As the coronavirus disease 2019 (COVID-19) pandemic progresses, child health advocates must continue to address the pandemic’s impact on child health and well-being. School meal programs serve as a critical safety net against food insecurity and malnutrition for vulnerable children worldwide.1  When the pandemic emerged as a global threat in the early months of 2020, most national governments shuttered schools as part of their efforts to slow viral spread. In total 194 countries, including the United States, closed schools and universities by early April 2020.2  Overnight, school-aged children lost access to affordable, nutritious meals.1  This occurred in the setting of pandemic-related economic contraction, job losses, supply chain disruptions, and rising food costs.3,4  It comes as no surprise that food insecurity has skyrocketed across the United States, especially among families with children.57  Early analyses suggest the prevalence of food insecurity in US households with children at least doubled, if not tripled, from prepandemic levels.57  Furthermore, experts report this rise in food insecurity cannot be explained by unemployment alone, pointing to the loss of school meals as a major contributor.7 

Even brief spells of food insecurity have detrimental consequences for child health and well-being; students living in households that experience food insecurity during the summer are more likely to lose reading skills, gain excessive weight, and have mental health and behavioral problems compared with peers.8  As pediatricians, we must call for strong policies to protect school-aged children from pandemic-intensified food insecurity.

The US Department of Agriculture (USDA) runs several federally funded child nutrition programs, many of which are integrated into our nation’s school systems. The 2 largest programs, the National School Lunch Program (NSLP) and School Breakfast Program (SBP), provide free or reduced-price meals to children of low-income families. Approximately 29.6 million children participated in NSLP and 14.8 million participated in SBP daily in 2019.9  For children receiving both school lunch and breakfast, these programs provide nearly half of the calories they consume in a school day.10 

The USDA has 2 approaches to address summer food insecurity in students who depend on school meals during the academic year. The Summer Food Service Program (SFSP) relies on community organizations, such as churches, schools, and recreation centers to plan and manage meal distribution in low-income areas. Unfortunately, the program serves less than one-seventh of the students who qualify.11  Barriers to use of SFSP include access to transportation, administrative burden, and food distribution.11  Another program, the Summer Seamless Option, allows schools already serving meals through the NSLP and SBP to continue offering these meals over the summer.12 

When schools closed in the spring of 2020, the USDA took steps to replace the meals typically supplied by schools and community sites.13  The USDA implemented a series of waivers that lifted restrictions normally attached to school meal funding. For example, the USDA waivers permitted schools and program sites to distribute meals directly to parents or guardians in the child’s absence, outside of traditional mealtimes, and in noncongregate settings. Recognizing the tremendous need, school districts and community sites across the country stepped up, creating meal distribution programs overnight. Initiatives varied from grab-and-go pickup locations to meal delivery by school bus.14  Some school food authorities partnered with local nonprofit organizations or private businesses to distribute groceries and shelf-stable goods.15 

Although these Herculean efforts undoubtedly served as a lifeline for millions of children and their families, the USDA child nutrition program waivers have 2 critical limitations. First, the USDA did not mandate schools to provide food during school closures, so many did not. Second, like the SFSP, school districts have struggled with the logistics of physically handing out meals in noncongregate settings.14  Despite these limitations, the USDA waivers facilitated meal distribution to vulnerable children across the country. Fortunately, the USDA has extended some of the waivers to include the upcoming 2020–2021 school year, anticipating that pandemic-related school closures will continue.16  We recommend that the USDA should extend all child nutrition program waivers for the entire duration of this public health crisis. Additionally, the USDA should streamline the process by which states apply for the waivers. Currently, states must apply for each waiver individually, which creates significant administrative burden and limits the states’ ability to respond quickly. Lastly, the USDA should provide additional logistic guidance and support for school districts to address barriers to reaching vulnerable children.

Another potential policy option eliminates the onus for schools and community organizations to distribute meals during school closures. Electronic Benefits Transfer (EBT) programs provide families with debit cards containing funds for grocery purchases. This model has been successfully piloted to address summer food insecurity in children.17  In 2011, the USDA launched the summer EBT program. Although limited to a select group of states, the summer EBT program reduced food insecurity and improved nutritional intake in participating children, demonstrating the ability of this model to address food insecurity during school closures.17  The Families First Coronavirus Response Act, signed into law on March 18, 2020, created the Pandemic Electronic Benefits Transfer (P-EBT) program. The legislation allowed states to directly provide funds to households that lost access to the NSLP during pandemic-related school closures. As of June 2020, 46 states and the District of Columbia have been approved to operate a P-EBT program.18 

Given the efficacy of the EBT model, this type of program should play a critical role in alleviating pandemic-intensified food insecurity. We therefore recommend that the P-EBT program should be continued for the 2020–2021 school year to ensure vulnerable children have uninterrupted access to food in the event of ongoing school disruptions due to COVID-19. Additionally, the previously piloted summer EBT program should be expanded nationwide as a means of supporting families throughout the coming years of economic recovery.

Food-insecure children living in rural communities represent a particularly vulnerable group during pandemic-related school closures. Rural communities across the country have higher rates of poverty and food insecurity.11  Families in rural areas may live a considerable distance away from schools, child nutrition program sites, and grocery stores, limiting their ability to benefit from most USDA child nutrition programs. In 2019, the USDA partnered with the Texas Department of Agriculture and Baylor University’s Texas Hunger Initiative to pilot a summer meals program targeted at children in rural or remote communities in east and west Texas. The program, called Meals-to-You (MTY), mailed weekly meal boxes to each child eligible for free or reduced-price meals.19  MTY successfully addressed the transportation barriers that previously kept these families from accessing existing nutritional support programs.19  This program was expanded to select counties in New Mexico and Alaska for summer 2020.20  In March 2020, the USDA announced a public-private partnership based on the MTY pilot and managed by Baylor University’s Collaborative on Hunger and Poverty to provide meals to rural children affected by pandemic-related school closures. The Emergency Meals-to-You (eMTY) program mails boxes of shelf-stable goods every 2 weeks to children who typically received lunch through NSLP.21 

Programs like summer MTY and eMTY provide children in rural and isolated communities with a consistent adjunct to the family’s food supply when schools are not in session. With the inevitability of COVID-19–related disruptions to the 2020–2021 school year, we recommend that eMTY programs are extended through the next school year and expanded to serve more remote communities. Additionally, the summer MTY programs should be expanded nationwide to secure reliable access to food during summer months beyond the scope of the COVID-19 pandemic.

Although the pandemic has had a multitude of devastating effects, it provides a unique opportunity to create meaningful change by creating sustainable solutions to address food insecurity in school-aged children (see Table 1 for a summary of proposed policy recommendations). In the coming months, the policies we develop in response to the current crisis have the potential to greatly strengthen the safety net protecting our children from hunger and poor nutrition.

As pediatricians, we are in a prime position to identify and address food insecurity. We urge all pediatric providers to incorporate sensitive food insecurity screening into all outpatient clinic appointments and emergency department visits and at least once during each inpatient admission. The American Academy of Pediatrics recommends the Hunger Vital Sign, a well-regarded 2-question screening tool.8  For families who screen positive, pediatric practices should refer families to local food banks and food distribution sites as well as provide information about evidence-based programs that ameliorate food insecurity such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).25  As the COVID-19 pandemic continues to unfold, food insecurity in children will remain in flux. It is our privilege and responsibility as pediatricians to strive to alleviate the burden of food insecurity on children.

We applaud the efforts of school districts, food banks, nonprofit organizations, private donors, and volunteers in striving to provide meals for vulnerable children during these unprecedented times.

Drs Hetrick and Rodrigo conceptualized and drafted the initial manuscript and reviewed and revised the manuscript; Dr Bocchini contributed to research and content discussions and provided critical contributions to the revision process; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

COVID-19

coronavirus disease 2019

EBT

Electronic Benefits Transfer

eMTY

Emergency Meals-to-You

MTY

Meals-to-You

NSLP

National School Lunch Program

P-EBT

Pandemic Electronic Benefits Transfer

SBP

School Breakfast Program

SFSP

Summer Food Service Program

USDA

US Department of Agriculture

1
World Food Programme
.
State of School Feeding Worldwide 2013.
Rome, Italy
:
World Food Programme
;
2013
.
2
United Nations Educational, Scientific and Cultural Organization
.
Education: from disruption to recovery. 2020. Available at: https://en.unesco.org/covid19/educationresponse. Accessed July 7, 2020
3
US Bureau of Labor Statistics
.
Consumer Price Index news release. 2020. Available at: https://www.bls.gov/news.release/archives/cpi_06102020.htm. Accessed July 7, 2020
4
Macias
CJ
.
Is the food supply strong enough to weather the COVID-19 pandemic? Feeding a growing nation. 2020. Available at: https://www.ucdavis.edu/food/news/is-food-supply-strong-enough-to-weather-covid-19-pandemic/. Accessed July 7, 2020
5
Bauer
L
;
The Hamilton Project
.
The COVID-19 crisis has already left too many children hungry in America. 2020. Available at: https://www.hamiltonproject.org/blog/the_covid_19_crisis_has_already_left_too_many_children_hungry_in_america. Accessed May 11, 2020
6
Schanzenbach
DW
,
Pitts
A
;
Institute for Policy Research
.
Food insecurity in the Census Household Pulse Survey data tables. 2020. Available at: https://www.ipr.northwestern.edu/documents/reports/ipr-rapid-research-reports-pulse-hh-data-1-june-2020.pdf. Accessed July 7, 2020
7
Bitler
MP
,
Hoynes
HW
,
Schanzenbach
DW
.
The social safety net in the wake of COVID-19. 2020. Available at: https://www.brookings.edu/wp-content/uploads/2020/06/Bitler-et-al-conference-draft.pdf. Accessed July 7, 2020
8
Council on Community Pediatrics
;
Committee on Nutrition
.
Promoting food security for all children
.
Pediatrics
.
2015
;
136
(
5
).
9
US Department of Agriculture Food and Nutrition Service
.
Child nutrition tables. 2020. Available at: https://www.fns.usda.gov/pd/child-nutrition-tables. Accessed May 24, 2020
10
Cullen
KW
,
Chen
T-A
.
The contribution of the USDA school breakfast and lunch program meals to student daily dietary intake
.
Prev Med Rep
.
2016
;
5
:
82
85
11
Food Research & Action Center
.
Hunger doesn’t take a vacation: summer nutrition status report.
2019
. Available at: https://frac.org/wp-content/uploads/frac-summer-nutrition-report-2019.pdf. Accessed May 10, 2020
12
US Department of Agriculture Food and Nutrition Service
.
An opportunity for schools. 2020. Available at: https://www.fns.usda.gov/school-meals/opportunity-schools. Accessed July 5, 2020
13
US Department of Agriculture Food and Nutrition Service
.
FNS responds to COVID-19. 2020. Available at: https://www.fns.usda.gov/disaster/pandemic/covid-19. Accessed June 30, 2020
14
Sugar
R
.
The scramble to feed the kids left hungry by the coronavirus crisis. Vox. April 17, 2020. Available at: https://www.vox.com/the-goods/2020/4/17/21220016/school-lunch-coronavirus-meal-programs. Accessed May 11, 2020
15
Abad-Santos
A
.
How US schools are (and aren’t) providing meals to children in the Covid-19 crisis. Vox. March 28, 2020. Available at: https://www.vox.com/2020/3/28/21197965/coronavirus-school-shutdown-free-meals. Accessed July 16, 2020
16
US Department of Agriculture
.
USDA provides flexibilities to ensure kids receive meals this fall. 2020. Available at: https://www.usda.gov/media/press-releases/2020/06/25/usda-provides-flexibilities-ensure-kids-receive-meals-fall. Accessed June 30, 2020
17
Collins
AM
,
Klerman
JA
,
Briefel
R
, et al
.
A summer nutrition benefit pilot program and low-income children’s food security
.
Pediatrics
.
2018
;
141
(
4
):
e20171657
18
US Department of Agriculture Food and Nutrition Service
.
State guidance on coronavirus Pandemic EBT (P-EBT). 2020. Available at: https://www.fns.usda.gov/snap/state-guidance-coronavirus-pandemic-ebt-pebt. Accessed July 5, 2020
19
US Department of Agriculture
.
Innovation and collaboration bring summer meals to children in rural Texas. 2020. Available at: https://www.usda.gov/media/blog/2019/08/15/innovation-and-collaboration-bring-summer-meals-children-rural-texas. Accessed July 5, 2020
20
Meals-to-You
.
Meals-to-you. 2020. Available at: https://mealstoyou.org. Accessed July 5, 2020
21
Baylor University Media and Public Relations
.
Baylor University receives $75,000 gift from H-E-B to combat food insecurity during COVID-19 pandemic. 2020. Available at: https://www.baylor.edu/mediacommunications/news.php?action=story&story=219073. Accessed May 22, 2020
22
US Department of Agriculture Food and Nutrition Service
.
Child nutrition programs: COVID-19 waivers by state. 2020. Available at: https://www.fns.usda.gov/disaster/pandemic/covid-19/cn-waivers-flexibilities. Accessed July 5, 2020
23
Summer EBT for Children
.
Welcome to summer EBT for children. 2020. Available at: www.sebtc-mi.com. Accessed July 5, 2020
24
The Chickasaw Nation
.
Summer EBT for children program. 2020. Available at: https://chickasaw.net/summerebt. Accessed July 5, 2020
25
Keith-Jennings
B
,
Llobrera
J
,
Dean
S
.
Links of the Supplemental Nutrition Assistance Program with food insecurity, poverty, and health: evidence and potential
.
Am J Public Health
.
2019
;
109
(
12
):
1636
1640

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.