What do one slice of bread, 17 small grapes, and a half cup of boiled potatoes have in common?
One serving of each of these foods is 15 grams of carbohydrates.
While this combination of items is a bit unusual, it highlights the arithmetic involved in managing blood sugar levels in diabetes. The process of counting carbohydrates and calculating insulin doses profoundly influences the daily lives and well-being of children living with diabetes. Further, the complications of uncontrolled diabetes during childhood can span into adulthood, including conditions such as dyslipidemia, hypertension, kidney disease, and neuropathy, among others.
Enter Lucía, a young Latina mother who arrived on the pediatrics hospital floor with her son for hyperglycemia — his second such admission in the month. As the senior pediatrics resident overseeing his care, I became uniquely acquainted with the case. Soon, whispers of medical neglect circulated among the medical staff, reaching the ears of social services, and ultimately leading to Child Protective Services (CPS) involvement. The frequency of her son’s hospital admissions raised concerns about Lucía’s ability to meet her son’s basic needs.
Lucía had two sons, Miguel and Tomás, the latter now under my care. Both boys were diagnosed with diabetes, relying on daily insulin doses to manage their condition. However, as overdue bills piled up, Lucía found herself in an impossible dilemma: divide the medication between her sons or risk leaving one without.
She confided in me that she had chosen to split the insulin, unable to afford both prescriptions. Her intention wasn’t neglect but rather a desperate attempt to navigate the harsh realities of the family’s financial situation. With each child receiving less insulin than they needed, their blood sugars soared, resulting in Tomás’ readmission.
This case underscores the intricate balance families often navigate. Diabetes management isn't just about glucose monitoring; it often involves walking an economic tightrope. Lucía’s actions were borne out of necessity, not neglect. For families like hers, the cost of managing diabetes isn't just measured in units of insulin or blood sugar levels but in dollars and cents, in skipped meals and rationed doses.
Lucía and her sons found themselves in the crosshairs of economic hardship, medical necessity, and, now, the child welfare system. Annually, millions of reports of suspected child abuse and neglect flood state and local CPS agencies. The U.S. Children’s Bureau defines medical neglect as a form of maltreatment resulting from a caregiver’s failure to provide appropriate health care although financially able to do so, or when offered the financial means to do so. However, even in cases where patients face documented financial barriers, the term “neglect” can become a catch-all among medical professionals.
Lucía’s case highlights the deeper socioeconomic and racial/ethnic disparities that exist within the child welfare system. While poverty heightens the risk of neglect, it is crucial to acknowledge that poverty alone does not signify neglect. The faces of the children in the child welfare system are largely Black and brown, often representing the most economically disadvantaged. Families from diverse racial and ethnic backgrounds may experience inequitable outcomes within the child welfare system. Specifically, cases that involve Black children are reported and substantiated by public child welfare agencies at a rate approximately twice that of cases that involve white children. Moreover, Black, Latino, and American Indian/Alaska Native families are disproportionately affected by poverty, heightening their likelihood of being reported to CPS compared with families with greater resources.
Reflecting on Lucía’s case, it is evident that poverty is sometimes mistaken for neglect, even by the most well-intentioned medical teams. This misconception can lead to families unnecessarily interfacing with the child welfare and court systems. These interactions can potentially result in child removal and termination of parental rights. It is important not to blame mothers like Lucía, but rather confront the reality that child health is intricately linked to economic stability, housing, and other systemic factors. Economic hardship can and does impact our patients’ and families’ ability to adhere to medical recommendations and safeguard the health of their children.
Addressing the impact of economic insecurity is crucial to mitigating instances of child neglect and fostering the healthy development of children and families. A paradigm shift is necessary, one that views financial instability as a call for support rather than a trigger for CPS involvement. Our health care system must become more attuned to the needs of diverse families like Lucía’s, incorporating cultural sensitivity and a social determinants of health approach into pediatric care. Additionally, implementing objective, evidence-based protocols for identifying child abuse and neglect can help mitigate the bias surrounding race and poverty that impact health outcomes.
For in the end, it’s not just about numbers (or counting carbs) — it’s about people.
How have you addressed external factors affecting your patients' health? Share your experiences in the comment section.
All names and identifying information have been modified to protect patient privacy.
Dr. Tasia Isbell is a pediatrician at Boston Children's Hospital and Boston Medical Center. She enjoys cycling, traveling, and exploring the world through cuisine. She tweets at @DrTasiaIsbell. Dr. Isbell is a 2023–2024 Doximity Op-Med Fellow.
Image by claudenakagawa / Shutterstock
