Diana B. Cutts

Maternal Depression, Changing Public Assistance, Food Security, and Child Health Status

OBJECTIVE To examine the association of positive report on a maternal depression screen (PDS) with loss or reduction of welfare support and foods stamps, household food insecurity, and child health measures among children aged < or =36 months at 6 urban hospitals and clinics. METHODS A convenience sample of 5306 mothers, whose children <36 months old were being seen in hospital general clinics or emergency departments (EDs) at medical centers in 5 states and Washington, District of Columbia, were interviewed from January 1, 2000 until December 31, 2001. Questions included items on sociodemographic characteristics, federal program participation and changes in federal benefits, child health status rating, childs history of hospitalizations since birth, household food security status, and a 3-question PDS. For a subsample interviewed in the ED, whether the child was admitted to the hospital that day was recorded. RESULTS PDS status was associated with loss or reduction of welfare support and food stamps, household food insecurity, fair/poor child health rating, and history of child hospitalization since birth but not low child growth status measures or admission to the hospital at the time of ED visit. After controlling for study site, maternal race, education, and insurance type as well as child low birth weight status, mothers with PDS were more likely to report fair/poor child health (adjusted odds ratio [AOR]: 1.58; 95% confidence interval [CI]: 1.33-1.88) and hospitalizations during the childs lifetime (AOR: 1.20; 95% CI: 1.03-1.39), compared with mothers without PDS. Controlling for the same variables, mothers with PDS were more likely to report decreased welfare support (AOR: 1.52; 95% CI: 1.03-2.25), to have lost food stamps (AOR: 1.56; 95% CI: 1.06-2.30), and reported more household food insecurity (AOR: 2.69; 95% CI: 2.33-3.11) than mothers without PDS. CONCLUSION Positive maternal depression screen status noted in pediatric clinical samples of infants and toddlers is associated with poorer reported child health status, household food insecurity, and loss of federal financial support and food stamps. Although the direction of effects cannot be determined in this cross-sectional survey, child health providers and policy makers should be aware of the potential impact of maternal depression on child health in the context of welfare reform.

US Housing insecurity and the health of very young children.

OBJECTIVES We investigated the association between housing insecurity and the health of very young children. METHODS Between 1998 and 2007, we interviewed 22,069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each childs household. Our indicators for housing insecurity were crowding (> 2 people/bedroom or>1 family/residence) and multiple moves (≥ 2 moves within the previous year). RESULTS After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43), as were multiple moves (AOR = 1.91; 95% CI = 1.59, 2.28). Crowding was also associated with child food insecurity (AOR = 1.47; 95% CI = 1.34, 1.63), and so were multiple moves (AOR = 2.56; 95% CI = 2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR = 1.48; 95% CI =1.25, 1.76), developmental risk (AOR 1.71; 95% CI = 1.33, 2.21), and lower weight-for-age z scores (-0.082 vs -0.013; P= .02). CONCLUSIONS Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.

Food Insecurity and Risk of Poor Health Among US-Born Children of Immigrants

OBJECTIVES We investigated the risk of household food insecurity and reported fair or poor health among very young children who were US citizens and whose mothers were immigrants compared with those whose mothers had been born in the United States. METHODS Data were obtained from 19,275 mothers (7216 of whom were immigrants) who were interviewed in hospital-based settings between 1998 and 2005 as part of the Childrens Sentinel Nutrition Assessment Program. We examined whether food insecurity mediated the association between immigrant status and child health in relation to length of stay in the United States. RESULTS The risk of fair or poor health was higher among children of recent immigrants than among children of US-born mothers (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.02, 1.55; P < .03). Immigrant households were at higher risk of food insecurity than were households with US-born mothers. Newly arrived immigrants were at the highest risk of food insecurity (OR = 2.45; 95% CI = 2.16, 2.77; P < .001). Overall, household food insecurity increased the risk of fair or poor child health (OR = 1.74; 95% CI = 1.57, 1.93; P < .001) and mediated the association between immigrant status and poor child health. CONCLUSIONS Children of immigrant mothers are at increased risk of fair or poor health and household food insecurity. Policy interventions addressing food insecurity in immigrant households may promote child health.

A Brief Indicator of Household Energy Security: Associations With Food Security, Child Health, and Child Development in US Infants and Toddlers

OBJECTIVE. Household energy security has not been measured empirically or related to child health and development but is an emerging concern for clinicians and researchers as energy costs increase. The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children <36 months of age. METHODS. A cross-sectional study that used household survey and surveillance data was conducted. Caregivers were interviewed in emergency departments and primary care clinics form January 2001 through December 2006 on demographics, public assistance, food security, experience with heating/cooling and utilities, Parents Evaluation of Developmental Status, and child health. The household energy security indicator includes energy-secure, no energy problems; moderate energy insecurity, utility shutoff threatened in past year; and severe energy insecurity, heated with cooking stove, utility shutoff, or ≥1 day without heat/cooling in past year. The main outcome measures were household and child food security, child reported health status, Parents Evaluation of Developmental Status concerns, and hospitalizations. RESULTS. Of 9721 children, 11% (n = 1043) and 23% (n = 2293) experienced moderate and severe energy insecurity, respectively. Versus children with energy security, children with moderate energy insecurity had greater odds of household food insecurity, child food insecurity, hospitalization since birth, and caregiver report of child fair/poor health, adjusted for research site and mother, child, and household characteristics. Children with severe energy insecurity had greater adjusted odds of household food insecurity, child food insecurity, caregivers reporting significant developmental concerns on the Parents Evaluation of Developmental Status scale, and report of child fair/poor health. No significant association was found between energy security and child weight for age or weight for length. CONCLUSIONS. As household energy insecurity increases, infants and toddlers experienced increased odds of household and child food insecurity and of reported poor health, hospitalizations, and developmental risks.

Household food insecurity is a risk factor for iron-deficiency anaemia in a multi-ethnic, low-income sample of infants and toddlers.

OBJECTIVE The present study examines the relationships of household food security status with Fe deficiency (ID) and Fe-deficiency anaemia (IDA) among children less than 3 years of age, and associated factors that contribute to ID and IDA. DESIGN Cross-sectional study and chart review. The US Food Security Survey Module was administered to adult caregivers as part of the Childrens Sentinel Nutrition Assessment Project (C-SNAP). Haematological data were obtained from medical records. SETTING A large metropolitan medical centre in Minneapolis, Minnesota, USA. SUBJECTS A multi-ethnic sample of 2853 low-income children aged <36 months who received care at the medical centre. RESULTS Among the caregivers, 23.3 % reported low household food security and 11.6 % reported very low household food security (VLFS). After controlling for background factors, children from households with VLFS were almost twice as likely to have IDA than were children from households with high or marginal food security (OR = 1.98, 95 % CI 1.11, 3.53); the corresponding associations for ID were not statistically significant. CONCLUSIONS The prevalence of IDA in early childhood is significantly larger in low-income infants and toddlers living in VLFS households. Asian, Hispanic and African-American children have elevated prevalences of ID and IDA. Breast-feeding may be associated with elevated ID and IDA, while participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may be protective for ID.

“Do You Wanna Breathe or Eat?”: Parent Perspectives on Child Health Consequences of Food Insecurity, Trade-Offs, and Toxic Stress

ObjectivesThis study among 51 parents of young children under age four investigated how parents that report marginal, low and very low food security characterize how trade-offs associated with food insecurity affect parents’ mental health and child well-being.MethodsWe carried out 51 semi-structured audio-recorded interviews after participants responded to a survey regarding food security status and maternal depressive symptoms. Each interview was transcribed. Through a content analysis, we coded “meaning units” in each manuscript and organized them by themes in ATLAS.ti. Among participants reporting both food insecurity and depressive symptoms, we identified three primary areas of concern: trade-offs, mental health, and child well-being.ResultsParents described how trade-offs associated with food insecurity have a profound relationship with their mental health and home environment that strongly affects young children. Descriptions of hardships include anxiety and depression related to overdue bills and shut-off notices, strains with housing costs, and safety. Parents described how their own frustration, anxiety, and depression related to economic hardship have a negative impact on their children’s physical health, and their social and emotional development.ConclusionsParents in food insecure households recognize that trade-offs between food and other basic necessities are associated with their personal stress and poor mental health that, in turn, affects their children’s health and development. Partnerships between healthcare providers, policymakers, and parents are essential to successfully address and prevent the poor child health outcomes of toxic stress associated with food insecurity and poverty.

Health of Children Classified as Underweight by CDC Reference but Normal by WHO Standard

OBJECTIVE: To ascertain measures of health status among 6- to 24-month-old children classified as below normal weight-for-age (underweight) by the Centers for Disease Control and Prevention (CDC) 2000 growth reference but as normal weight-for-age by the World Health Organization (WHO) 2006 standard. METHODS: Data were gathered from children and primary caregivers at emergency departments and primary care clinics in 7 US cities. Outcome measures included caregiver rating of child health, parental evaluation of developmental status, history of hospitalizations, and admission to hospital at the time of visit. Children were classified as (1) not underweight by either CDC 2000 or WHO 2006 criteria, (2) underweight by CDC 2000 but not by WHO 2006 criteria, or (3) underweight by both criteria. Associations between these categories and health outcome measures were assessed by using multiple logistic regression analysis. RESULTS: Data were available for 18 420 children. For each health outcome measure, children classified as underweight by CDC 2000 but normal by WHO 2006 had higher adjusted odds ratios (aORs) of adverse health outcomes than children not classified as underweight by either; children classified as underweight by both had the highest aORs of adverse outcomes. For example, compared with children not underweight by either criteria, the aORs for fair/poor health rating were 2.54 (95% confidence interval: 2.20–2.93) among children underweight by CDC but not WHO and 3.76 (3.13–4.51) among children underweight by both. CONCLUSIONS: Children who are reclassified from underweight to normal weight in changing from CDC 2000 to WHO 2006 growth charts may still be affected by morbidities associated with underweight.

Failure to thrive as distinct from child neglect.

To the Editor .— As pediatricians and psychologists who have conducted research involving children with failure to thrive (FTT) and/or treated literally thousands of children with FTT, we wish to share our concerns regarding the report “Failure to Thrive as a Manifestation of Child Neglect”1 from the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and Committee on Nutrition. Six aspects of the report are particularly troubling. First, the report does not make it sufficiently clear that FTT as a manifestation of child neglect represents a minority of children with FTT. We agree that, in some cases, FTT may be a marker of neglect and that the diagnosis of abuse and/or neglect should be considered if there is any history of “intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a childs well-being; and/or family that is resistant to recommended interventions despite multidisciplinary team approach.” Indeed, children with both FTT and neglect have lower cognitive skills initially and years after treatment …

Nutritional-Assistance Programs Play a Critical Role in Reducing Food Insecurity

Programs Play a Critical Role in Reducing Food Insecurity The recent report by Melchior et al1 on food insecurity raised concerns about the effectiveness of nutritionalassistance programs and highlighted the role played by maternal mental health and domestic violence. Evidence from Children’s HealthWatch (www. childrenshealthwatch.org) provides additional information on the link between nutritional-assistance programs and children’s health and wellbeing. Many income-eligible families are not reached by nutritionalassistance programs because of either bureaucratic barriers or insufficient funding.2–5 The evidence is clear that children benefit from nutritionalassistance programs, such as the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps), and eligible families who do not receive WIC and SNAP benefits have greater food insecurity than thosewho do.3,4 Thus, the problem is with the accessibility and reach of nutritionalassistance programs, not with their effectiveness.2–5

Anaemia, lead poisoning and vitamin D deficiency in low-income children: do current screening recommendations match the burden of illness?

OBJECTIVE Low-income children are routinely screened for anaemia and elevated blood lead levels (EBLL) but not for vitamin D deficiency. We sought to determine the relative prevalence of and the relationship among vitamin D deficiency, anaemia and EBLL among healthy low-income paediatric clinic patients. DESIGN Retrospective chart review. SETTING Paediatric outpatient clinic in an urban safety net hospital in a northern US state. SUBJECTS Healthy toddlers and children under 6 years of age (n 127) who were seen for a routine well child check-up (WCC). RESULTS The prevalence of vitamin D insufficiency (25-hydroxyvitamin D (25(OH)D) < 30 ng/ml) was 62 %; the prevalence of vitamin D deficiency (25(OH)D < 20 ng/ml) was 29 %. These rates were far higher than those for anaemia (Hb < 11·0 g/dl) at 10 %, EBLL (Pb > 9 μg/dl) at 1 % or even mildly EBLL (Pb 5-9 μg/dl) at 4 % (range: 1-11). There was no relationship among any of the following: vitamin D status, anaemia or EBLL. The vast majority of children with vitamin D deficiency had both normal Hb (86 %) and Pb level (100 %). After controlling for childs age, gender and race/ethnicity, there was no association between Hb (continuous, g/dl) and vitamin D deficiency (adjusted OR (aOR) = 0·97, 95 % CI 0·64, 1·47; P = 0·88). The only significant predictor of vitamin D deficiency was increasing age in years (aOR = 1·39, 95 % CI 1·03, 1·86; P = 0·03). None of these associations changed materially when deficiency was defined as <15 ng/ml. CONCLUSIONS Vitamin D deficiency was far more common than anaemia or EBLL, and Hb and Pb status were not predictors of vitamin D status.