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DOI: 10.1542/peds.2006-3717
2008;121;65Pediatrics
Deborah A. Frank
Cutts, Mariana Chilton, Timothy Heeren, Suzette M. Levenson, Alan F. Meyers and
Ruth Rose-Jacobs, Maureen M. Black, Patrick H. Casey, John T. Cook, Diana B.
Development
Household Food Insecurity: Associations With At-Risk Infant and Toddler
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ARTICLE
Household Food Insecurity: Associations With
At-Risk Infant and Toddler Development
Ruth Rose-Jacobs, ScD
a
, Maureen M. Black, PhD
b
, Patrick H. Casey, MD
c
, John T. Cook, PhD
a
, Diana B. Cutts, MD
d
, Mariana Chilton, PhD, MPH
e
,
Timothy Heeren, PhD
f
, Suzette M. Levenson, MEd, MPH
g
, Alan F. Meyers, MD, MPH
a
, Deborah A. Frank, MD
a
a
Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts;
b
Department of Pediatrics, University of Maryland
School of Medicine, Baltimore, Maryland;
c
Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas;
d
Department of Pediatrics,
Hennepin County Medical Center, Minneapolis, Minnesota;
e
Department of Community Health Prevention, Drexel University School of Public Health,
Philadelphia, Pennsylvania;
f
Department of Biostatistics and
g
Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
OBJECTIVES. In this study, we evaluated the relationship between household food secu-
rity status and developmental risk in young children, after controlling for potential
confounding variables.
METHODS. The Children’s Sentinel Nutritional Assessment Program interviewed (in
English, Spanish, or Somali) 2010 caregivers from low-income households with
children 4 to 36 months of age, at 5 pediatric clinic/emergency department sites (in
Arkansas, Massachusetts, Maryland, Minnesota, and Pennsylvania). Interviews in-
cluded demographic questions, the US Food Security Scale, and the Parents’ Evalu-
ations of Developmental Status. The target child from each household was weighed,
and weight-for-age z score was calculated.
RESULTS. Overall, 21% of the children lived in food-insecure households and 14% were
developmentally “at risk” in the Parents’ Evaluations of Developmental Status as-
sessment. In logistic analyses controlling for interview site, child variables (gender,
age, low birth weight, weight-for-age z score, and history of previous hospitaliza-
tions), and caregiver variables (age, US birth, education, employment, and depressive
symptoms), caregivers in food-insecure households were two thirds more likely than
caregivers in food-secure households to report that their children were at develop-
mental risk.
CONCLUSIONS. Controlling for established correlates of child development, 4- to 36-month-old children from low-
income households with food insecurity are more likely than those from low-income households with food security
to be at developmental risk. Public policies that ameliorate household food insecurity also may improve early child
development and later school readiness.
T
HE US DEPARTMENT of Agriculture estimates that 16.7% of all US households with children ⬍6 years of age (2.94
million households; 12.79 million people) had food insecurity (FI) in 2005, reporting limited or uncertain
availability of enough food for an active healthy life.
1
The relationships between FI and children’s health, behavior,
and development seem to vary according to the child’s age, gender, and ethnicity. Among children 3 to 8 years of
age, FI has been associated with low physical function,
2
poor academic performance, greater weight gain among
girls,
3,4
and low psychosocial functioning.
5
Among adolescents, FI has been associated with low psychosocial
functioning
2
and overweight.
6
Among children ⬍3 years of age, FI has been associated with caregiver reports of poor
infant health and likelihood of hospitalization, suggesting adverse health consequences.
7,8
Among 3-year-old children
and their mothers, FI has been associated with self-reported maternal depression and anxiety, as well as child
behavior problems.
9
The first 3 years of a child’s life are marked by dramatic changes in cognitive, linguistic, social, and emotional
development and in self-regulation, setting the stage for school readiness and adult well-being.
10
Adequate nutrients
www.pediatrics.org/cgi/doi/10.1542/
peds.2006-3717
doi:10.1542/peds.2006-3717
Key Words
child development, infant, child, preschool,
child nutrition, hunger, early intervention,
risk factors
Abbreviations
FI—food insecurity
PEDS—Parents’ Evaluations of
Developmental Status
Accepted for publication Jun 19, 2007
Address correspondence to Ruth Rose-Jacobs,
ScD, Department of Pediatrics, Boston
University School of Medicine, 91 East
Concord St, Room 5106, Boston, MA 02118.
E-mail: rrosejac@bu.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2008 by the
American Academy of Pediatrics
PEDIATRICS Volume 121, Number 1, January 2008 65
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are required to support this normal rapid growth and
development. Therefore, even mild nutritional deficits
during critical periods of brain growth among infants
and toddlers may be detrimental.
10–12
FI may occur with or without reports of hunger.
13–15
Hunger, a term used by the Economic Research Service
of the US Department of Agriculture
16
when this study
began, occurs when FI is severe enough, or lasts long
enough, that household members repeatedly reduce
their food intake below normal levels. In the United
States, adults in households with FI may ration the
available food to try to prevent children from experienc-
ing hunger.
The purpose of this investigation was to evaluate the
relationship between household FI and infant and tod-
dler development for children ⬍36 months of age. Spe-
cifically, we hypothesized that, after controlling for im-
portant child and caregiver factors associated with
poverty and/or known to influence early development,
children in food-insecure, compared with food-secure,
households would be more likely to be at risk for devel-
opmental problems, even at the least-severe end of the
food security scale (ie, household FI without reported
hunger).
METHODS
Setting and Instruments
The Children’s Sentinel Nutritional Assessment Program
conducted household-level surveys and medical chart
audits (July 2004 to June 2005) at 5 central-city medical
centers. The sample was recruited from primary care
clinics (Baltimore, MD, and Minneapolis, MN) and hos-
pital emergency departments (Baltimore, MD, Boston,
MA, Little Rock, AR, and Philadelphia, PA). Sites were
staffed by interviewers during times of peak patient flow.
At each site, as staffing permitted, all caregivers who met
the study criteria were approached, with the exception
of caregivers of critically ill or injured children. Eligibility
criteria included child age of ⬍37 months, state resident,
caregiver able to speak English, Spanish, or Somali (Min-
neapolis only), caregiver knowledgeable about the
child’s household, and no Children’s Sentinel Nutri-
tional Assessment Program interview within the previ-
ous 6 months. Institutional review board approval was
obtained at each site. Children were weighed and mea-
sured and caregivers were interviewed in private set-
tings.
The Children’s Sentinel Nutritional Assessment Pro-
gram survey instrument includes questions regarding
demographic information, including caregiver employ-
ment, and the child’s lifetime history of hospitalizations
since discharge from the newborn nursery, household
food security questions,
17
a maternal depression screen,
18
and the Parents’ Evaluations of Developmental Status
(PEDS).
19
Household food security status was derived
from the 18-item US Food Security Scale, a valid, reli-
able, household-level measure of food security that was
scored and scaled in accordance with established proce-
dures.
17
Households were classified as food insecure if
they reported that they could not afford enough food for
an active healthy life for all household members (ie,
caregivers endorsed ⱖ3 of the 18 core food security
questions).
1,20
Households were classified as having FI
with hunger if household members reduced their food
intake in ⱖ3 of the past 12 months.
1,15
Caregivers’ de-
pressive symptoms were measured by using a 3-item
maternal depression screening instrument.
18
The depres-
sion screening instrument has sensitivity of 100%, spec-
ificity of 88%, and positive predictive value of 66%,
compared with the 8-item Rand screening instrument.
18
The depression screen was scored as positive if a respon-
dent endorsed any 2 of the 3 items.
Developmental risk was measured with the PEDS,
19,21
a screening instrument for children from birth through 7
years of age that meets the standards set by the Ameri-
can Academy of Pediatrics for developmental screening
tests.
21–23
The PEDS includes 10 questions and is largely
unaffected by sociodemographic variables, geographic
location, parental education and employment, and par-
ent and child gender.
19,21
Caregivers are asked to report
any concerns (no, yes, or a little) about the child’s de-
velopment in 8 areas, as follows: expressive and recep-
tive language, fine and gross motor, behavior, social/
emotional, self-help, and school. In addition, caregivers
are asked 2 open-ended questions about concerns in the
global/cognitive area and “other concerns.” In standard
scoring of the PEDS,
19,21
endorsed items (yes or a little)
are classified as significant or nonsignificant concerns
depending on the age of the child. Children with ⱖ2
significant concerns are at developmental risk. The sen-
sitivity and specificity of the PEDS are better for children
⬎4 months of age than for newborns.
19
Therefore, we
restricted our sample to children ⬎4 months of age.
Caregivers of children at developmental risk, as de-
termined by PEDS scoring, were offered information
about local early intervention service agencies, and fol-
low-up consultation with the child’s pediatrician was
recommended. Caregivers of children with 1 significant
concern or ⱖ1 nonsignificant concern were encouraged
to discuss their concerns with the child’s pediatrician.
At the time of the caregiver interview, child weight
and length were recorded. To ensure that weights and
lengths were recorded in the same manner, equipment
and training were standardized across sites. Child weight
and length were obtained either by project staff mem-
bers or from medical chart reviews conducted on the
same day as the caregiver interview. Because of practical
constraints within emergency departments, length was
not always measured. Weight-for-age is a composite
measure of growth.
24,25
Weight-for-age z scores were
calculated by using the US Centers for Disease Control
and Prevention age- and gender-specific reference val-
ues.
26
Underweight was defined as a z score ⱖ2 SDs
below the mean weight-for-age value; overweight was
defined as ⱖ2 SDs above the mean weight-for-age
value.
27
Data Analyses
Of the 3052 caregivers who were approached for recruit-
ment, 226 (7%) were ineligible because the caregivers
did not speak English or Spanish (or Somali, in Minne-
66 ROSE-JACOBS et al
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apolis), did not have knowledge of the child’s house-
hold, were not state residents, had been interviewed in
the past 6 months or the potential child in the dyad was
⬍4 months of age. Of the remaining 2826 caregivers
(93%), 347 (12%) refused to be interviewed and 469
(17%) were missing ⱖ1 of the analysis variables and
therefore were not included in the analyses. The final
analysis sample included 2010 caregiver/child dyads.
The subjects with complete data, compared with incom-
plete data, were less likely to be foreign-born caregivers
(26% vs 32%; P ⫽ .01) or employed (46% vs 53%; P ⫽
.01) or to have children with low birth weights (14% vs
18%; P ⫽ .04). Caregiver country of birth and employ-
ment status, as well as child’s low birth weight status,
were among the variables included as covariates in the
study regression analyses.
Multivariate logistic analyses were used to evaluate FI
(yes or no) as a predictor of developmental risk. Covari-
ates were identified on the basis of their theoretical or
empirical importance to child development during pre-
liminary analyses. Child-related covariates were gender,
age at time of interview, weight-for-age z score, low
birth weight (ⱕ2500 g or ⬎2500 g), ever breastfed (yes
or no), history of previous hospitalizations (yes or no),
and type of health insurance (public, private, or none).
Caregiver-related covariates were education (less than
high school graduation, high school diploma, or more
than high school education), marital status (married or
not married), employment status (yes or no), positive
depressive symptoms on the screening instrument,
country of birth (United States or other), and geographic
site of interview. Ethnicity was tested as a covariate but
was not included because it was highly collinear with
caregiver country of birth and geographic site of inter-
view and was not associated with PEDS status (Table 1).
We calculated an adjusted odds ratio for the multivariate
analysis to determine the statistical significance and
strength of the relationship between FI and develop-
mental risk.
We evaluated whether the threshold for the effect on
developmental risk occurred at the level of household FI
without hunger. We constructed a subsample (n ⫽
1891) of the original sample of 2010 by excluding care-
givers who reported FI with hunger and reanalyzed the
covariate-controlled logistic regression models.
RESULTS
In the sample of 2010 families, 21% (n ⫽ 427) reported
household FI, including 6% (n ⫽ 119) that reported FI
with hunger. The majority (91%; n ⫽ 1486) of the
respondents were the birth mother of the child. Com-
pared with children in food-secure households, children
in food-insecure households were younger and more
likely to have been breastfed and to receive public health
insurance (Table 1). Groups did not differ significantly
(P ⱖ .05) with respect to child’s gender, incidence of low
birth weight, mean weight-for-age z score, categorical
classification as underweight or overweight, or prior
hospitalizations. Caregivers who reported household FI
were less likely to be ⬍21 years of age, to have been born
in the United States, and to be employed. They had less
education and were more likely to report depressive
symptoms than were caregivers who reported house-
hold food security. Food-secure and food-insecure care-
givers differed with respect to ethnicity but did not differ
with respect to marital status. FI rates did differ accord-
ing to site of data collection. Regardless of FI status,
underweight and overweight were documented at ⬎3
times the number of children expected with weight-for-
age values of ⬍5th percentile (⬃16%) and ⬎95th per-
centile (⬃20%). Almost 14% (n ⫽ 278) of the 2010
caregivers reported developmental risk on the PEDS.
Table 2 shows the proportions of children with devel-
opmental risk in unadjusted and covariate-adjusted
analyses and the strength of the relationships stratified
according to child and caregiver characteristics. With
TABLE 1 Sample Demographic Characteristics According to FI
(N ⴝ 2010)
Food Secure
(n ⫽ 1583)
Food Insecure
(n ⫽ 427)
P
Site of data collection, %
Baltimore 29 19 ⬍.0001
Boston 28 30
Little Rock 25 14
Minneapolis 12 33
Philadelphia 6 4
Child variables
Age, %
4–12 mo 38 45 .05
13–24 mo 40 36
25–36 mo 22 19
Gender, %
Female 53 56 .28
Male 47 44
Low birth weight (⬍2500 g), % 15 14 .46
Weight-for-age z score, mean 0.034 0.021 .87
Weight-for-age z score ⱖ2 SD below
mean, %
6 6 .50
Weight-for-age z score ⱖ2 SD above
mean, %
6 4 .21
Breastfed, % 50 64 ⬍.0001
Health insurance, %
Public 83 92 ⬍.0001
None 2 4
Private 15 4
Any previous hospitalizations, % 26 30 .15
Caregiver variables
⬍21 y of age, % 15 11 .03
Race/ethnicity, %
Asian 1 ⬍1 ⬍.0001
Black 61 53
Hispanic 16 34
White 22 11
Native American ⬍11
Born in United States, % 79 55 ⬍.0001
Married, % 32 34 .61
Employed, % 49 36 ⬍.0001
Education, %
Some high school 26 37 ⬍.0001
High school graduate 41 41
College graduate 34 22
Maternal report of depressive
symptoms, %
29 48 ⬍.0001
PEDIATRICS Volume 121, Number 1, January 2008 67
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TABLE 2 Descriptions of Sample According to Developmental Risk (N ⴝ 2010), Unadjusted and Adjusted for Covariates
Unadjusted for Covariates Adjusted for Covariates
Developmental
Risk (n ⫽ 278), %
Odds Ratio
(95% CI)
P Odds Ratio
(95% CI)
P
Category of FI
FI 18 1.48 (1.11–1.97) .007 1.76 (1.26–2.46) .001
Food security 13 1.00 1.00
Site of data collection
Baltimore 16 1.00 .001 1.00 .0003
Boston 13 0.79 (0.56–1.11) 0.93 (0.62–1.40)
Little Rock 16 1.01 (0.72–1.42) 0.95 (0.65–1.40)
Minneapolis 7 0.41 (0.26–0.66) 0.44 (0.23–0.81)
Philadelphia 21 1.40 (0.83–2.36) 1.42 (0.79–2.55)
Child variables
Age
4–12 mo 7 1.00 ⬍.001 1.00 ⬍.0001
13–24 mo 16 2.48 (1.78–3.47) 2.43 (1.70–3.48)
25–36 mo 23 3.96 (2.78–5.64) 4.22 (2.87–6.21)
Gender
Female 10 1.00 ⬍.001 1.00 ⬍.001
Male 17 1.75 (1.35–2.28) 1.69 (1.27–2.53)
Birth weight
Low birth weight (⬍2500 g) 22 1.97 (1.44–2.71) ⬍.001 1.81 (1.26–2.59) .001
Birth weight of ⬎2500 g 13 1.00 1.00
Weight-for-age z score
⬎2 SD below mean 30 2.98 (1.98–4.47) ⬍.001 2.66 (1.68–4.24) .0002
Within normal range 13 1.00 1.00
⬎2 SD above mean 16 1.30 (0.80–2.11) 1.25 (0.74–2.11)
Breastfeeding status
Breastfed 13 1.00 .22 1.00 .949
Not breastfed 15 1.18 (0.92–1.52) 1.01 (0.75–1.37)
Health insurance
Public 13 1.00 .40 1.00 .600
None 19 1.54 (0.79–3.02) 1.35 (0.65–2.80)
Private 15 1.12 (0.77–1.63) 1.17 (0.74–1.85)
Previous hospitalizations
Any 22 2.39 (1.83–3.12) ⬍.0001 1.80 (1.35–2.40) ⬍.0001
None 11 1.00 1.00
Caregiver variables
Age
⬍21 y 12 0.87 (0.59–1.27) .46 1.02 (0.66–1.56) .936
ⱖ21 y 14 1.00 1.00
Race/ethnicity
Asian 15 0.97 (0.21–4.47) .41 NA NA
Black 14 0.85 (0.62–1.17)
Hispanic 12 0.71 (0.47–1.07)
White 16 1.00
Native American 25 1.77 (0.47–6.74)
Country of birth
United States 15 1.00 .009 1.00 .763
Other 10 0.66 (0.48–0.90) 0.93 (0.60–1.46)
Marital status
Married 14 1.00 .60 1.00 .304
Not married 14 1.00 (0.77–1.32) 0.83 (0.59–1.18)
Employment status
Employed 12 1.00 .02 1.00 .010
Not employed 16 1.37 (1.06–1.77) 1.48 (1.10–1.98)
Education
Some high school 14 1.03 (0.75–1.41) .76 1.07 (0.76–1.53) .867
High school graduate 13 1.00 1.00
College graduate 15 1.12 (0.83–1.51) 1.09 (0.77–1.53)
Maternal depressive symptoms
Yes 19 1.93 (1.50–2.50) ⬍.0001 1.70 (1.27–2.28) .0004
No 11 1.00 1.00
NA indicates not applicable; CI, confidence interval.
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respect to FI group, 18% of children in food-insecure
households, compared with 13% of children in food-
secure households, were reported to be at developmen-
tal risk (P ⫽ .007).
The results of multivariate logistic analyses revealed
that children from food-insecure households, compared
with those from food-secure households, were two
thirds more likely to experience developmental risk (ad-
justed odds ratio: 1.76; 95% confidence interval: 1.26–
2.46; P ⫽ .001). In multivariate analyses unadjusted and
adjusted for other covariates, children were more likely
to have developmental risk if they were older, were
male, had a low birth weight, were underweight, and
had a history of hospital admissions. Children who were
underweight, compared with normal weight, were al-
most 3 times more likely to experience developmental
risk. In addition, caregivers who were unemployed or
reported depressive symptoms were more likely to re-
port that their children were at developmental risk.
There were also geographic site differences in the propor-
tions of children with developmental risk. Caregivers’ age
and education were not significantly related to develop-
mental risk. The one association that changed with adjust-
ments for covariates was the association between foreign-
born caregivers and PEDS results; the unadjusted analysis
indicated significance, whereas the relationship of foreign-
born caregivers with developmental risk was no longer
present after adjustment. When the analysis was repeated
after removal of the families that reported FI with hunger,
the negative relationship between FI and increased devel-
opmental risk was maintained (adjusted odds ratio: 1.77;
95% confidence interval: 1.23–2.56; P ⫽ .002).
DISCUSSION
This study identified an association between FI and de-
velopmental risk among children ⬍36 months of age
from low-income (poor and near-poor) households. Al-
though the detrimental effects of poverty on child de-
velopment are well documented,
28
our study found that
the additional association between FI and developmen-
tal risk in young children from poor and near-poor
households was present even after controlling for theo-
retically chosen and statistically identified confounding
variables. These control variables included child factors,
such as previous hospitalizations, low birth weight, and
current weight-for-age z score, that usually would be
identified by clinicians as markers of physiologic risk.
13,29
The nearly identical relationship between developmen-
tal risk and FI that was observed when households that
reported FI with hunger were removed from the analysis
suggests that the threshold for effects on young chil-
dren’s developmental risk occurs even in households at
the less-severe end of the FI continuum. Our findings of
greater incidence of developmental risk for very young
children from low-income households with limited or
uncertain food supplies are consistent with previous
findings for school-aged children.
3,4,13,30
There are at least 2 possible pathways that may ex-
plain the association between FI and developmental risk.
In a nutritive pathway, FI may compel families to limit
the quality of food given to their children, leading to
micronutrient deficiencies. There is some evidence of an
association between FI and iron deficiency,
31
which has
been linked to developmental problems
32–34
and may
contribute to the increased rate of developmental risks
among children in households with FI. There also may
be nonnutritive pathways linking FI and developmental
risk. In one possible pathway, families with FI are con-
fronted with the stress and anxiety of not having a
steady reliable source of food
35
and are at risk for depres-
sive symptoms.
9,36
Caregiver depression has a negative
influence on child development,
37
particularly in the
presence of poverty.
38
In the present study, almost one
half of the caregivers in food-insecure households re-
ported symptoms of depression, possibly because care-
givers in households with FI thought that they could not
provide a secure source of food. However, as with other
cross-sectional studies that reported associations be-
tween FI and maternal depressive symptoms,
9,36
it is not
clear whether depression preceded or followed FI.
In another possible nonnutritive pathway, a caregiver
report of FI could be a marker for extreme poverty.
Caregivers who reported FI had fewer years of formal
education, were less likely to be employed, and had
children who were more likely to be enrolled in public
health insurance programs than did caregivers who re-
ported food security. Although these factors associated
with poverty were controlled for in the current analysis,
we did not measure whether these extremely low-in-
come households had more-limited access to resources
besides food, including toys, books, and other learning
materials, and experiences known to be important for
promoting child development.
39,40
Our findings must be interpreted in light of several
important methodologic issues. First, the study was a
sentinel study (conducted in English, Spanish, and So-
mali) of caregivers and their children 4 to 36 months of
age who were waiting for care at 1 of 5 emergency
departments and/or clinics that serve large numbers of
families from low-income backgrounds. Although the
sentinel sample included poor and near-poor caregivers
and their children, who were at high baseline risk for
negative health and developmental outcomes, the care-
givers of the most severely ill and injured children were
not included because of their need for immediate med-
ical care. Second, the cross-sectional design can neither
establish a causal relationship nor unequivocally ascer-
tain the direction of effect between FI and developmen-
tal risk. However, our study results are consistent with
recent developmental findings from a longitudinal eval-
uation of children from kindergarten through third
grade.
3
Third, although we controlled statistically for
important covariate and confounding factors, other un-
measured confounders might have influenced the find-
ings. A less-stimulating home environment related to
poverty is probably the most important unmeasured
confounder in the relationship between FI and develop-
mental risk. Although we sampled caregivers from poor
and near-poor families and adjusted for variables related
to poverty, such as type of health insurance and care-
giver education and employment, we did not have a
PEDIATRICS Volume 121, Number 1, January 2008 69
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measure of family income or the quality of the home
environment.
Finally, shared-method variance (ie, the same care-
givers reported food security and developmental con-
cerns) could have influenced the results. That is, it is
possible that caregivers who were concerned about food
access tended to report concerns about child develop-
ment because they were generally concerned about the
overall family situation. However, this threat was mini-
mized because families who expressed concerns but not
endorsement of the food security items were not classi-
fied as having FI, in keeping with the US Department of
Agriculture guidelines.
As expected, cognitive, language, and behavioral con-
cerns are more likely to be identified as the infant
develops into toddlerhood, when there are greater ex-
pectations of the child and more-complex and more-
frequent interactions with the outside world than during
the early months. Therefore, although we controlled for
the age of the children at the time of examination,
caregivers of toddlers were more likely to report that the
children were at developmental risk than were caregiv-
ers of younger infants. In addition, birth weight, health,
and gender are factors that were found in many other
studies to influence development, particularly for chil-
dren living in poverty, depending on the developmental
outcome measured.
39–41
Consistent with the work of oth-
ers, children in this sample who had low birth weights,
had been previously hospitalized, and were male were
more likely to be at developmental risk than were chil-
dren who had normal birth weights, had not been hos-
pitalized, and were female. Caregivers who were not
born in the United States and caregivers who were em-
ployed were less likely to report that their children were
at developmental risk than were caregivers in the con-
trasting groups.
The clinical and public policy implications of this study
are striking. Infants who have experienced multiple nega-
tive environmental factors are at risk for long-term devel-
opmental consequences.
42
Therefore, the multiple factors
for children living in poor and near-poor households who
experience household FI and developmental risk could
have long-term implications into school age. In contrast,
focused interventions in young children have been shown
to improve school readiness and long-term outcomes.
30,43–47
Therefore, early identification and remediation of FI, as
well as developmental delay, are prudent.
This study of FI and child development highlights the
importance of early identification of at-risk children in a
model of preventative medicine. The American Acad-
emy of Pediatrics recommends that an algorithm be
implemented at each well-child visit and states, “early
identification of developmental problems should lead to
further developmental and medical evaluation, diagno-
sis, and treatment, including early developmental inter-
vention.”
48
Evidence suggests that household FI (with or
without the report of family hunger), even in the pres-
ence of appropriate weight-for-age values, is an impor-
tant risk factor for the health, development, and behav-
ior of children ⬍3 years of age and, in the future, should
be included in algorithms for developmental surveil-
lance.
7,49
Interventions for FI and developmental risk are avail-
able and overall have been successful.
44–46,50
Linking
families to the Food Stamp Program and/or the Supple-
mental Nutrition Program for Women, Infants, and Chil-
dren participation, as well as Early Intervention, Early
Head Start, Head Start, and mental health services, is an
important intervention that should be recommended if
indicated by the risk surveillance or developmental
screening. Participation in the Supplemental Nutrition
Program for Women, Infants, and Children has been
associated with positive infant growth and health.
51
Frongillo et al
52
reported that starting participation in the
Food Stamp Program during the kindergarten to third-
grade years was associated with academic (reading and
math) improvement, compared with stopping participa-
tion in the Food Stamp Program during that same
period.
CONCLUSIONS
This study has shown that there is a statistically robust
association between household FI and developmental
risk during the first 3 years of life, when brain growth is
rapid. Given the prevalence of FI in US households with
young children, large numbers of children may be at risk
of potentially preventable developmental deficits, even if
they are not underweight for age. In a time of limited
resources, providing nutritional and developmental in-
terventions to young children and their families is a
proactive step that might decrease the need for later,
more-extensive interventions for developmentally or
behaviorally impaired children of school age.
53
Future
studies should evaluate the longitudinal relationship of
FI and infant and toddler development. Those studies
should consider direct evaluation of the caregiving en-
vironment and child development, as well as other im-
portant factors (such as health status, public assistance
programs, and caregiver mental health) that may alter
the relationship between FI and child development.
ACKNOWLEDGMENTS
This research was supported by grants from the W.K.
Kellogg Foundation, MAZON: A Jewish Response to
Hunger, the Gold Foundation, the Minneapolis Founda-
tion, Project Bread: The Walk for Hunger, the Sandpiper
Foundation, the Anthony Spinazzola Foundation, the
Daniel Pitino Foundation, the Candle Foundation, the
Wilson Foundation, the Abell Foundation, the Claneil
Foundation, the Beatrice Fox Auerbach donor-advised
fund of the Hartford Foundation (on the advice of Jean
Schiro Zavela and Vance Zavela), Susan Schiro and Peter
Manus, the Eos Foundation, the Endurance Fund, the
Gryphon Fund, the Shoffer Foundation, and anony-
mous donors.
We are very grateful to the families that participated
in this study. We also thank Zhaoyan Yang for excellent
management of surveillance and interview data and SAS
programming. Special thanks go to Nicole Neault, MPH,
Stephanie Ettinger De Cuba, MPH, Joni Geppert, MPH,
70 ROSE-JACOBS et al
by guest on June 3, 2013pediatrics.aappublications.orgDownloaded from
Tu Quan, Susan Goolsby, Anna Quigg, MA, Jodi Marani,
MEd, and Jennifer Breaux, MPH, for excellence in train-
ing, scheduling, and supervising interview staff members
and for diligence in coding, cleaning, and preparing
questionnaires for data entry. We would also like to
thank Frances P. Glascoe, PhD, author of the Parents’
Evaluations of Developmental Status, for her consulta-
tion on the use of the PEDS in our study.
REFERENCES
1. Nord M, Andrews M, Carlson S. Measuring Food Security in the
United States: Household Food Security in the United States, 2005.
USDA Economic Research Service, Economic Research Report
Number 29, Washington, DC, November 2006. Available at:
www.ers.usda.gov/Publications/ERR29/ERR29.pdf. Accessed
November 11, 2006
2. Casey PH, Szeto KL, Robbins JM, et al. Child health-related
quality of life and household food security. Arch Pediatr Adolesc
Med. 2005;159:51–56
3. Jyoti D, Frongillo E, Jones S. Food insecurity affects children’s
academic performance, weight gain, and social skills. J Nutr.
2005;135:2831–2839
4. Alaimo K, Olson CM, Frongillo EA. Food insufficiency and
American school-aged children’s cognitive, academic, and psy-
chosocial development. Pediatrics. 2001;108:44 –53
5. Olson CM. Nutrition and health outcomes associated with food
insecurity and hunger. J Nutr. 1999;129(suppl):521S–524S
6. Casey PH, Szeto K, Lensing S, Bogle M, Weber J. Children in
food-insufficient, low-income families: prevalence, health, and
nutrition status. Arch Pediatr Adolesc Med. 2001;155:508 –514
7. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is
associated with adverse health outcomes among human in-
fants and toddlers. J Nutr. 2004;134:1432–1438
8. Cook JT, Frank DA, Levenson SM, et al. Child food insecurity
increases risks posed by household food insecurity to young
children’s health. J Nutr. 2005;136:1073–1076
9. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the
risks of depression and anxiety in mothers and behavior prob-
lems in their preschool-aged children. Pediatrics. 2006;118(3).
Available at: www.pediatrics.org/cgi/content/full/118/3/e859
10. Shonkoff JP, Phillips DA, eds. From Neurons to Neighborhoods:
The Science of Early Childhood Development. Washington, DC:
National Academy Press; 2000
11. Dobbing J. The later growth of the brain and its vulnerability.
Pediatrics. 1974;53:2– 6
12. Dobbing J, Sands J. Vulnerability of developing brain, part IX:
the effect of nutritional growth retardation on the timing of the
brain growth-spurt. Biol Neonate. 1971;19:363–378
13. Frongillo EA Jr. Validation of measures of food insecurity and
hunger. J Nutr. 1999;129(suppl):506S–509S
14. Weinreb L, Wehler C, Perloff J, et al. Hunger: its impact on
children’s health and mental health. Pediatrics. 2002;110(4).
Available at: www.pediatrics.org/cgi/content/full/110/4/e41
15. Hamilton W. Household Food Security in the United States in 1995:
Technical Report of the Food Security Measurement Project. Alexan-
dria, VA: Department of Agriculture, Food and Nutrition
Service; 1997
16. Nord M, Andrews M, Carlson S. Measuring Food Security in the
United States: Household Food Security in the United States, 2004.
USDA Economic Research Service, Economic Research Report
Number 11, Washington, DC, October 2005. Available at
www.ers.usda.gov/publications/err11/err11.pdf. Accessed Au-
gust 8, 2006
17. Bickel G, Nord M, Price C, Hamilton W, Cook J. Measuring Food
Security in the United States: Guide to Measuring Household Food
Security, Revised 2000. Department of Agriculture, Food and
Nutrition Service, Alexandria, VA, March 2000
18. Kemper KJ, Babonis TR. Screening for maternal depression in
pediatric clinics. Am J Dis Child. 1992;146:876 –878
19. Glascoe FP. Collaborating With Parents: Using Parents’ Evaluation
of Developmental Status to Detect and Address Developmental and
Behavioral Problems. Nashville, TN: Ellsworth and Vandermeer
Press; 1998
20. Yip R, Binkin NJ, Fleshood L, Trowbridge FL. Declining prev-
alence of anemia among low-income children in the United
States. JAMA. 1987;258:1619 –1623
21. Glascoe FP. Evidence-based approach to developmental and
behavioral surveillance using parents’ concerns. Child Care
Health Dev. 2000;26:137–149
22. American Academy of Pediatrics, Committee on Children With
Disabilities. Developmental surveillance and screening of in-
fants and young children. Pediatrics. 2001;108:192–196
23. Halfon N, Regalado M, Sareen H, et al. Assessing development
in the pediatric office. Pediatrics. 2004;113(suppl):1926 –1933
24. Woodruff BA, Duffield A. Assessment of Nutritional Status in
Emergency-Affected Populations: Adults. Geneva, Switzerland:
United Nations, Administrative Committee on Coordination,
Subcommittee on Nutrition; 2000
25. Kielman A, McCord C. Weight-for-age as an index of risk of
death in children. Lancet. 1978;1:1247–1250
26. Centers for Disease Control and Prevention, National Center for
Health Statistics. CDC growth charts: United States. Available
at: www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_
charts.htm. Accessed October 11, 2006
27. Svedberg P, World Institute for Development Economics Re-
search. Poverty and Undernutrition: Theory, Measurement, and
Policy. New York, NY: Oxford University Press; 2000
28. National Institute of Child Health and Human Development
Early Child Care Research Network. Duration and develop-
mental timing of poverty and children’s cognitive and social
development from birth through third grade. Child Dev. 2005;
76:795– 810
29. Kleinman R. Pediatric Nutrition Handbook. 5th ed. Elk Grove
Village, IL: American Academy of Pediatrics; 2004
30. Noble KG, Tottenham N, Casey BJ. Neuroscience perspectives
on disparities in school readiness and cognitive achievement.
Future Child. 2005;15:71– 89
31. Skalicky A, Meyers AF, Adams WG, Yang Z, Cook JT, Frank
DA. Child food insecurity and iron deficiency anemia in low-
income infants and toddlers in the United States. Matern Child
Health J. 2006;10:177–185
32. Grantham-McGregor S, Ani C. A review of studies on the effect
of iron deficiency on cognitive development in children. J Nutr.
2001;131(suppl 2):649S– 666S
33. Black MM. Micronutrient deficiencies and cognitive function-
ing. J Nutr. 2003;133(suppl 2):3927S–3931S
34. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW. Poorer
behavioral and developmental outcome more than 10 years
after treatment for iron deficiency in infancy. Pediatrics. 2000;
105(4). Available at: www.pediatrics.org/cgi/content/full/105/
4/e51
35. Alaimo K, Olson CM, Frongillo EA. Family food insufficiency,
but not low family income, is positively associated with dyst-
hymia and suicide symptoms in adolescents. J Nutr. 2002;132:
719 –725
36. Casey P, Goolsby S, Berkowitz C, et al. Maternal depression,
changing public assistance, food security, and child health sta-
tus. Pediatrics. 2004;113:298 –304
37. Dawson G, Ashman SB, Panagiotides H, et al. Preschool out-
comes of children of depressed mothers: role of maternal be-
havior, contextual risk, and children’s brain activity. Child Dev.
2003;74:1158 –1175
PEDIATRICS Volume 121, Number 1, January 2008 71
by guest on June 3, 2013pediatrics.aappublications.orgDownloaded from
38. Petterson SM, Albers AB. Effects of poverty and maternal
depression on early child development. Child Dev. 2001;72:
1794 –1813
39. Bradley RH, Corwyn RF. Socioeconomic status and child de-
velopment. Annu Rev Psychol. 2002;53:371–399
40. Watson JE, Kirby RS, Kelleher KJ, Bradley RH. Effects of
poverty on home environment: an analysis of three-year out-
come data for low birth weight premature infants. J Pediatr
Psychol. 1996;21:419 –431
41. Aber JL, Jones SJ, Cohen J. The impact of poverty on the
mental health and development of very young children. In:
Zeanah CH, ed. Handbook of Infant Mental Health. New York, NY:
Guilford Press; 2000:113–128
42. Sameroff AJ. Environmental risk factors in infancy. Pediatrics.
1998;102(suppl E):1287–1292
43. Rouse C, Brooks-Gunn J, McLanahan S. Introducing the issue.
Future Child. 2005;15:5–14
44. Walker SP, Chang SM, Powell CA, Grantham-McGregor SM.
Effects of early childhood psychosocial stimulation and nutri-
tional supplementation on cognition and education in growth-
stunted Jamaican children: prospective cohort study. Lancet.
2005;366:1804 –1807
45. Devaney BL, Ellwood MR, Love JM. Programs that mitigate the
effects of poverty on children. Future Child. 1997;7:88 –112
46. Barnett WS. Long-term effects of early childhood programs on
cognitive and school outcomes. Future Child. 1995;5:25–50
47. Black MM, Dubowitz H, Krishnakumar A, Starr RH Jr. Early
intervention and recovery among children with failure to
thrive: follow-up at age 8. Pediatrics. 2007;120:59 –69
48. American Pediatric Association, Council on Children With Dis-
abilities, Section on Developmental Behavioral Pediatrics,
Bright Futures Steering Committee and Medical Home Initia-
tives for Children with Special Needs Project Advisory Com-
mittee. Identifying infants and young children with develop-
mental disorders in the medical home: an algorithm for
developmental surveillance and screening. Pediatrics. 2006;118:
405– 420
49. Rose-Jacobs R, Cabral H, Cook JT, Martin B, Frank DA. House-
hold food insufficiency and Bayley Scales of Infant Develop-
ment scores between 6 and 36 months. In: 14th Biennial Inter-
national Conference on Infant Studies. Chicago, IL: International
Society of Infant Studies; 2004
50. Love JM, Kisker EE, Ross C, et al. The effectiveness of Early
Head Start for 3-year-old children and their parents: lessons for
policy and programs. Dev Psychol. 2005;41:885–901
51. Black MM, Cutts DB, Frank DA, et al. Special Supplemental
Nutrition Program for Women, Infants, and Children partici-
pation and infants’ growth and health: a multisite surveillance
study. Pediatrics. 2004;114:169 –176
52. Frongillo EA, Jyoti DF, Jones SJ. Food Stamp Program partic-
ipation is associated with better academic learning among
school children. J Nutr. 2006;136:1077–1080
53. Shonkoff JP, Meisels SJ. Handbook of Early Childhood Interven-
tion. 2nd ed. New York, NY: Cambridge University Press; 2000
ADULT SUPERVISION
“At Mascoutah Middle School in Illinois, 13-year-old Megan Coulter was
recently given detention for hugging two friends goodbye before the week-
end—a violation of the school’s ban on ‘public displays of affection.’ One
California school district worried about ‘bullying, violence, self-esteem and
lawsuits’ also banned tag, cops and robbers, touch football and every other
activity that involved ‘bodily contact.’ In some schools, free play has been
replaced by organized relay races and adult-supervised activities, in order to
protect children from spontaneous outbreaks of creativity. This makes sense
to the sort of person who thinks children must at all costs be protected from
the scrapes of life and insulated from the prospect of having to deal with social
interactions or disappointment. We’re already paying the price for the epi-
demic of overprotectiveness. Congress has appropriated more than $600
million to encourage kids to walk or bike to school. An entire generation of
kids now rides in minivans to schools where they aren’t allowed to chase one
another, swing on swings or play dodgeball. And we wonder why we have an
obesity problem.”
Sykes C. Wall Street Journal. November 18, 2007
Editor’s note: Mr. Sykes is the author, most recently, of 50 Rules Kids Won’t Learn in School. St. Martins, 2007
Noted by JFL, MD
72 ROSE-JACOBS et al
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DOI: 10.1542/peds.2006-3717
2008;121;65Pediatrics
Deborah A. Frank
Cutts, Mariana Chilton, Timothy Heeren, Suzette M. Levenson, Alan F. Meyers and
Ruth Rose-Jacobs, Maureen M. Black, Patrick H. Casey, John T. Cook, Diana B.
Development
Household Food Insecurity: Associations With At-Risk Infant and Toddler
Services
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