Homelessness in Infancy Has Lasting Health Effects in Kids

Troy Brown, RN

May 07, 2019

Children who experienced homelessness or housing instability in infancy had higher rates of asthma, more emergency department visits, and higher healthcare costs through age 6 years, compared with those who had stable housing, new data show.

"Children born during a period of family homelessness have significantly greater health risks from birth through early childhood. Our analyses suggest that unstable housing's impact on infants and children goes beyond the more general effects of poverty," the authors write.

Robin E. Clark, PhD, University of Massachusetts Medical School, Worcester, and colleagues' findings were published in the May issue of Health Affairs.

To identify infants who had experienced homelessness, the researchers used claims-based diagnosis and procedure codes from Medicaid claims and Massachusetts emergency shelter enrollment records. They identified all live births that occurred during the 12 months immediately preceding or the 12 months after the date of shelter entry between 2008 and 2015.

"We adopted this broader definition of homelessness based on research showing that housing instability often precedes shelter entry and that unstable housing is associated with increased health risks and use of health care services," they explain.

They identified 5762 infants with a history of homelessness; 5553 infants were matched with regard to sex, race/ethnicity, location, and birth month.

During an infant's first year, those who experienced homelessness were significantly more likely to visit an emergency department or to be hospitalized than those in the matched group. In addition, median healthcare costs were higher for the infants who experienced homelessness.

Homeless infants were no more likely to receive care in a neonatal intensive care unit, but for those who did receive such care, median stays were longer. There were no significant differences in the rates of infants with short gestation periods or fetal growth retardation, but homeless infants were significantly more likely to have low birthweight (16.13% vs 12.07%; P = .01).

"Greater risk of low birthweight among homeless infants suggests that the focus on ensuring a stable living situation should begin before or during pregnancy. Early identification and stabilization is essential for preventing longer-term effects on children's health," Clark told Medscape Medical News.

Infants in the homeless group had higher rates of upper respiratory infections (59.15% vs 51.65%), other lower respiratory diseases (43.93% vs 32.22%), fevers of unknown origin (39.22% vs 29.68%), allergic reactions (37.96% vs 32.87%), other nutritional, endocrine, or metabolic disorders (37.42% vs 32.32%), injuries due to external causes (12.18% vs 8.75%), developmental disorders (11.37% vs 5.83%), and asthma (9.84% vs 5.92%) during their first year of life (for all, P < .0001).

Most of these differences in health conditions continued for 2 or 3 years.

Differences in rates of fever and allergies were significant during the first 2 years, and differences in rates of respiratory diseases, nutritional disorders, and injury remained significant at 3 years.

Rates of asthma persisted through age 6 years. They rose steadily during the first 4 years and remained high for the following 2 years.

"Unstably housed children are at greater risk for developing asthma. While there are many potential contributing factors, stress and poor-quality housing may be particularly important. Helping a family get permanent, decent housing quickly may be one of the most important strategies for improving asthma outcomes. Again, knowing about a child's history of unstable housing may prompt clinicians to look more closely for evidence of asthma and other respiratory conditions," Clark said.

Emergency department visits and healthcare spending remained significantly higher in the exposed group vs the unexposed group through age 6 years.

Assess Living Situation at Each Encounter

"Infants and children experiencing unstable housing have frequent healthcare encounters, which presents an important opportunity for screening, identification, and referral for those at risk for homelessness. Housing situations can change rapidly, so it is important to ask about a child's living situation at each encounter," Clark told Medscape Medical News.

Clark explained that it is important to have strong relationships with social service providers who have housing expertise. He said that screening may be ineffective if housing is not available or is hard to obtain.

Children remain at increased risk for health problems even after obtaining stable housing. Knowing that a child has previously been homeless may provide the clinician with clues for preventing or addressing future health problems, Clark continued.

Effective screening and a "strong working relationship with community providers who can respond quickly" are key to reducing the duration of a child's experience with unstable housing. Clinicians should monitor a child's health and social situation for several years after housing stabilizes, Clark added.

"Solutions to family homelessness go beyond the bounds of healthcare. While clinicians play a critical role in identifying families at risk and addressing their immediate healthcare needs, longer-term solutions require more affordable housing and more reliable financial support for pregnant women and young families. We must all broaden our view of health interventions to include social factors, like affordable housing, that play a critical role in determining health," he concluded.

The authors have disclosed no relevant financial relationships.

Health Aff. Published online May 6, 2019. Full text

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