BACKGROUND AND OBJECTIVES Representative enrollment of racial and ethnic minoritized populations in biomedical research ensures the generalizability of results and equitable access to novel therapies. Previous studies on pediatric clinical trial diversity are limited to subsets of journals or disciplines. We aimed to evaluate race and ethnicity reporting and representation in all US pediatric clinical trials on ClinicalTrials.gov. METHODS We performed a cross-sectional study of US-based clinical trials registered on ClinicalTrials.gov that enrolled participants aged <18 years old between October 2007 and March 2020. We used descriptive statistics, compound annual growth rates, and multivariable logistic regression for data analysis. Estimates of US population statistics and disease burden were calculated with the US Census, Kids’ Inpatient Database, and National Survey of Children’s Health. RESULTS Among 1183 trials encompassing 405 376 participants, race and ethnicity reporting significantly increased from 27% in 2007 to 87% in 2018 (P < .001). The median proportional enrollment of Asian American children was 0.6% (interquartile range [IQR], 0%–3.7%); American Indian, 0% (IQR, 0%–0%); Black, 12% (IQR, 2.9%–28.4%); Hispanic, 7.1% (IQR, 0%–18.6%); and white 66.4% (IQR, 41.5%–81.6%). Asian American, Black, and Hispanic participants were underrepresented relative to US population demographics. Compared with expected proportions based on disease prevalence and hospitalizations, Asian American and Hispanic participants were most consistently underrepresented across diagnoses. CONCLUSIONS While race and ethnicity reporting in pediatric clinical trials has improved, the representative enrollment of minoritized participants remains an ongoing challenge. Evidence-based and policy solutions are needed to address these disparities to advance biomedical innovation for all children.

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Medical education and the health system must address challenges that, despite significant effort, seem unsolvable. Health systems science (HSS)-the fundamental understanding of how care is delivered, how health professionals work together to deliver that care, and how the health system can improve patient care and health care delivery-is increasingly being recognized as a potential source of solutions to these challenges.

Before I could finish my third knock, the examination room door swung open. I looked down, my gaze meeting a 4-year-old Black girl twirling effortlessly around the room for her well-child visit. Gross motor skills-check. She answered my questions about her shirt with ease and told me a story about her grandma. Language and communication-check. I handed her my pen. She drew a detailed picture of me with quite a large head, but I didn't take it personally. Fine motor skills-check. Milestones were on target. After finishing my examination and a discussion about kindergarten readiness, I asked her mom if there was anything else she wanted to discuss. Her mom hesitated. I reiterated that this is her time and nothing is off the table. Her mom sheepishly admitted that her daughter had begun saying that she is not Black. At that moment, as if a signal went off, the bright little girl said, "I'm not Black, you're Black… Black is ugly." The dagger of those words echoed, ricocheting off the walls, beelining to my gut. I looked to her mother who said that she had been repeating this to both her and her grandmother. Wounded and reeling, I sat stunned with a familiar sadness and disappointment. Saddened that this is likely one of many protective conversations her mom will have about self-love and navigating the world as a Black girl, disappointed at the possibility that a 4-year-old has started to pick up on cues of racism from her environment. Symptoms of internalized racism, heartbreakingly-check.A child's brain is a sponge, soaking up both the beauty and toxicities of this world. Internalized racism is the unconscious and conscious individual inculcation of the racist stereotypes, images, and ideologies perpetuated by white supremacy about one's racial group that leads to a system of oppression. 1 Similarly to this patient, I developed behaviors of internalized racism at a young age, showing before I had understanding that there is some societal classification system weakening my sense of self. When the world is entangled in racism, the default is for racist ideas to seep into a child's porous mind. An intentional and supportive environment can counteract racism's harmful sequelae, shifting self-doubt to selfdetermination and avoidance to acceptance. This patient's mom and I tag-teamed to describe that Black is beautiful, smart, creative, and worthy of love. I went to the Reach Out and Read library to see if there was a book that featured a Black protagonist. I hoped that her mom could use the strength-based story of a Black character to springboard conversations on race and positive identity formation. However, I came up empty. I could not find a single book that featured a Black main character, not to mention a book that discussed race.

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