Over the decades, pediatric care has improved health of children by treating disease, advancing immunizations, and improving surgery and pharmacotherapy. The future of pediatrics will be the promotion of healthy lifestyles and the prevention of disease for all children. What follows is an “advocacy primer,” written by a former AAP president who became an advocate for children as he developed his clinical practice, first treating the individual and then, the community.

Honest and realistic pediatricians agree that advocacy, by a variety of players (themselves, parents, teachers, coaches, religious leaders, and others), is just as likely to improve child outcomes as the medical care they provide during encounters with patients and families. Herein, the term pediatrician is used for one of multiple health professionals and lay child advocates who work to improve the outcomes of children. Pediatricians also recognize the impact of social drivers of health (SDoH) (poverty, food insecurity, transportation barriers, inadequate housing/homelessness, equity/racism, domestic violence, substance abuse, and mental health disorders) on child outcomes and their need to engage in advocacy to address common SDoH. Herein, SDoH and social determinants of health are used interchangeably because most references use “determinants” whereas today most authorities see these “determinants” as “drivers” of action on behalf of at-risk people. (1) Today, there are a variety of SDoH screening instruments to assist pediatricians in identifying at-risk children (https://www.aap.org/en/patient-care/screening-technical-assistance-and-resource-center/screening-tool-finder/). It can be challenging to address SDoH issues within the confines of the typical pediatric practice. However, if patients are to achieve optimal outcomes, pediatricians must understand the power and scope of their advocacy and the importance of venturing outside traditional patient care settings to become effective advocates for children and families.

Advocacy can add much joy and satisfaction to the day-to-day practice of pediatrics. Each patient encounter provides an opportunity for advocacy. Many patients benefit from pediatricians’ direct communication during encounters, their outreach to other members of the community-based advocacy team, and their efforts to improve community-based health services. Once pediatricians evolve into strong patient advocates, they can consider ways to engage in more comprehensive advocacy at state, national, or global levels so that the larger health-care system provides all patients access to affordable, user-friendly health services that improve outcomes.

In 1931, pediatrician advocates founded the American Academy of Pediatrics (AAP) when they could not convince the American Medical Association to engage in federal government advocacy to improve the lives of women and children. (2) Advocacy thus has always been an integral component of pediatrics as practiced in the United States. Some pediatricians have established food pantries, implemented early literacy programs such as Reach Out and Read, and engaged in other advocacy programs in their efforts to address the holistic needs of patients. However, our current regulation-heavy and technology-driven system consumes much of the time and energy that pediatricians could devote to advocacy. The Accreditation Council for Graduate Medical Education (ACGME) competency “Systems-based Practice" (3) is new to many pediatricians, and many pediatricians find it challenging to link patients with necessary and available community-based services. Plus, most pediatricians underestimate their credibility when they step out of their comfortable patient care settings into the arena of child and family advocacy. (4)

The AAP Policy Statement, “Community Pediatrics: Navigating the Intersection of Medicine, Public Health, and Social Determinants of Children’s Health,” approved in 2013 and reaffirmed in 2017, “recognizes the importance of pediatric involvement in child advocacy at local, state, and federal levels to ensure all children have access to a high-quality medical home and to eliminate child health disparities.” (4) This AAP policy recommends that “pediatricians must successfully merge their traditional clinical skills with public health, population-based approaches to practice, and advocacy” to address SDoH issues. (4)

This AAP policy statement further says that there are major child health problems that cannot be addressed in the practice model alone, including infant mortality; preventable infectious diseases; sedentary lifestyles; long-term health-care needs; obesity; metabolic syndrome and other historically adult-onset chronic diseases; high levels of intentional and unintentional injuries; exposure to violence in all forms; risks of neurodevelopmental disabilities; illnesses from exposure to environmental tobacco smoke, lead, and other environmental hazards; substance abuse; mental health conditions; poor school readiness; family dysfunction; sexual health; unwanted pregnancies and sexually transmitted diseases; relatively low rates of breastfeeding; social, medical, behavioral, economic, and environmental effects of disasters; inequitable access to medical homes and basic material resources; and poverty. (4)

The policy refers to social determinants of health (5) as the economic and social conditions that shape the health of individuals and communities and quotes former AAP President Robert Haggerty, the Founding Editor of Pediatrics in Review, emphasizing the need for pediatricians to develop collaborative approaches to ensure optimal outcomes for children: “We must become partners with others, or we will become increasingly irrelevant to the health of children.”

The 2023 proposed recommendations of the ACGME for pediatric residency training include unambiguous language supportive of pediatrician advocacy: “Pediatricians are advocates for children. They have a strong presence within communities, where they promote health and health equity in ways that build public trust in the profession. In their interactions with others, they exhibit cultural humility and empathy. They are grounded in principles of social justice, advocate for underserved populations, and seek to eliminate disparities in care. They are collaborative leaders who lead by example and practice interprofessional team-based care. Pediatricians communicate effectively with patients, families, treatment teams, communities, and within health care systems.” (6)

Given the revolutionary changes in our society since 1930, and the realities that SDoH need the attention of the child health system, pediatricians must recommit themselves to comprehensive approaches to advocacy. There are multiple ways for pediatricians to advocate effectively for their patients.

Each patient gives the pediatrician an opportunity to engage in advocacy. Maybe the patient needs a timely referral; maybe the parent needs information about resources in the community or on the Internet to improve patient care; maybe someone besides the parents might assist the family in ensuring needed comprehensive health and human services. For example, imagine that a new 2-year-old patient who is obviously on the autism spectrum presents to a pediatric practice and nothing has ever been done to evaluate the child for developmental disability or to refer the child for necessary support services. During the encounter, the practice-based team could perform standardized screening for autism, test hearing, send out a buccal swab for genetic testing, initiate referrals for speech and occupational therapy, make a referral to a developmental-behavioral pediatric subspecialist, connect the family with the regional Individuals with Disabilities Education Act (7) coordinator, notify the Exceptional Children’s Program (8) in the public schools that this child will need to be enrolled in their preschool program as soon as eligible, connect the family with the local Head Start (9) agency, and refer the child for Medicaid-funded community-based care coordination services. The busy pediatrician could initiate all these services without leaving the examination room, thanks to standard practice infrastructure, including a cyber-secure electronic medical record (EMR) system. SDoH screening and referral mechanisms can be incorporated into the EMR. In addition, community partners could respond to the needs of the pediatrician in real-time within the EMR. Technology actually makes practice-based advocacy much easier for today’s pediatricians.

Besides having well-trained staff and solid practice infrastructure, pediatricians must understand the local system of care and work to improve that system. Pediatricians are highly respected in the community and can assist the larger community in implementing progressive changes that improve child outcomes. There are multiple groups of at-risk children who may benefit from communitywide care coordination initiatives: children in foster care; children with developmental disabilities, including those on the autism spectrum; children with behavioral health problems; children with asthma; obese/overweight children; children with diabetes; and many other children with significant risk factors. Pediatricians can improve child outcomes by providing input and leadership to community-based coalitions. The AAP’s CATCH (Community Access to Child Health) Program provides grant-funded support for members who want to improve their community-based systems of care. (10)

Most of the infrastructure and funding of the pediatric system of care is determined by state government administrators and elected officials. For example, payment of providers who provide services for children eligible for Medicaid and the Children’s Health Insurance Program is determined at the state government level. Pediatricians who understand what children need at the local level must involve themselves in the decision-making process at the state level if their patients are to have access to the health and human services they need to achieve optimal outcomes.

Pediatricians live and work in the same communities as elected state officials and often provide medical homes for the children of these leaders. Personal relationships with elected leaders are especially important and should be nurtured when possible. Most AAP chapters coordinate state government advocacy via listservs and virtual committees and welcome “key contact pediatricians” to assist in creating and continually improving the statewide system of care to the benefit of children, families, and pediatricians.

The AAP’s Committee on State Government Affairs, appointed by the AAP Board of Directors, convenes twice annually to monitor state trends, identify new opportunities, and provide counsel to state advocacy staff working with AAP chapters to help them achieve their state advocacy goals. The AAP has a new digital advocacy guide (https://www.aap.org/en/advocacy/state-advocacy) to help support advocates with information, tools, and resources on how to be effective child health advocates.

Most of the money necessary to fund health and human services programs for children comes from the federal government. In many states, more than 70% of Medicaid funding, 75% of Children’s Health Insurance Program funding, and more than 50% of immunization funding comes from the federal government. Therefore, it is particularly important for child health professionals to ensure that the leaders of the federal government understand how important it is for states to receive optimal federal funding for key children’s programs.

The AAP has an office in Washington, DC, where professional advocacy staff ensure that the opinions of pediatricians are shared with federal government leaders. The Board of Directors of the AAP appoints member pediatricians to the Committee on Federal Government Affairs, which meets at least twice a year to give guidance and support to the staff of the Washington Office. The pediatricians on this committee provide direction for federal advocacy efforts through developing board-approved policy for the AAP. The AAP conducts the Advocacy Conference in Washington every spring and coordinates a network of key contact pediatricians who assist the larger AAP in advancing its child advocacy agenda. AAP state chapters send members to the Advocacy Conference. Attendees engage in face-to-face discussions with their members of Congress to promote the advocacy agenda of the AAP. AAP members should contact their AAP state chapters if they would like to attend this meaningful and educational advocacy event.

The AAP has become increasingly involved in the challenges of global health. One does not have to think farther back than the COVID-19 pandemic to understand that the health problems of other countries affect what goes on in the United States. In the areas of human immunodeficiency virus and other infectious diseases, immunizations, and neonatal resuscitation, the AAP has become a leader on the world scene.

Global pediatric advocacy can occur in a variety of ways. It can involve global training programs such as Helping Babies Breathe or working with international vaccine alliances to improve vaccination rates. During the past 20 years, we have seen worldwide mortality in children younger than 5 years drop by 50%, in large part due to work on the United Nations Millennium Development Goals and Sustainable Development Goals by many groups, including pediatricians.

The AAP has an amazing “library” of educational resources and has published many of these materials in multiple languages. The AAP offers global virtual membership to pediatricians who live in other countries, and the fees for global membership are adjusted to reflect the economic status of the countries according to World Bank data. Through international membership, many child health professionals gain access to AAP educational materials. Sister pediatric societies in Africa and Asia are drawing on AAP advocacy expertise and have been trained by AAP members in advocacy strategies that can be adapted to their local systems of care. By engaging child advocates in other countries, the AAP can learn about worldwide “best practices” for meeting the needs of at-risk children.

The AAP’s Section on Global Health develops policy statements on issues pertinent to global health, and its members advocate directly within Congress and the administration to ensure US foreign assistance policies and programs prioritize children’s health and well-being. Child health professionals who want to become involved in the global advocacy initiatives of the AAP should consider joining the AAP’s Section on Global Health and reviewing the AAP publication Global Child Health Advocacy: On the Front Lines, authored by pediatric experts in global child health. (11)

If pediatricians are to improve outcomes for children, they must step outside traditional face-to-face and virtual patient encounters to engage the larger community in the collaborative effort necessary to help children achieve optimal outcomes. Pediatricians must do all they can to help their patients become healthy, responsible, productive, happy adults. Today, it is easy for pediatricians to burn out as they spend more and more time addressing the administrative challenges of the health-care system. By creatively incorporating advocacy into their daily routines, pediatricians can regain the joy of practicing medicine. The AAP, at the practice, community, state, federal, and global levels, has resources for child health professionals who want to improve their advocacy skills and efforts. Serious and successful advocacy will enrich the lives and careers of pediatricians while also achieving the main goal of our profession: improving the outcomes of our patients!

I acknowledge the following persons who assisted in the writing of this document: Judy Dolins, MPH; Francis Rushton, MD, FAAP; Kathleen Clarke-Pearson, MD, FAAP; Olson Huff, MD, FAAP; Marian Earls, MD, FAAP; and the following American Academy of Pediatrics staff: Mark Del Monte, JD, CEO/Executive Vice President; Mandy Slutsker, MPH, Director, Global Child Health Advocacy; Dan Walter, MPA, Senior Policy and Government Affairs Analyst; Tamar Magarik Haro, Senior Director, Federal and State Advocacy; Janna Patterson, MD, MPH, FAAP, Senior Vice President, Global Child Health and Life Support; and Jamie Poslosky, Senior Director, Advocacy Communication.

AUTHOR DISCLOSURE: Dr Tayloe has disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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