Addressing Food Insecurity Among Hospitalized Children: Upstream and Downstream Approaches

Hospitalization can be a traumatic experience for patients and their caregivers. Recognizing the emotional toll that acute illness can have on families, children’s hospitals often provide a range of services focused on easing the adjustment to life in the hospital, from toothbrushes and laundry rooms for personal hygiene, to chaplaincy services for spiritual counsel. However, health systems do not always recognize or address the significant financial impacts of hospitalization on their patients and families. Hospitalization can lead to or exacerbate financial strain resulting from lost wages; travel, food, and parking expenses; medication copays; and other costs incurred during a child’s hospital stay.¹ Hospitalization can also lead to the development of new social needs, such as the need for child care or elder care for family members at home, or new housing instability if families are evicted from a shelter or lose temporary housing during their hospital stay.

Recent research has highlighted the risk of food insecurity (FI) among families admitted to the hospital.^2,3 Many hospitals provide free meals for admitted children, but caregivers accompanying these children often have to purchase meals from a limited selection of expensive local vendors.⁴ Time spent at their child’s bedside may also mean that caregivers are unable to prepare food at home, instead relying on more expensive take-out or delivery options to feed other family members. And for caregivers without flexible schedules or paid family medical leave, compounded financial strain from lost wages may limit expendable income.^5,6

To address these concerns, many children’s hospitals have implemented universal FI screening. Although workflows vary across institutions, hospitals typically respond to positive screens with some combination of (1) referral to local community-based resources (eg, food banks, community meal programs, food delivery services), (2) direct provision of hospital-based food resources (eg, meal vouchers, in-hospital food pantry access), (3) information about government nutrition benefit programs, including the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and (4) connection to a social worker for more tailored guidance and support.^7,8

In this issue of Hospital Pediatrics, Asay et al present findings from a cross-sectional survey of caregivers of children admitted to an urban children’s hospital investigating their awareness and use of local food resources.⁹ In this hospitalized population, the authors found that rates of FI were more than double the national average among households with children. Although rates of food resource knowledge in their population were relatively high, almost half of their food-insecure cohort had never used available food resources. Their findings suggest that hospital-based FI screening and provision of resource information may increase awareness of local food resources among families of hospitalized children.

As the authors note, there are some limitations to the generalizability of their findings. This study was conducted during the SARS-CoV-2 pandemic, a period when national FI rates more than tripled and many emergency food systems rapidly mobilized and increased outreach to meet these escalating demands.¹⁰ Additionally, this study population included mostly caregivers living in urban communities, where residents might have greater awareness of and closer geographic proximity to available food resources compared with families in suburban or rural areas.^11,12 Finally, this study was conducted in a health system with a hospital-based food pantry, which may have led to greater awareness of local food resources among their participants.¹³

Despite these limitations, their findings offer several insights to help guide implementation of FI screening and resource provision in the pediatric inpatient setting. The authors found that rates of FI in their hospitalized population were substantially higher than national and local estimates of FI among households with comparable social demographics. They use these findings to reinforce the idea that food security is a dynamic state, rather than a static trait. As such, even families who were previously food secure could acutely develop FI from the socioeconomic burdens of hospitalization. Therefore, in addition to screening questions assessing FI over a 12-month period, such as those in the validated Hunger Vital Sign, hospitals should consider incorporating screening questions that specifically assess for acute FI during a child’s hospital stay.^3,14 Similarly, there is no consensus on the appropriate frequency for implementing social needs screening to optimize family support while minimizing screening burden. Although quarterly or semiannual screening may be the ideal cadence in an outpatient setting, the authors’ findings suggest that the potential for new FI resulting from a child’s admission may warrant screening families at every hospitalization.

The authors conclude that hospital-based FI screening and provision of resource information can increase awareness of local food resources among families of hospitalized children. It is important to consider these findings in the context of known limitations of health care–based social interventions. Although hospital-based food resources, such as the Feed1st Program referenced in this study, and paper or electronic referrals to local community-based resources, can help meet the needs of marginalized communities living near the hospital, there are several reasons why these interventions might not be the best way to reach all families in need.

First, health system–provided referrals to local food resources may overwhelm these programs, limiting their capacity to serve other families in need. These interventions could have the unintended consequence of decreasing availability of food resources for children and families without adequate access to health care, if limited community-based resources are preferentially channeled toward individuals who received referrals in health care settings. Second, as a growing number of state governments devote funding to addressing health-related social needs through their Medicaid programs,¹⁵ they may have less funding available to improve outreach for and boost participation in government nutrition benefit programs like WIC and SNAP, which are available to all state residents regardless of health status. Last, food resources that are located at the hospital or in the surrounding communities may not be feasible long-term resources for families living farther away, particularly families in rural communities. These families may face greater socioeconomic strains in the event of hospitalization because of longer travel times, prolonged absences from work, and limited access to resources at home.¹⁶ As many smaller children’s hospitals and pediatric units within safety-net hospitals close, and the geographic catchment area for children’s hospitals continues to broaden, hospital social workers are challenged with maintaining up-to-date lists of relevant resources for an expanding population.¹⁷

To address these challenges, health systems should ideally invest in both health system–based and community-based approaches to identifying social needs and connecting families to resources, prioritize connecting families with both local food resources and key government nutrition benefit programs, including WIC and SNAP, and consider leveraging geocoded resource technology, such as the online resource map used in this study, to ensure they are able to locate available and appropriate food resources for all families.

Health systems should also recognize that they might not always be equipped to effectively address social adversity. Proper investment in social care is costly, and much of the health care workforce may not have the time, experience, or expertise needed to adequately address social needs.¹⁸ Health system investment in key personnel including social workers (who have the knowledge and experience required to manage these needs), community health workers (who can build a trusted connection with patients they serve through shared lived experiences), and community advisory boards (which can gather direct input from community members on healthcare-based social care initiatives) may help bridge this gap. Nonprofit hospitals should also use their community benefit spending to invest directly in community-based organizations focused on reducing FI and promoting food justice. These organizations have often built trust with the communities they serve and may have more specialized expertise in addressing nuanced issues related to FI within marginalized communities.

In addition, although health system–based interventions to address FI can meaningfully impact individual patients and families, these interventions are less likely to move the needle on FI at the population level. Health systems should therefore also intervene upstream, using their role as anchor institutions to advocate for a stronger social safety net and more equitable social policies. Addressing FI at the population level requires influencing the political structures leading to inequities in access to affordable, nutritious food.¹⁹ For example, federal nutrition programs such as SNAP, WIC, and the National School Lunch Program typically undergo congressional reauthorization every 5 years. This period serves as an opportune window to advocate for critical policy changes like increasing the value of monthly SNAP benefits, protecting WIC and SNAP eligibility among low-income households regardless of employment or immigration status, and modernizing the WIC and SNAP programs to boost participation, particularly in underresourced and non–English-speaking communities.²⁰

Addressing food insecurity requires a multipronged approach that ideally includes both health system–based social care interventions and upstream policy changes. To mitigate the adverse effects of food insecurity on child health, children’s hospitals should not only invest in social care programs and conduct rigorous evaluations of these programs, like the work done by Asay et al, but also advocate for policy changes that mitigate inequities in food access and promote a more just and equitable food system.