As we awoke this month to another dispiriting report of the numbers of coronavirus disease 2019 (COVID-19) infections and deaths, a new set of horrifying statistics hit the airwaves. By the end of April 2020, 2 in 5 households with children <12 were food insecure (meaning they were unable to afford enough food for all household members to live active, healthy lives), and, in nearly one-half of these households, parents reported that their children were directly experiencing food insecurity (FI).1 These levels exceed those found at any time since FI measurement was implemented in the late 1990s, including during the previous Great Recession of 2007–2009.1 We cannot address this accelerating threat to our patients as individual clinicians in our examination rooms. Rather, as urged by the American Academy of Pediatrics, we need to advocate collectively to ensure that existing nutrition programs reach all children and that the “dose” of available interventions is sufficient to decrease FI over the long-term.2
Ample scientific research establishes that FI experienced at even the mildest levels has acute and later chronic effects on health, cognition, and socioemotional adaptation. Young children raised in food insecure households are at a greater risk of fair or poor health, hospitalizations, developmental delays, cognitive impairment, poor academic performance, abnormal weight and BMI, and decreased social skills.3 Inadequate nutritional intake in childhood can also increase vulnerability to future adverse chronic conditions, such as obesity, diabetes, and cardiovascular disease.4 The American Academy of Pediatrics recommends pediatricians see these risks are minimized by optimizing families’ access to federal nutrition assistance programs, which provide food (such as the National School Lunch Program and the Child and Adult Care Food Program) or resources for food purchases from retail outlets (including the Special Supplemental Nutrition Program for Women Infants and Children [WIC] and the Supplemental Nutrition Assistance Program [SNAP]). Research demonstrates that participation in these programs can prevent or mitigate FI, decrease the risk of hospitalizations, and improve health and academic achievement.5,6 Although the philanthropic food network is making heroic efforts to address increased need during this time, it acknowledges that these efforts cannot match federal programs in their scope or geographic reach and will not be able to shoulder the burden of meeting current and anticipated ongoing need alone. Ultimately, the impact COVID-19 will have on our children’s current and future health will depend on the government’s sustained response to many areas of increased deprivation, including nutritional deprivation, particularly as social distancing guidelines continue and essential programs, such as the National School Lunch Program and Child and Adult Care Food Program, are interrupted.7
Of all the crucial public nutrition programs enumerated, SNAP reaches the most children nationwide and is the best designed to respond quickly during economic downturns.5 Although other nutrition supports are only available during a specific time of year or to a subpopulation of eligible children, SNAP is a countercyclical entitlement program that provides year-round assistance throughout childhood. Research demonstrates that SNAP protects children’s health by reducing FI and improving families’ ability to meet their other basic needs. SNAP can improve overall child health, help children have a healthy weight for age, and support cognitive and emotional development and academic performance.5,8
The initial response from Congress has begun to address the immediate financial impact of COVID-19 and rising FI. The Families First Coronavirus Response Act gave states broad flexibility and authority to temporarily supplement and modify nutrition programs with the approval of the US Department of Agriculture. The Coronavirus Aid, Relief, and Economic Security Act provided an additional $15.5 billion for SNAP to respond to the projected increase in applications due to newly eligible families. Although recent legislation has expanded access to nutrition assistance and provided modest, temporary increases in benefits for some families, additional long-term measures that keep food on the table for struggling families and sustain and enhance SNAP are necessary to reduce threats to food security and health.
Every pediatric provider knows the hazards of prematurely withdrawing an effective therapy before the illness is truly resolved: such premature termination of care can prolong and worsen illness. Past efforts to increase SNAP benefits in response to the Great Recession effectively mitigated the recession’s impact on families while they were in effect9 but these were withdrawn before the risk of FI and its health correlates had abated.10 Furthermore, the Great Recession demonstrated that it takes much longer for families previously facing financial hardships to recover from a recession than others.11 Before the current COVID-19 epidemic, FI trends for families with young children had still not returned to the 2007 pre-Recession levels after the national economy had recovered.10 Given this evidence, it is essential that long-term solutions to promote food security are implemented immediately and sustained over time.
A staggering number of our patients and their families who participate in SNAP may lose access to all or some of this critical therapy because of changes in recently enacted or proposed regulations. Before the COVID-19 outbreak, the administration had issued 3 regulatory proposals that, if implemented, would collectively reduce benefits or cut over 1.5 million households with children from SNAP and, collaterally, remove nearly 1 million children from accessing free school lunch.12,13 These proposed changes would withdraw critical assistance for the very families disproportionately impacted by COVID-19. Furthermore, sweeping expansions of rules known as public charge, which threaten the immigration status of people who use some public benefits, including SNAP, took effect in February 2020. Even before implementation, evidence of fear of being deemed a public charge was documented. During the pandemic, immigrant families’ willingness to access critical emergency provisions, even those for which they are eligible, has been impacted by the chilling effect of this rule change.
As in our clinical work, attention needs to be focused not only on making efficacious treatments available to the entire population at risk, but also on the adequacy of the dose provided. Congress should boost SNAP maximum benefits by 15%, mirroring policy action during the Great Recession, which effectively reduced FI and improved the health of young children and families.14 Although a waiver made available through the Families First Coronavirus Response Act allowed states to provide families with the maximum benefit for their household size, the across-the-board 15% increase differs by boosting the maximum benefit for all families, even those in the poorest households who were already at the maximum benefit before the pandemic. This action addresses underlying benefit inadequacies to match the real and increasing cost of healthy food and provide for its purchase.5,15,16
SNAP protects the health of our young patients and their families. Given the threats posed by COVID-19, compounded by regulations that threaten access to SNAP, pediatric providers have a critical opportunity to not only protect but to enhance SNAP and other tools to prevent and alleviate FI. We need to use our expertise to advocate together with the public and political leaders for rapid and long-term policies to nourish families and halt the impact recent regulatory changes will have on our nation’s children. Reach out to your legislators to demand sustainable assistance; share stories from the frontline; contact key decision-makers in your state; connect your patients to nutrition support. Children are hungry today: their bodies and brains will not be healed with promises of an economic recovery next week, next month, or next year.
We thank Stephanie Ettinger de Cuba and Allison Bovell-Ammon for their review of the article.
Drs Frank and Ochoa conceptualized the perspective piece, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Bruce drafted the initial manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
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.