#355 -🚶‍➡️[Life Course Series] - How Do Inequities Shape the Life Course of Preterm Infants?

In this episode, we chat with Dr. Tim Nelin and Dr. Yarden Fraiman, two authors from the recently published special issue of Children on the life course implications of preterm birth. Together, they explore how inequities—both environmental and social—can shape the long-term health trajectories of preterm infants.

Dr. Nelin introduces the idea of “micro” and “macro” environments, showing how factors such as air pollution, green space, violence, and neighborhood social vulnerability not only contribute to preterm birth risk but also affect infants once they leave the NICU. His research underscores how the same exposures tied to prematurity continue to drive health disparities long after hospital discharge.

Dr. Fraiman focuses on ADHD as a case study of inequity across the life course. He describes the “ADHD care cascade,” illustrating how systemic bias and structural racism impact recognition, diagnosis, and treatment of ADHD among children born preterm. The conversation highlights how inequities layer over time, widening gaps in health and educational outcomes.

While the challenges are significant, the discussion also points to solutions—ranging from policy interventions and community partnerships to family-centered approaches. This episode emphasizes the urgent need to think upstream, addressing the drivers of inequity to create meaningful change for preterm infants and their families.

Transcript

Ben Courchia MD
Okay, we're joined for this next section by two authors from this very special series. We have the pleasure of having on today Dr. Tim Nelin and Dr. Yarden Freeman. Welcome to the podcast. We're very excited to have you here to discuss health equity and the life course health development for preterm infants. I want to dive into a few of the topics because we have a limited amount of time, and I feel like we needed three times that amount of time to discuss the dense papers that you've both written.

Tim, I wanted to start with you talking a little bit about neighborhood environments and preterm health development. I think in the paper that you wrote, you talk about this concept of micro and macro effects. I think it's an interesting concept in terms of looking at that and how that affects the health outcome of preterm infants. Can you give us a bit of an overview of how these neighborhood environments play a role in that epidemiology?

Tim Nelin
Yeah, that is a wonderful question. Thank you so much for starting there. And this may be a little bit of an oversimplification, but I'd like to break it down into thinking about the macroenvironment and the microenvironment. The microenvironmental exposures are specific to the individual's non-genetic exposures that may include things like diet, physical activity, smoking, social relationships. The macroenvironment contains different exposures that an individual has a little bit less control over – things like ambient air pollution exposure, neighborhood violence, green space, or neighborhood social vulnerability. We think that both of those are really connected to perinatal health outcomes. When we look broadly at different markers of macroenvironmental exposures, we find that the same exposures associated with preterm birth risk are often associated with adverse health outcomes of preterm infants. That’s important because some of the same exposures that contributed to an infant’s preterm birth risk are the same exposures that infant will face once they leave the hospital.

Ben Courchia MD
Yeah. And one of the examples you mentioned is bronchopulmonary dysplasia and how there are stark differences in incidences and prevalence of that specific morbidity depending on various factors. Can you tell us a little bit more about that, or are there other morbidities that are quite striking in how they differ between different environments?

Tim Nelin
Yeah. I think we would be remiss not to mention the racial disparities here. Black birthing parents are twice as likely to give birth preterm compared to white birthing parents. When we look at births at less than 28 weeks, black infants are more than three times more likely to be born at that gestation. These are the infants most vulnerable and most at risk for BPD, neurodevelopmental impairment, longer hospital stays, and adverse outcomes after NICU discharge. My group, with Heather Burris, looked at markers of the neighborhood environment quantified by the CDC Social Vulnerability Index and found that higher neighborhood social vulnerability was associated with higher odds of ED visits and inpatient readmissions in the year after NICU discharge among infants with BPD.

Ben Courchia MD
Thank you very much. Yarden, I wanted to segue into your article, titled “A Narrative Review of the Association Between Prematurity and Attention Deficit Hyperactivity Disorder and Accompanying Inequities Across the Life Course.” I think you do a tremendous job illustrating some of the points we’ve already started discussing, focusing specifically on ADHD. Can you tell us a little bit about how the inequities in preterm birth and the associated morbidities like ADHD translate into health disparities that last throughout the lives of these children?

Yarden S. Fraiman
Yeah, absolutely. Thanks so much for that question. Many of us know about the increased risk of developing ADHD among preterm infants, particularly those born at lower gestational ages. There’s even data to support that late preterm infants also have an increased risk. As Tim mentioned, we already know the inequities that exist in preterm birth, particularly among black birthing parents and their infants. We’ve done a really good job studying that inequity in neonatology, and then our pediatric colleagues examine inequities in childhood. But we haven’t fully connected how inequity in one period of life relates to inequity later on.

When we think about ADHD, we know from pediatric literature that there are inequities in symptom recognition, referral, evaluation, diagnosis, treatment, and maintenance. We call that the ADHD care cascade. So instead of studying inequity at one point in time, we can start to see how inequities are connected. Black birthing parents are more likely to have preterm infants, putting those babies at higher risk for ADHD. After NICU discharge, minoritized infants are less likely to be seen in early intervention or high-risk follow-up programs that perform neurodevelopmental screening. When minoritized children get to school, they are more likely to be identified as having problematic behaviors but less likely to receive an ADHD diagnosis. That means they don’t get medication or the appropriate services, and the inequity grows over time.

ADHD is just one example—similar patterns exist for asthma and BPD. What we wanted to highlight is that it’s time we stop measuring inequity cross-sectionally and begin to measure it longitudinally, following inequity over time.

Ben Courchia MD
Yeah, two words I’m taking away from your paper are “cascade” and “layers.” You have a beautiful figure showing the variables involved in identifying, diagnosing, and managing ADHD. You also discuss how inequities can layer over time. ADHD is particularly interesting because it’s such a unique pathology. You write that there are unique characteristics of ADHD among preterm-born children, suggesting a unique subtype and pathophysiology in this population. You talk about the ADHD being divided into three subtypes: the hyperactive or impulsive, the inattentive, or combined hyperactive and inattentive. While the combined phenotype is the most common in the general population, among preterm-born children the inattentive subtype is most common. This can lead to increased misdiagnoses since it’s the less frequent subtype overall.

You also discuss whether the increased risk of ADHD among preterm infants might result from systemic bias due to increased medical monitoring and screening. But you conclude that it’s unlikely that increased monitoring explains the excess ADHD diagnoses among preterm-born children. It’s a fascinating lens into the life of our preemies as they leave the NICU.

Tim, I wanted to ask about the educational and economic consequences. What are some of the social and educational impacts of these early health disparities as babies grow into adolescence and adulthood?

Tim Nelin
Absolutely. The cascade continues to grow as time goes on, especially with continued exposure to adverse environmental conditions that are difficult to escape. Across the lifespan of preterm infants, we see disparities in educational attainment and other social outcomes. It highlights the need for policies (federal, state, and local)as well as healthcare-level interventions to combat and diminish this cascade.

Ben Courchia MD
So as we’re halfway through this conversation, I want to spend time on how we fix this. What interventions are within reach to minimize these disparities and lead to meaningful changes? Tim, you mentioned green spaces and neighborhood changes. Can you tell us about specific interventions and how they translate into correcting inequities?

Tim Nelin
That’s a great question. On a local policy level, things like increasing green space are important. Increased exposure to green space is associated with decreased neighborhood violence and improved surroundings. It can reduce exposure to extreme heat and air pollution.

On a policy level, complementary efforts include supporting doulas, community health workers, and regulating ambient air pollution exposure. The EPA recently lowered the annual exposure threshold from 12 to 9 micrograms per cubic meter, but the 24-hour threshold hasn’t changed. We continue to see evidence that exposure above even the current limits is associated with adverse outcomes.

Ben Courchia MD
We’re recording this on election day, so I feel like the way to attain some of these solutions is for us as physicians to vote with our feet and support policies that favor positive interventions.

Yarden, transitioning to your paper focusing on ADHD, I want to ask about symptom recognition inequities. You wrote that it’s unclear whether increased symptom recognition by parents is a result of cultural differences, variations in interpretation, or differences stemming from experiences of structural racism and racial trauma. You cite a study where white teachers reported more ADHD symptoms for black children than their black parents did, and those with more negative racial attitudes gave higher symptom ratings. This creates such a complex paradigm. How do you see the path forward to mitigate these macro and micro challenges?

Yarden S. Fraiman
It’s so interesting, right? When we see racialized access to diagnosis and treatment, we need to think upstream. As Heather Burris once told me, we need to be “upstreamists.” When we see inequities, our instinct as physicians is to look at the individual level—what’s happening with that patient—but what’s upstream, I believe, is racism, both macro (structural and institutional) and micro (internalized and interpersonal).

So we need interventions at each level. At the interpersonal level, we can address behavioral expectations and biases that shape symptom recognition. Unlike BPD, there’s no objective diagnostic test for ADHD—so much depends on cultural norms and interpretation, and that kind of also contributes to the racialization of that diagnosis.

Now, I think when we think about inequities, you asked me about the step forward, I think about those inequities and the step forward in terms of the different levels. So if you're thinking about internalized racism, you're thinking about cultural expectations within a community around appropriate behavior. You can think about interpersonal racism. In terms of the ways in which our biases, both implicit and explicit, impact our willingness or ability to recognize symptoms. Thinking about those teachers and caregivers that have biases that then impact their likelihood to see problematic behaviors in children.

But there's also structural and institutional drivers of inequity that we also need to be thinking about, because I don't want us to only focus on individual people. So if we think about structural drivers: when are clinics open? Who can take off time from work as a result of economic inequity in our communities? The lack of diagnosis and treatment and medication and maintenance is also due to structural drivers and institutional drivers. The criminalization of problematic school behaviors among minoritized children, particularly black and brown boys is also a downward pressure when you think about that gap growing. We need to be thinking about the levers we pull at each one of those micro and macro levels. Because I think as physicians, we're so driven to just see like, how can I help this one patient and not realize that actually what's driving that inequity is there's probably a much bigger lever we can pull at the structural or institutional level. Similarly to Tim's point, thinking about the environment.

Ben Courchia MD
Yeah, it’s easy to see the problem in front of you but harder to conceptualize the bigger, less visible problem. As we wrap up, I want to say that while this topic can feel depressing, reading your papers actually made me optimistic. I feel like there’s a clear path forward and we could make some meaningful changes. Do you share that sentiment, and what are you excited about over the next 10 or 20 years?

Tim Nelin
I do share that optimism. It starts with having a more nuanced understanding of the drivers—recognizing that it’s racism, not race, that drives differential exposure and experiences. With better understanding, we can create place-based interventions at both healthcare and policy levels.

I’m excited about community partnerships and efforts like Heather Burris’s work with doula care. I’m also encouraged by economic policy changes, such as tax credits and financial supports for new parents, which showed promise during COVID with the expanded child tax credit. There’s growing appetite for investing in these place-based interventions to improve health equity.

Yarden S. Fraiman
I’m excited too. I’ve seen a shift from health disparities research, which simply shows differences, to health inequities research, which identifies unjust and preventable differences, and now toward health justice–oriented research. This approach names racism explicitly and seeks to understand and address its drivers. That shift allows for more collaboration across disciplines, with families, and with communities. We need to design interventions that truly center families and communities and identify where we can pull the biggest levers to close gaps.

Ben Courchia MD
Yes, collaboration is key. It’s time to move beyond our hospital walls and engage with communities. I recall a Journal Club discussion about a Michigan team that partnered with Muslim community leaders to gain approval for donor milk, which turned out to be one of the most effective quality improvement initiatives. It shows how impactful community partnerships can be.

Tim, Yarden, thank you so much for sharing your thoughts on your papers. We’ll link everything in the show notes. Congratulations on this great work, and best of luck for the future.