The association of environmental exposures and area-level socioeconomic status with pediatric hydrocephalus outcomes

Abstract

Previous research has identified an association of socioeconomic status with poor health outcomes related to the treatment of pediatric hydrocephalus. However, the impact of environmental exposures and neighborhood disadvantage remains unexplored. The authors sought to determine how these factors affect hydrocephalus outcomes. This study is an analysis of prospectively collected registry data of pediatric hydrocephalus patients from 2008 to 2023 at a single institution. Geospatial analysis was conducted using the patient’s address at the time of the initial procedure for treatment of hydrocephalus. Socioeconomic status was quantified using the Area Deprivation Index (ADI), and environmental exposure data were obtained from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry and satellite-derived ground-level fine particulate matter, linked to patients’ addresses using hospital administrative data. Multivariable Cox regressions with robust standard errors to adjust for clustering of area-level measures were utilized to assess the independent association of neighborhood and environmental factors with shunt revisions and complications. In total, 881 patients who underwent primary shunt insertion for nontraumatic etiologies were included. The median (IQR) ADI percentile was 78 (61–90). The most common hydrocephalus etiology was intraventricular hemorrhage of prematurity (33%), followed by myelomeningocele (12%). At the latest follow-up, 48% of patients had experienced at least one shunt failure. The median (IQR) follow-up duration was 5.6 (1–11) years. In a multivariable Cox proportional hazards model, high ozone exposure areas (HR 1.38, 95% CI 1.05–1.82) and high ADI (HR 1.46, 95% CI 1.15–1.86) were independently associated with an increased risk of failure. High coal exposure was associated with an increased risk of shunt infection (HR 1.92, 95% CI 1.28–2.88). High PM 2.5 (particulate matter with a diameter ≤ 2.5 μm) was also significantly associated with increased all-cause mortality (HR 3.16, 95% CI 1.11–8.99). Exposure to environmental toxins and elevated neighborhood disadvantage are associated with worse outcomes in children with hydrocephalus. Environmental exposure may increase inflammatory pathways in children and reflect poor socioeconomic status. These results highlight social and environmental risk factors that warrant further investigation through biochemical or qualitative means.