In 1946, the National School Lunch Act was passed establishing the school lunch program and making meals a permanent part of schools. Congress declared it a measure of “national security” to ensure the health of the nation’s children by encouraging the consumption of nutritious foods.1 Since then, the meals program has expanded, both in reach (including breakfast) and size (over 100 000 schools now participate).2 The National School Lunch Program and the School Breakfast Program serve over 30 million and 12 million children annually, respectively, with free or reduced-price meals.2,3 Low-income children who participate have lower rates of food insecurity (FI), improved dietary intake, and higher academic achievement.4,10 Although the success of these programs is clear, there remains an important issue: What happens to families who rely on these programs during the summer, when school is not in session?

In this issue of Pediatrics, Collins et al11 have published “Impact of a Summer Nutrition Benefit on Low-Income Children’s Food Security and Diet Quality,” which describes the Summer Electronic Benefit Transfer for Children demonstrations project. The US Department of Agriculture received funding to test a summer electronic benefit transfer (EBT) program for children receiving free or reduced-price school meals. Fifty thousand households at 16 sites were randomly selected between 2011 and 2013 to receive $60 per month, $30 per month, or no EBT over the summer. EBT is a system that transfers government benefits to an account to purchase products, similar to a debit card.12 Households that received a benefit via EBT had a lower prevalence of children with low FI, compared with households that did not. Children receiving the EBT also had improved nutritional outcomes, including increased fruit and vegetable consumption. The study is a rigorous, methodologically sound evaluation of the effect of a public assistance program on children’s nutrition. Although the results have clear policy implications, the findings also have important clinical relevance.

First, clinicians should be aware that low-income families are often vulnerable during the summer school recess or break. FI increases in the summer for families whose children receive free or reduced-price meals during the school year.4,13 The nutritional quality of the foods children eat in the summer also worsens.14 The US Department of Agriculture currently runs an existing program, the Summer Food Service Program, to provide meals in the summer. Approved sites, such as recreation centers, serve free meals and snacks. As noted by Collins et al,11 only a small proportion of children participate. In 2016, 3 million children participated in the summer meals program, one-sixth of the children who receive free or reduced-price meals. Barriers to participating included the limited number of sites available and difficulty accessing sites because of transportation.15 

Second, this study reveals that when families are successfully connected with nutritional resources, they use them. As reported in the study, 90% of the households who were issued the $60 EBT used the benefits at least once and the mean percentage of benefits redeemed was 77%. The American Academy of Pediatrics has recommended that all pediatricians screen for FI and other social determinants of health (SDH) to connect families to services.3,16 Increasing research has resulted in strategies to address SDH screening in pediatric practices, and providing referrals in practices increases the resources families access.17,22 In their study, Collins et al11 add further support to the American Academy of Pediatrics recommendations by showing that once families are successfully connected to resources, they will use them.

Third, public assistance programs can improve children’s health. To warrant screening for SDH, programs that effectively address families’ needs need to be available. In the study, families who received the EBT benefit had a lower prevalence of child FI and improved nutritional outcomes. The study is one of the few randomized trials in which the effect of a public assistance program on children’s food security and nutrition is investigated. Although the results may not be generalizable to other times of the year, populations, or programs, the authors of this study do provide support for the idea that successfully connecting families in need to well-designed programs can improve children’s health and nutrition.

As funding for public assistance programs continues to be debated, it becomes increasingly important to provide strong evidence for how these programs improve the lives of children and families. The Collins et al11 study is a welcome addition to the literature because it is one of the few trials in which the effect of a public assistance program on children’s food security and nutrition is evaluated. Although continued research and advocacy are needed to understand how to improve health outcomes by addressing SDH, the study’s authors add important policy information about how programs can be effectively designed to address families’ needs. As an increasing number of pediatric practices screen for FI, clinicians can connect families to resources, such as food pantries and the summer feeding programs highlighted in this study, to improve the health of their patients.3,17,20,21 

     
  • EBT

    electronic benefit transfer

  •  
  • FI

    food insecurity

  •  
  • SDH

    social determinants of health

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-1657.

1
Gunderson
GW
.
The National School Lunch Program: Background and Development
.
Washington, DC
:
US Government Printing Office
;
1971
2
Hopkins
LC
,
Gunther
C
.
A historical review of changes in nutrition standards of USDA child meal programs relative to research findings on the nutritional adequacy of program meals and the diet and nutritional health of participants: implications for future research and the summer food service program.
Nutrients
.
2015
;
7
(
12
):
10145
10167
[PubMed]
3
Council on Community Pediatrics
;
Committee on Nutrition
.
Promoting food security for all children.
Pediatrics
.
2015
;
136
(
5
). Available at: www.pediatrics.org/cgi/content/full/136/5/e1431
[PubMed]
4
Huang
J
,
Barnidge
E
.
Low-income children’s participation in the National School Lunch Program and household food insufficiency.
Soc Sci Med
.
2016
;
150
:
8
14
[PubMed]
5
Nalty
CC
,
Sharkey
JR
,
Dean
WR
.
School-based nutrition programs are associated with reduced child food insecurity over time among Mexican-origin mother-child dyads in Texas Border Colonias.
J Nutr
.
2013
;
143
(
5
):
708
713
[PubMed]
6
Bartfeld
JS
,
Ahn
HM
.
The School Breakfast Program strengthens household food security among low-income households with elementary school children.
J Nutr
.
2011
;
141
(
3
):
470
475
[PubMed]
7
Clark
MA
,
Fox
MK
.
Nutritional quality of the diets of US public school children and the role of the school meal programs.
J Am Diet Assoc
.
2009
;
109
(
suppl 2
):
S44
S56
[PubMed]
8
Hanson
KL
,
Olson
CM
.
School meals participation and weekday dietary quality were associated after controlling for weekend eating among U.S. school children aged 6 to 17 years.
J Nutr
.
2013
;
143
(
5
):
714
721
[PubMed]
9
Frisvold
DE
.
Nutrition and cognitive achievement: an evaluation of the School Breakfast Program.
J Public Econ
.
2015
;
124
:
91
104
[PubMed]
10
Hinrichs
P
.
The effects of the National School Lunch Program on education and health.
J Policy Anal Manage
.
2010
;
29
(
3
):
479
505
[PubMed]
11
Collins
A
,
Klerman
J
,
Briefel
R
, et al
.
Impact of a summer nutrition benefit on low-income children’s food security and diet quality.
Pediatrics
.
2018
;
141
(
4
):
e20171657
12
United States Department of Agriculture
;
Food and Nutrition Service
. General electronic benefit transfer (EBT) information.
2017
. Available at: https://www.fns.usda.gov/ebt/general-electronic-benefit-transfer-ebt-information. Accessed July 25, 2017
13
Huang
J
,
Barnidge
E
,
Kim
Y
.
Children receiving free or reduced-price school lunch have higher food insufficiency rates in summer.
J Nutr
.
2015
;
145
(
9
):
2161
2168
[PubMed]
14
Wang
YC
,
Vine
S
,
Hsiao
A
,
Rundle
A
,
Goldsmith
J
.
Weight-related behaviors when children are in school versus on summer breaks: does income matter?
J Sch Health
.
2015
;
85
(
7
):
458
466
[PubMed]
15
Food Research & Action Center
. Summer nutrition programs. Available at: www.frac.org/programs/summer-nutrition-programs. Accessed July 25, 2017
16
Council on Community Pediatrics
.
Poverty and child health in the United States.
Pediatrics
.
2016
;
137
(
4
):
e20160339
[PubMed]
17
Beck
AF
,
Tschudy
MM
,
Coker
TR
, et al
.
Determinants of health and pediatric primary care practices.
Pediatrics
.
2016
;
137
(
3
):
e20153673
[PubMed]
18
Beck
AF
,
Klein
MD
,
Kahn
RS
.
Identifying social risk via a clinical social history embedded in the electronic health record.
Clin Pediatr
.
2012
;
51
(
10
):
972
977
19
Fleegler
EW
,
Lieu
TA
,
Wise
PH
,
Muret-Wagstaff
S
.
Families’ health-related social problems and missed referral opportunities.
Pediatrics
.
2007
;
119
(
6
). Available at: www.pediatrics.org/cgi/content/full/119/6/e1332
[PubMed]
20
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT.
Pediatrics
.
2015
;
135
(
2
). Available at: www.pediatrics.org/cgi/content/full/135/2/e296
[PubMed]
21
Gottlieb
LM
,
Hessler
D
,
Long
D
, et al
.
Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial.
JAMA Pediatr
.
2016
;
170
(
11
):
e162521
[PubMed]
22
Burkhardt
MC
,
Beck
AF
,
Conway
PH
,
Kahn
RS
,
Klein
MD
.
Enhancing accurate identification of food insecurity using quality-improvement techniques.
Pediatrics
.
2012
;
129
(
2
). Available at: www.pediatrics.org/cgi/content/full/129/2/e504
[PubMed]

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.