Neighborhood-Level Education Disparities Linked to ICU Risk in Infant Respiratory Infections

Introduction: Lower respiratory tract infections (LRTIs) are the top cause of hospitalization and ICU admission in children under two. Social determinants of health (SDoH), including neighborhood-level factors measured by the Child Opportunity Index 3.0 (COI), may influence disease severity. The 3 COI domains are education, health/environment, and social/economic. We hypothesized that lower COI across all domains would be associated with ICU admission.


Methods: This retrospective cohort study examined children < 2 years old who received acute care for LRTI at a large academic center from 2018–2023. Patients were identified via ICD-10 codes; demographic, clinical, and COI data were extracted from the medical record. Patients were cohorted by admission status (ICU, non-ICU inpatient, or outpatient) and compared to COI domains by strata (Very High (VH), High (H), Moderate (M), Low (L), Very Low (VL)) normalized to Ohio.


Results: Among 29,938 patients, 30% were hospitalized, and 11% required ICU care. ICU patients were younger, more likely to be premature, have a history of wheezing, and have public or no insurance. Overall, lower COI (VL/L) was more prevalent among ICU patients (57%) compared to non-ICU inpatient (53%) and outpatient (52%) (p < 0.001). The education subdomain showed the largest difference between VL and VH in all cohorts (ICU: 37% vs 12%, non-ICU: 35% vs 13%, outpatient: 40% vs 14%; p < 0.001). The health/environment and social/economic domains showed narrower overall differences when compared to education but the ICU cohorts had the widest disparities (health/environment ICU: VL 30% vs VH 10%, non-ICU: 27% vs 11%, outpatient: 28% vs 10%; social/economic ICU: VL 32% vs VH 14%, non-ICU: 29% vs 16%, outpatient: 29% vs 17%; p< 0.001).


Conclusions: These findings suggest that neighborhood-level SDoH, as indicated by lower COI across domains, are associated with increased LRTI severity. All COI domains showed differences, but the education domain demonstrated the widest disparities from VL to VH across cohorts. ICU patients demonstrated known risk factors and exhibited the highest discrepancies between VL and VH in all subdomains. Understanding and addressing these education disparities is critical to develop targeted interventions to mitigate health inequities in vulnerable pediatric populations.