Understanding the social situation and environment of your patients helps in tailoring the counseling, screening, and preventive services you provide. Economic status is an important part of this information. Economic status has been well established as a risk factor for many health conditions. Overall childhood mortality increases with lower incomes, especially mortality related to trauma (motor vehicle accidents and homicide) and fire. Many specific sources of morbidity and mortality are also inversely related to family income, and knowing your patient’s financial status will allow you to focus on these known risks with support from clinical evidence.

Poor children are at greater risk for elevated blood lead levels, especially in the “high-normal” range of 5 to 10 μg/dL. Recall that children with these blood levels, although below the usual cut-off of 10 μg/dL, still have an increased risk of worse developmental outcomes. These children also have a higher risk of iron deficiency, so screening for anemia is especially important. There is some evidence that anemia per se is not sensitive enough as a screen for iron deficiency, which by itself seems to be related to impaired cognitive development even in the absence of anemia. Therefore, consider taking a more careful dietary history with such patients and consider obtaining protoporphyrin levels as a more sensitive screen for iron deficiency.

Poor children also tend to have more emergency department (ED) visits for asthma and are more likely to be admitted to the hospital when they do present to the ED, which suggests that their increased use of the ED results at least partly from more severe disease than children who are not poor. Children from lower-income homes are also more likely to die from respiratory disease. This understanding of the social elements of health care should motivate you to be especially thorough in your asthma care. Assure that your poor patients have backup inhalers and inhalers at school. Consider how much albuterol they are using and their degree of control. To some patients, using albuterol
a few times per week is “not that much.” You may take it for granted that inhaled steroids offer improved asthma control with minimal and acceptable adverse effects; however, many families are very reluctant to use inhaled steroids.