Hospitalization May Allow Us to Identify Food-Insecure Children

Approximately 15.9 million children in the United States have been identified as food insecure, which means that they live in households that have limited access to nutritionally adequate and safe foods. These families are often unable to provide balanced meals, and they may sometimes reduce portions or skip meals entirely. As a result, children experiencing food insecurity are at increased risk for health issues such as iron-deficiency anemia, headaches, stomachaches, and upper respiratory infections. They are also at higher risk for anxiety, depression, developmental concerns, and behavioral problems. Children with household food insecurity have significantly greater odds of poor health and hospitalization. For all these reasons, the American Academy of Pediatrics recently released a policy statement recommending that pediatricians screen for food insecurity at routine health maintenance visits.

In a recent study, Banach considered the hospital setting as another way to identify patients with food insecurity. Using data from the National Health and Nutrition Examination Survey (NHANES), she examined the prevalence of food insecurity and identified sociodemographic groups at risk for food insecurity among hospitalized children. She also estimated how many hospitalized children were receiving public nutrition assistance, with the hope that contact during hospitalization would offer another opportunity to provide families with needed resources.

The use of NHANES allows a cross-sectional analysis of individuals aged 0 to 19 years in the US population from 2007-2012. Surveyors administered the United States Department of Agriculture Food Security Survey Module, a validated questionnaire created to measure food insecurity. A recent hospitalization was defined as occurring within the last year. Multiple logistic regression analyses examined associations of food insecurity with age, sex, race/ethnicity, insurance status, family income, and hospitalization.

Analysis revealed that approximately a quarter (25.3%) of children who were recently hospitalized lived in food-insecure households. Among children not recently hospitalized, 19.6% lived in food-insecure households. Recently hospitalized low-income, uninsured, or Hispanic children had an even greater risk of food insecurity—more than one-third of these children lived in food-insecure households. Overall, recently hospitalized low-income children and uninsured children had the highest prevalence of household food insecurity. 

Through estimations of eligibility for nutritional assistance, it was found that 26.9% of patients who potentially could have been receiving Women, Infants, and Children (WIC) benefits had not enrolled, and 31% of patients potentially eligible for the Supplemental Nutrition Assistance Program (SNAP) had not enrolled. 

While these data are nationally representative, there are some limitations to this study. The NHANES data are collected via self-report, which is subject to recall bias, inaccuracies, and underreporting. As the definition of food insecurity within this study was fairly strict, there was some concern that health risks may have been underestimated. Even marginal food insecurity has been shown to lead to adverse health outcomes in children. There is also the possibility of reverse causality. Families with a hospitalized child could find it challenging to maintain employment or enroll in supplemental nutritional services.

Health care providers inside and outside the hospital setting should be aware of the high percentage of families who are eligible for supplemental nutritional assistance in the form of WIC or SNAP but have not enrolled. Many families leave supplemental programs when their child turns 1 year old when they need to recertify, or they may no longer feel that the program is worth continuing. Families should be encouraged to renew at the 1-year visit, and hospitals can assist with enrollment as needed. 

Research has established that food insecurity can lead to adverse health outcomes. With this in mind, we should take every chance to identify families at risk and assist with resources. Health care providers should remember both to screen at the time of hospitalization and check for re-enrollment in supplemental nutritional programs at the 1-year visit. These are potentially high-yield opportunities to improve the health of your patient’s entire family.  

Jessica Tomaszewski, MD, is an assistant clinical professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware. 

Charles A. Pohl, MD—Series Editor, is a professor of pediatrics, senior associate dean of student affairs and career counseling, and associate provost for student affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.