Food security is defined as access to enough food at all times for an active, healthy life1. Pre-pandemic, food insecurity affected 399,270 (15.1%) children in Pennsylvania (https://map.feedingamerica.org/county/2018/child/pennsylvania), higher than reported nationally (10.5%)1.
Food insecurity is associated with adverse child developmental outcomes2. Mechanisms that mediate these findings are not entirely clear, but structural inequities (e.g. poverty, access to education and health care) are contributing factors2,3.
The American Academy of Pediatrics endorses food security assessment; however, data in the PICU are lacking 4. Therefore, our objective was to analyze the prevalence and contributing factors of food insecurity among PICU families.
The University of Pittsburgh Medical Center (UPMC) Quality Improvement Review Committee approved this project conducted at the UPMC Children’s Hospital of Pittsburgh.
PICU social work staff administered the 2-question Hunger Vital Signs™ between April 1, 2019 and June 30, 2019 on Mondays-Fridays during routine family consultation5. Families whose children reside at a long-term care facility were excluded. Screens were positive if either question was affirmative; if positive, families were offered a meal, supermarket gift card (up to $20), and assessment of Supplemental Nutrition Assistance Program (SNAP) eligibility. Patient and hospital related data were abstracted from the electronic medical record.
The primary outcome was prevalence of food insecurity. Fisher’s exact and Wilcoxon rank sum were used to compare food secure and insecure groups. A multivariable logistic regression model tested the association between covariates and food insecurity. Statistical analysis was conducted using STATA 15.1 software package. Note that to account for multiple comparisons (n=11), significance for the multivariable analysis is p < 0.0004.
Twenty-seven (20%) of 137 families screened were food insecure (Supplementary Figure 1). Twenty-nine families (21%) participated in SNAP, including 14 families (10%) who screened negative. Black families reported a higher prevalence of food insecurity compared to white families (56% vs. 30%, p<0.001) (Table 1). Severity of illness scores were similar between groups.
Table 1:
Baseline patient characteristics and outcomes for all families and by food security status.
| N (%) or Median (IQR) | All Families N = 137 | Food Secure (N = 110) | Food Insecure (N = 27) | p value* |
|---|---|---|---|---|
| Male | 86 (63) | 66 (60) | 20 (74) | 0.192 |
| Age, years | 3 (1–10) | 3 (1–10) | 4 (1–12) | 0.580 |
| Race | <0.001 | |||
| White | 89 (65) | 81 (74) | 8 (30) | |
| Black | 34 (25) | 19 (17) | 15 (56) | |
| Other | 14 (10) | 10 (9) | 4 (15) | |
| Body mass index | 18.5 (16.7–21.2) | 18.3 (16.7–21.1) | 19.7 (16.3–22.7) | 0.774 |
| PELOD-2 Score | 5 (3–10) | 5 (2–10) | 7 (4–14) | 0.131 |
| PRISM IV Score | −4.44 (−3.7—−4.8) | −4.43 (−3.7—−4.8) | −4.47 (−4.0—−5.0) | 0.617 |
| Mechanical Ventilation | 88 (65) | 71 (65) | 17 (65) | 1.000 |
| Hospital LOS, hours | 133 (69–308) | 124 (69–271) | 161 (68–411) | 0.446 |
| Disposition | 0.456 | |||
| Home | 125 (92) | 101 (93) | 24 (89) | |
| Other | 11 (8) | 8 (7) | 3(11) |
pairwise comparison between food secure and food insecure cohorts
IQR, interquartile range; PRISM, Pediatric Risk of Mortality; PELOD, Pediatric Logistic Organ Dysfunction; LOS, length of stay
In a multivariable analysis, black race (odds ratio [OR] 14.20, 95% confidence interval [CI] 4.34–46.70), other minority race (6.57, [1.42–30.32]) and worse Pediatric Organ Dysfunction Score (PELOD-2 score, 1.16, [1.05–1.28]) were associated with food insecurity (Supplemental Table 1).
The prevalence of food insecurity among PICU families was double the general US population1. These results are consistent with a study conducted in the emergency department of a tertiary children’s hospital but higher than our center’s primary care (~5%), gastroenterology (3.3%), and cystic fibrosis clinics (12%) (Communication by A.C., unpublished data)6. Reasons for greater prevalence in the PICU are unclear but may include differences in questionnaire delivery and delayed access to care, and deserve more focused study. Our data highlight the vital need to understand and address racial and care access disparities particularly given structural health inequalities in the US, recent changes to SNAP benefits, and the pandemic’s exacerbation of unmet needs (https://www.fns.usda.gov/snap/work-requirements).
As a result of these findings, we have implemented expanded universal social determinants of health screening and support in our PICU. However, several challenges remain, including optimization of a family-centered approach to screening and support for families with children in the PICU.
Supplementary Material
Acknowledgments
Gift cards were provided by a grant obtained by the Division of Community Health’s Food Insecurity Task Force from the Pittsburgh Foundation.
We thank Delia O’Leary, MSW, Sherry Gunn, MSW, Ashle’ Hall, MSW, and Jessica Schneck, MSW, former students in the Department of Social Work, University of Pittsburgh for assisting in the study design, data collection, and provision of care to patients and families in the PICU.
We thank our colleagues at the UPMC Children’s Hospital of Pittsburgh for sharing unpublished food insecurity results in their respective patient populations: Kristin Mary Hannibal, MD, Katherine Watson, DO, Carlene DeBee, RN, BSN, and Samantha Faulds, MS, RHIA from General Academic Pediatrics; Iris Yann RD, LDN, Kathryn Vicini RD, LDN, Kristina Rae Fayad RD, LDN, and Daniel Weiner, MD from the Cystic Fibrosis Center; and Angela Sandell, MD, Kristen Bennett, MD, Amy Bonfilli, RN, and Leah Siebold, MD from the Pediatric Gastroenterology Clinic.
Conflicts of Interest and Source of Funding: PICU family gift cards were provided by a grant obtained by the Division of Community Health’s Food Security Task Force from Whole Foods Market Community Giving Program. The Henry H. Hillman Foundation supported the Improving Food Security for Pittsburgh Families with Young Children grant (S.E.M. and A.C.). Authors report grant funding as follows: Support from the Children’s Hospital of Pittsburgh Foundation (Ann and Michael Popper Family for the Critical Illness Recovery for ChiLdrEn program) (E.L.F.); 1K23HD099331-01A1 (C.M.H).
Tweet: Universal #PedsICU #FoodInsecurity screening and support is Vital to support #WholeChildandFamily recovery @PicsP
Copyright form disclosure: Drs. Morrow, Carpenter, and Fink’s institutions received funding from Henry H. Hillman Foundation. Drs. Carpenter’s and Fink’s institutions received funding from Whole Foods Market Community Giving Program. Dr. Horvat’s institution received funding from National Institutes of Child Health and Human Development 1K23HD099331-01A1. Drs. Horvat and Fink received support for article research from the National Institutes of Health (NIH). Dr. Fink’s institution received funding from Children’s Hospital of Pittsburgh Foundation.
Footnotes
The remaining authors have disclosed that they do not have any potential conflicts of interest.
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