When a Meal Train Isn’t an Option

Social networks are a crucial support during a time of crisis.1 Whether it be chronic or acute, expected or unexpected, a first or even the last—a child’s hospitalization is a crisis for most families. The emotional and financial stress make child hospitalizations extremely difficult for families. Even before the medical bills arrive, expenses begin to pile up almost immediately. Lost wages, additional travel costs, parking expenses, childcare for kids at home, and high in-hospital food costs can make hospital stays a financial nightmare for families.2 Hospital cafeterias often do not accept SNAP benefits (colloquially, food stamps) as these funds generally cannot be used in restaurants.3 Yet many low-income families report that they do not have family and friends who can provide help during a crisis. There is no one to organize a meal train, as extra food is sparse. As a result, hunger may pull families away from the hospital bedside seeking food at more affordable places. And the hunger caregivers experience at bedside may exacerbate the mental fog4 many caregivers report while their children are in the hospital.Can pediatric hospitals fill that gap? In this issue of Hospital Pediatrics, Dr Jungbauer et al present a mixed-methods assessment of support for food insecurity among hospitals with pediatric wards in Oregon.5 The authors considered hospital assessment and policies around both household food insecurity (HFI) and inpatient food insecurity (IFI) which are related but not completely overlapping entities. HFI refers to what most people commonly think of regarding food insecurity—not having enough food in the home on a day-to-day basis. HFI is measured by reporting access to food over a specific time period, most commonly a year. IFI refers to not having enough food to eat during a child’s hospitalization. IFI affects many caregivers and family members due to the financial stressors of hospitalization, even those who did not experience FI in the home. While the hospital should provide adequate nutrition for the patient, families are often left without sufficient food.Jungbauer demonstrates heterogeneity across hospitals in how they both screen for and support families with both kinds of FI. In the quantitative assessment of 17 hospitals (of 18 surveyed), less than a third reported that they always or almost always screened families for HFI. Most commonly, families with HFI were referred to social work and public assistance programs. None of the 17 hospitals routinely screened families for IFI; most (76%) relied on informal assessments from bedside staff to determine if a caregiver/family was not eating. About a third of the surveyed hospitals did not provide support to feed families with IFI during hospitalization; 12 of the 17 hospitals surveyed offered some form of free meals to nonbreastfeeding caregivers.The lack of universal screening to identify IFI may result in disparities in resource allocation. Informal assessment may systematically under-identify needs in some populations. For example, families who prefer languages other than English may not be given the same opportunities to disclose needs as English-speaking caregivers. Additionally, caregivers who are unable to be at bedside may not have the same opportunities to develop informal relationships with nurses which would foster a nurse asking a caregiver if they need help with food during hospitalization. In addition to language and structural barriers impeding informal screening, health care provider bias may lead to differential screening based on appearance or presentation. Therefore, it is likely that even in hospitals with robust food support programs, there are inconsistencies in the implementation of resources.Additionally, the lack of clear institutional resources causes bedside staff difficulties when screening. How does a staff member feel when a family confides lack of food and yet has no means to help? The authors give examples of bedside staff buying food for families who are hospitalized. These directed acts of kindness reflect what is known in psychology as the “singularity effect.”6 The greatest intensity of emotion stems from having a single individual in front of you who needs help; this intensity is more than knowing a larger group of unidentifiable individuals at a hospital also need help. While feeding a single caregiver is a temporary solution, it is impossible for sustainability, equitable allocation, and it violates hospital policy—even with the best intent. The quotations from Junbauer highlight the distress hospital providers experience when they identify a resource need and cannot offer solutions. Being asked to screen for needs without resources can lead to pseudoinefficacy,7 the inability to recognize the good that we can do because there are needs we cannot help, which can lead to provider apathy.For the minority of hospitals who had meal tray programs, sustainability of programs to support IFI is a problem. Only 2 hospitals reported sustainable funding for programs to reduce IFI. Within the 6 months following the quantitative surveys, 2 of the 12 hospitals who initially had meal support had stopped their programs to support families with IFI due to institutional changes. The grief at losing this resource was apparent in the qualitative interviews. The authors identify “moral injury” as a topic for staff at hospitals who lost resources and those without adequate resources.With limited resources, hospitals need to consider which type of food support intervention should be prioritized. From a hospital’s perspective, the idea of feeding families within our walls, becoming the meal train, is a noble one. Of note, this is a phenomenon specific to hospitals who serve children—as hospitals who care for adults do not feel compelled to feed spouses or adult caregivers of the elderly or infirmed. Adult caregivers do go hungry during pediatric hospitalization, yet the direct physical effects on the pediatric patient should be minimal as the patient should receive nutrition from the hospital. Any positive health impacts to the child would be because a fed caregiver may be able to engage more during the hospitalization and better prepared to manage recovery after hospitalization. Bedside staff are likely more attuned to IFI compared to HFI as they witness caregiver IFI in their day-to-day tasks. Feeding hungry caregivers provides a sense of altruism for bedside staff and may alleviate some of the moral injury apparent in the Jungbauer interviews.Yet programs to address HFI may have a longer impact in a child’s life—especially if the resource involves connection to an ongoing public assistance program or a community food source. Hospitals investing in partnerships with community resources may improve the lives of children beyond the few days they spend in the hospital—especially given that financial effects of pediatric hospitalization do not end at discharge. While rates are unknown, it is likely that rates of food insecurity in the immediate post discharge period are higher than HFI prior to hospitalization because of the significant finance stress of the hospitalization.In short, we do not actually know which kinds of FI interventions are most impactful for children with relation to pediatric hospitalization. If a hospital had $100 to support a low-income child/family, would it be better to feed the family during the child’s hospital stay or give the family a $100 grocery gift card on the day of discharge so the family has food in the house when the child gets home?We need an evidence base. Research, such as that by Jungbauer and team to understand what programs hospitals provide, is an excellent start. But we must go beyond descriptive research. Hospitalists are poised to promote implementation strategies so that inpatient experience is universalized—and not one dependent on informal screening strategies. Hospitalists can evaluate programs to understand what outcomes change when families do not have to leave their child’s bedside to obtain food. We can evaluate how illness recovery after pediatric hospitalization might improve if a family didn’t have to choose between buying groceries or medications at discharge.8 But to do these things, we must implement programs with evaluation in mind. We must advocate for research to measure outcomes. We must partner with hospitals and payers to evaluate improvement of our pediatric health care systems to build the case for investment with sustainability.The author would like to thank Zel Auger (Walnut Hills Highschool) for his thoughtful edits to this commentary.