Redlining, Urban Heat, and Climate Hazards: Impacts on Children's Cardiometabolic Health.

Structural inequities, including historical redlining, have created compounding climate-related vulnerabilities in marginalized communities, with potential implications for pediatric cardiometabolic diseases (CMD). However, the joint effects of redlining, climate risk, and urban heat on pediatric CMD remain poorly understood. Using New York State hospital administrative data (2018-2022), we examined associations between neighborhood redlining, climate risk, urban heat, and CMD-related emergency department (ED) and outpatient visits among children aged < 18 years. Exposures included historical redlining (Home Owners' Loan Corporation grades C/D vs. A/B), climate risk (high vs. low, based on the Climate Vulnerability Index), and urban heat (high vs. low, based on satellite-derived land surface temperature). Associations were estimated using Poisson regression with interaction terms and subtype-specific analyses. Among 342,220 CMD-related visits in the climate-risk cohort and 9,195 in the urban-heat cohort (mean age, 7.4 years; 49% female), residence in historically redlined neighborhoods was associated with increased rates of CMD-related ED visits (rate ratios [RRs] = 1.15; 95% CI, 1.12-1.18) and outpatient visits (RR = 1.18; 95% CI, 1.17-1.20), with the strongest associations observed for comorbidity, hypertension, and type 1 diabetes (T1D). High-climate risk was associated with modestly lower overall rates of CMD-related ED visits (RR = 0.95; 95% CI, 0.94-0.96) and outpatient visits (RR = 0.96; 95% CI, 0.96-0.97), although elevated risks remained evident for selected CMD subtypes (e.g., hypertension, obesity, T1D). In the urban-heat cohort, most associations were not statistically significant (RRs = 1.00-1.03), except for outpatient visits for T1D, where higher urban heat exposure was associated with increased risk (RR = 1.28; 95% CI, 1.04-1.57). Co-exposure to historical redlining and high-climate-risk was associated with a modest increase in CMD-related ED visits (RR = 1.04; 95% CI, 1.01-1.07), whereas no significant associations were observed for co-exposure to redlining and urban heat (RR = 1.08; 95% CI, 0.78-1.49). Associations for outpatient visits were attenuated in both analyses. These findings suggest that redlining may be a stronger determinant of pediatric CMD healthcare utilization than climate-related hazards alone, highlighting the enduring health consequences of structural inequities and underscoring the need for targeted, climate-adaptive interventions, especially in historically redlined communities.