income. These children and families are disproportionately affected by food and housing insecurity because of the pandemic. With schools closed, children are no longer receiving free or reduced-price lunches at school, leading to increased food insecurity. Pediatricians must continue to prioritize food insecurity screening at every in-person or virtual visit and identify available resources to help support families. Existing programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP) will likely be overwhelmed with the vast increase in unemployment, and policymakers should work to expand funding for these services.

With heightened stress from disease and loss of income among the guardians of our most vulnerable children, we are concerned about our patients’ increased risk of trauma. We are already seeing startling increases in domestic abuse reports and suspected child abuse cases.⁵ School officials and teachers are the most common source of reports to child protective services; therefore, with school not in session, children not only lack a respite from potentially dangerous situations, but these acts are more likely to go unreported.⁵ The impact of toxic stress has been well described in the adverse childhood experiences studies, and there is no doubt that the uncertainty and fear of this pandemic will prolong stressful environments for children and their families. Pediatricians should be trained on supporting families through these trying times and should consider adding adverse childhood experience screening to their regular practice.

Much of what we do as pediatricians may now be on hold to flatten the curve and support our colleagues on the front lines, but there are many ways to support families during this time and to prepare to address their needs after a pause in services. We cannot underestimate our voice in advocacy to promote legislation for expanded support for at-risk communities through programs such as the EIP, WIC, and vaccination campaigns. We must work with public health officials and policymakers to plan targeted interventions in these communities. Once we are able to practice preventive medicine again, pediatricians will be at the forefront of the postpandemic response.