"Safety Cracks in Foster Care" in the April 1 Post-Dispatch highlighted the complicated interplay between child welfare and health care for children and youth in foster care. The story of Shakur Casanova Knight reveals that the work and efforts of serving both the health and safety needs of children and youth in foster care are inextricably linked, yet no clear system exists to support that collaboration in Missouri. As pediatricians who serve youth in foster care, we see plenty of opportunities to change this reality for children and youth in foster care while supporting the child welfare system's goals of safety and permanency.

Children and youth in foster care make up one of the most vulnerable populations in pediatrics. Although individual health concerns are varied, we know that rates of physical, developmental, mental health and dental problems are higher for children in out-of-home care than for other children. The complexity of their medical problems is compounded by inconsistent relationships with caregivers and medical providers.

Care for children and adolescents in foster care must be informed by an understanding of complex childhood trauma and the multiple adverse childhood experiences that affect health and resiliency. These facts are so well recognized that the American Academy of Pediatrics designates children in foster care as "children with special health-care needs."

It is hard to imagine a group of children who needs regular and comprehensive primary care more desperately than children in foster care. Many children in foster care lacked primary care prior to placement and experience fragmented health care during their time in care. Barriers make health care delivery challenging.

Some children and many adolescents experience frequent changes in placement that make continuity of care difficult. Also, for child welfare professionals, there are competing and important priorities, such as safety and permanency, which detract focus from quality health care. In addition, there are multiple people, such as caseworkers, guardians ad litum, foster parents, birth parents, family court judges, court-appointed special advocates, deputy juvenile officers and others involved in decision-making about the future and well-being of these children and youth.

Practitioners working with children in foster care quickly appreciate the complicated web in which these children find themselves. Acknowledgement of this complexity has led the AAP and the Child Welfare League of America to recommend an enhanced schedule for health supervision. Recommendations include an initial evaluation within 72 hours after a child enters out-of-home care, a comprehensive assessment within 30 days and a follow-up visit at 60 to 90 days.

Missouri does require certain health care visits when a child enters foster care that is in keeping with these recommendations. While these requirements are meaningful and in keeping with national organizations' best practices, no accountability for these services in an ongoing comprehensive way currently exists in Missouri. Whether these exams happen or not, we simply just do not know.

In addition, there are no medical personnel in the Children's Division to consult with or ask questions related to medical problems or needs. Would any of us want to raise our children without the opportunity to speak with a qualified pediatric medical professional? Other states do both — ensure accountability that medical supervision visits happen and provide consultation with pediatric medical professionals who review charts and cases and help children and youth obtain needed services.

As pediatricians, we understand the close ties between improved health, foster care placement stability and shorter time to permanency. While the child welfare system is ultimately responsible for health management, it is impossible to accomplish this in isolation. We have welcomed the opportunity to serve as key partners in the child welfare team in a new program we have developed to serve adolescents coming into care, Creating Options and Choosing Health, a pilot project to meet the health needs of youth coming into care in St. Louis.

April is Child Abuse and Neglect Prevention Month, so this is a perfect time for us to make new commitments to this special population. Opportunities and models can be brought to Missouri and strengthen the foundation that already exists. We believe stories like Shakur's encourage greater collaboration between health and child welfare practitioners as these children's futures are in our hands.

To shed light on these concerns and work toward positive change for this vulnerable population, the Missouri Chapter of the American Academy of Pediatrics will hold an open forum on foster care from 8:30 a.m. to 1 p.m. April 13 at the St. Louis University School of Medicine.

Dr. Katie Plax and Dr. Sarah Garwood are pediatricians specializing in adolescent medicine at Washington University School of Medicine and St. Louis Children's Hospital.