Pediatric Researchers: On the frontlines of healthy outcomes for children

The Department of Pediatrics and the Division of General Pediatrics at Boston University School of Medicine and Boston Medical Center are dedicated to children, adolescents, and young adults in urban communities. The commitment to keeping this population healthy by promoting safety and preventative medicine, dispensing high-quality clinical care, and advocating for them at a systems level is supported by a robust clinical research program.

Led by Howard Bauchner, MD ’79, faculty in the Division of General Pediatrics conduct an array of research whose outcomes directly affect the patients cared for on the Medical Campus and at the Neighborhood Health Centers associated with Boston Medical Center, as well as applications in the field of pediatrics.

Bill Adams, MD, BUSM associate professor of pediatrics, works in health informatics and is particularly interested in moving pre-visit information from parents, collected via the telephone, into the electronic health record (EHR). “Interactive telephony technologies offer a potentially more effective, patient-centered communication modality by guiding parents at home through interactive discussions that can gather information and actively reinforce recommendation and treatment,” said Adams. “Also, interactive telephony systems are particularly well suited for use in vulnerable populations since access to the telephone is nearly universal, and the system does not rely on reading printed text.”

His group has developed and implemented an integrated health information system called the Personal Health Partner (PHP). This novel model is a fully automated conversational system using synthetic speech and automatic speech recognition to gather personal health data and counsel parents before their children’s scheduled visits. The patient-entered data is then shared with the child’s primary care clinician via the EHR. The system also provides personalized follow-up assessment and counseling after the visit. PHP is standards-based to allow integration with standards-compliant EHR and personal health record (PHR) systems.

The project is supported by a grant from the Agency for Healthcare Research and Quality.

In the past two decades, medical advances have reduced the mortality of very low birth weight (VLBW) premature babies, which are those weighing less than 1,500 grams. However, these infants experience a myriad of serious health conditions and development issues that require regular coordinated care. These babies are vulnerable to neurological and neurosensory deficits including cerebral palsy as well as vision, hearing, and speech impairments. C. Jason Wang, MD, assistant professor of pediatrics and public health at BUSM and BUSPH, has authored a study that demonstrates that these infants are falling through the cracks and not receiving the treatments that can mitigate some of the most serious side effects of VLBW. “Ours is the first population-based study of ophthalmologic and audiologic follow-up in Medicaid-enrolled children with VLBW,” said Wang. “These findings reinforce the Institute of Medicine’s concerns regarding inadequate outcome data and health care services for preterm infants.”

His group developed a set of quality-of-care indicators designed to assess the overall quality of follow-up care for this high-risk population. These include general care, physical health, vision, hearing-and-speech and language assessments, and developmental, behavioral, and psychosocial assessments. The researchers are also studying the factors influencing the enrollment of VLBW children in early intervention programs, which has implications for identifying obstacles to critical treatment for these children and developing strategies to eliminate the barriers.

Because of the complex nature of the care of VLBW infants and the stress on families of caring for these children, Wang is developing a web portal to create a social network for these families to navigate their children’s care. He has received a grant from the Robert Wood Johnson Foundation and Verizon to provide laptops to families for this purpose.

Exposure to violence in childhood and adolescence is a national public health problem, and community violence disproportionately affects minority youths and youths living in urban environments. Renee Boynton-Jarrett, MD, BUSM assistant professor of pediatrics, studies the effects of violence on various health outcomes.

One study examined cumulative violence exposure and self-reported health from a nationally representative sample of adolescents. According to the results, witnessing gun violence, threat of violence, feeling unsafe, repeated bullying, and criminal victimization each independently and significantly increased the risk for poor self-reported health. The findings, published in Pediatrics, indicate that interventions promoting adolescent health and well-being cannot focus solely on changing unhealthy behaviors. “Broader social policy changes aimed at reducing violence exposure in childhood and adolescence, including promoting safer schools and communities, may have greater effects on health trajectories during adolescence and young adulthood,” said Boynton-Jarrett.

“Housing goes beyond shelter and community. The creation of a home, free from housing stress, may be the best prescription for the physical and mental health of all children, particularly those with asthma.”

Boynton-Jarrett notes that over the past two decades, the level of exposure to violence among youth and rates of childhood and adolescent obesity have increased. “The alarming rise in the prevalence of obesity among children and adults in the past twenty years suggests that environmental and behavioral influences may be fueling the present epidemic,” she said. With a grant from the WT Grant Foundation, she is investigat-

ing the role of neighborhood and familial violence in explaining the social inequalities in obesity risk during adolescence and exploring the mechanisms by which violence affects change in body mass index over time. She is using this work to develop a pilot intervention program.

Another member of the pediatrics faculty, Assistant Professor Shikha Anand, MD, studies the clinical management of obesity in children and adolescents, and, with the help of private philanthropy, has established six obesity clinics around the U.S. She is working to create a system that is both clinically and financially viable.

Emily Feinberg, PhD, RN, assistant professor of pediatrics, and Michael Silverstein, MD, associate professor of pediatrics, collaborate to study maternal depression and explore detection and treatment options in the community setting, using, for example, programs like Head Start and Early Intervention. Both are experimenting with motivational interviewing and cognitive behavior therapy.

It has long been understood that good nutrition is essential for the growth and development of healthy children. Food insecurity is a major problem for low-income populations, especially those in high cost-of-living areas. John Cook, PhD, BUSM

associate professor of pediatrics, studies the policy of nutrition. For the past five years, he has been a senior research scientist and principal investigator for the Children’s Health Watch (formerly the C-SNAP program), a national network of clinicians and public health specialists for research, in multiple pediatric settings, on the effect of U.S. social policy on young, low-income children’s health and nutrition.

His research includes examining the effects of hunger, food security, and energy security on children’s health and well-being and ways to increase access to affordable, healthy food. The research looks at the implications of energy costs for low-income families’ economic viability and food availability and affordability for them. Families with very limited resources are often forced to choose between heating and eating, which leads to poor nutrition, increased illness, and cognitive and developmental deficits that affect school performance.

Research has also identified social determinants like income, housing, education, and access to health care that greatly influence health and mortality. Megan Sandel, MD, assistant professor of pediatrics, is the National Medical Director with the National Center for Medical-Legal Partnership, and director of Pediatric Healthcare for the Homeless at Boston Medical Center. A nationally recognized expert on housing and child health, she is an environmental scientist who examines how the built environment affects the health and well-being of children, particularly those with asthma, which disproportionately affects nonwhite children living in urban areas and children living in poverty.

Lower socioeconomic status is correlated with increased housing hardships. Her research examines how housing stressors like the high cost of housing, overcrowding, neighborhood instability, and lack of control over housing, can affect health—especially asthma. She and her colleagues suggest that poor housing puts psychological stress on children and their families, which has consequences for their health and how they manage diseases such as asthma. “Housing goes beyond shelter and community. The creation of a home, free from housing stress, may be the best prescription for the physical and mental health of all children, particularly those with asthma,” said Sandel.

Through the Medical-Legal Partnership program, which was first developed at Boston Medical Center, Sandel has studied how educating residents and physicians on the need to bring legal services into the health care setting affects the health and well-being of patients, particularly those with low and moderate incomes. Medical-legal partnerships harness the expertise of both professions to educate providers and patients on how social determinants can affect health and advocate to ensure that programs and laws that benefit health and access to health care are implemented and enforced.

Some of the other research the pediatric group is engaged in looks at pain management in children with sickle cell disease, dietary patterns and how they contribute to various health outcomes, the relationship between breast-feeding and vitamin D deficiency, early infant obesity, and methylation, a chemical process that in postnatal development may have a role in the interaction of environmental factors like maternal care with gene expression.

“Our group has focused on improving the health and well-being of disadvantaged children through clinical care, research, and advocacy,” said Bauchner. “It has been my privilege to work with this extraordinary group of clinician investigators.”

This Campus & Alumni News story was written by Mary Hopkins.