Inadequacies of Supporting Families With Food Insecurity in the Hospital Setting

Since the 2016 Policy Statement on Poverty and Child Health, The American Academy of Pediatrics has recommended routine screening for Social Determinants of Health (SDOH) in the ambulatory setting.¹  Numerous evidence-based toolkits and resources have been provided for pediatricians to accomplish this goal including tools, such as the Hunger Vital Signs for food insecurity (FI),²  the Safe Environment for Every Kid³  and the Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education⁴  which all screen for multiple risk factors. While much work has been done to help ambulatory practices implement SDOH screening,^5,6  fewer articles have been published describing the use of SDOH screening in the inpatient setting.

In this month’s Hospital Pediatrics, Markowitz et al present the current state of affairs of SDOH screening in children’s hospital inpatient units across the country.⁷  Although the focus of the article centered on FI screening, it is important to note that many of the units used broader SDOH screens such as the Safe Environment for Every Kid, Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education, or homegrown screening tools in their electronic medical record. Although the study was limited by a 40% response rate, it does provide some insight into how children’s hospitals are responding to the issue of FI, especially given that the 60% of hospitals that chose not to participate may well have opted out because they provide even less support than those that did respond. Importantly, the authors point out that not only are children who are hospitalized at risk for FI, but the hospitalization itself can increase FI among families, especially those who have to travel far distances for definitive care. It does seem that the current response from across the country is both inadequate and uncoordinated.

Of the respondents to the survey, only 34% of the facilities have universal screening for SDOH, which is clearly the best practice and least susceptible to bias. In addition to the variation in screening types, the person doing the screening varied as well, with one-third completed by the social worker and one-third by a nurse, and only 4% completed by the physician (which was the same percent as food services). As noted by the authors, “Screening protocols and interventions varied among institutions. Children’s hospitals could consider improving screening protocols and interventions to ensure that needs are identified and addressed.” We couldn’t agree more.

The days of pediatric hospitalists only concerning themselves with what happens within the walls of their unit should have ended a decade ago, but with the massive disparities in outcomes over the past few years related to the COVID-19 pandemic as a result of disparate SDOH, we cannot ignore what our families are facing in their home environments. Although a longitudinal continuity relationship by a primary care provider is clearly the best time to intervene and help families receive the resources they need, by ignoring or not intervening at a time of crisis (eg, a hospitalization) we may be perpetuating and adding to trauma and poor outcomes.

A reader might be heartened to learn that 84% of hospitals self-report providing some meal assistance. However, this number should be considered in the context of reports of caregiver hunger during pediatric hospitalization around 40%⁸  as well as the limited response rate,⁸  which was likely to bias toward those who actually have a program. This discordance should raise a sense of urgency to consider if what hospitals currently do adequately supports families. Furthermore, it is simply not enough to screen for food insecurity; institutions must have reliable plans in place to adequately support struggling families. Failure to do so may result in a sense of moral distress for screeners who cannot help families asking for assistance. Furthermore, it may create a sense of lost trust with our patients and families who have shared their profoundly personal struggles without our responding with help.

Ideally, a hospital medicine “governing” group (such as Society of Hospital Medicine, AAP Section on Hospital Medicine, Children’s Hospital Association) would work with hospitalists, community resources, and families to develop best practice standards for screening for SDOH in the inpatient setting and either providing or linking families with the needed resources in the most seamless manner possible. Until clear guidance can be provided, it is likely a highly variable, hodge-podge approach will continue, which will perpetuate disparities in health and fail to improve the global health of all children. The paper by Markwotiz et al is a call to action for all pediatric hospitalists to become part of the solution to address the social determinants of health that perpetuate health disparities and help all children thrive and reach their full potential.