Nearly half of young children screened at a network of urban Federally Qualified Health Centers (FQHCs) in Indianapolis lacked enough diapers for adequate care. The situation is tied to maternal depression, low birth weight, and higher emergency department use, according to a new study published in Pediatrics.

Researchers from Indiana University and the Regenstrief Institute integrated a diaper insecurity question into the electronic health record (EHR) at nine Indianapolis FQHCs between June 2022 and July 2024. The screening was added to existing questionnaires on social drivers of health.

Of the 7700 patients aged 0-36 months who were screened, 3147 (41%) families reported not having enough diapers to change as often as needed for their child, the study found. Non-Hispanic Black (45%) and Hispanic (39.9%) children, as well as families preferring to communicate in Haitian Creole (66%), had the highest diaper insecurity rates. Non-Hispanic White children had the lowest (30%) diaper insecurity rates.

While clinicians achieved equitable screening by race and ethnicity, they screened families speaking languages other than English or Spanish less frequently, leaving gaps in resource referrals. Fewer than half of eligible patients were screened, Reinoso and her research colleagues noted.

“We did not have equitable screening for other languages,” said Deanna Reinoso, MD, associate professor of pediatrics at Indiana University School of Medicine, Indianapolis, and lead author of the study. “That really wasn’t intentional by pediatricians but rather reflects the lack of screening tools in multiple languages. If you don’t have them, it’s very difficult to provide that care with interpreter services.”

Uninsured families reported diaper insecurity at nearly 50% compared with just 8.7% of those with commercial insurance.

Most families who reported diaper insecurity also faced other challenges: 78% had food insecurity, 65% had transportation insecurity, 71% had difficulty paying rent or mortgage, and 88% had financial insecurity. Almost half (48%) received Supplemental Nutrition Program (SNAP) benefits, although SNAP and Special SNAP for Women, Infants, and Children do not cover diapers.

Reinoso said stigma often prevents parents from disclosing the problem unless a clinician asks.

“Most parents who are experiencing [diaper insecurity] feel like they’re the only one who isn’t able to provide this basic need,” she said. “If anybody starts to be aware of it and ask or screen for it, I think every single pediatrician across the country would be surprised at how prevalent it is.”

Susan Buttross, MD, Medical Director for the Center for Advancement of Youth at the University of Mississippi Medical Center in Jackson, Mississippi, and an American Academy of Pediatrics board member, said she has seen the same struggles in her practice.

Diaper insecurity increases the risk for diaper dermatitis, urinary tract infections, emergency department visits, and maternal depression — all of which “not only increase the vulnerability of our children but also increase healthcare costs,” Buttross said.

The Indiana study also found diaper insecurity was associated with maternal depression (P = .005) and low or very low infant birth weight (P = .006).

Reinoso recalled a case early in her training that shaped her focus. She described a toddler who died from abuse amid severe family stress. The child’s mother, unable to afford diapers, had tried to potty train him prematurely.

“There’s a lot of shame surrounding it for parents,” Reinoso said. “It’s not spoken about, it’s not resourced, [and] federal programs like SNAP or local food networks really don’t address this need.”

According to Reinoso, barriers extend beyond workflow.

Reinoso urged pediatricians, even those outside large systems, to start small.

“Every size pediatric clinic, both rural to urban, can begin to address diaper need by screening for diaper insecurity and partnering with their local diaper bank,” she said. “Maybe you only verbally screen and don’t have the capacity to universally screen with the EHR, but making sure you develop community partners is critical.”

Buttross also suggested systemic changes that could make a difference.

“One simple policy change that each state could implement would be to eliminate state sales tax on diapers,” she said. Buttross also called for expanding Medicaid and Temporary Assistance for Needy Families coverage to include diapers as a basic child health need.

Reinoso’s team is now working to validate diaper insecurity screening questions in English, Spanish, and Haitian Creole and to study parenting and toilet training in the context of diaper needs.

“Diaper insecurity has multiple health implications for infant and maternal health that need further intervention studies,” Reinoso said. “We hope to measure the impact not only on child health but also on maternal and infant mortality.”

Reinoso and Buttross did not report any relevant disclosures. Lara Salahi is a health reporter based in Boston.