Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants
Authors: Gutman Colleen K. , Aronson Paul L. , Singh Nidhi V. , Pickett Michelle L. , Bouvay Kamali , Green Rebecca S. , Roach Britta , Kotler Hannah , Chow Jessica L. , Hartford Emily A. , Hincapie Mark , St. Pierre-Hetz Ryan , Kelly Jessica , Sartori Laura , Hoffmann Jennifer A. , Corboy Jacqueline B. , Bergmann Kelly R. , Akinsola Bolanle , Ford Vanessa , Tedford Natalie J. , Tran Theresa T. , Gifford Sasha , Thompson Amy D. , Krack Andrew , Piroutek Mary Jane , Lucrezia Samantha , Chung SunHee , Chowdhury Nabila , Jackson Kathleen , Cheng Tabitha , Pulcini Christian D. , Kannikeswaran Nirupama , Truschel Larissa L. , Lin Karen , Chu Jamie , Molyneaux Neh D. , Duong Myto , Dingeldein Leslie , Rose Jerri A. , Theiler Carly , Bhalodkar Sonali , Powers Emily , Waseem Muhammad , Lababidi Ahmed , Yan Xinyu , Lou Xiang-Yang , Fernandez Rosemarie , Lion K. Casey 
Published: November 2023

Importance

Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language.

Objective

To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection.

Design, Setting, and Participants

This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source.

Exposures

Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English).

Main Outcomes and Measures

The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes.

Results

Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46).

Conclusions and Relevance

Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.