The emergence of a large and widespread shortage of infant formula in the US in May 2022 has focused attention on the need to ensure a robust infant feeding system. A recent study published in nutrients examined infant formula use, difficulties, support resources, and potentially helpful future measures in a sample of US parents.
Background
The crisis was triggered by the recall of baby food products by Abbott Nutrition, combined with the closing of a large manufacturing facility in Michigan. This company supplies 40% of the nation’s formula. Supply chain disruptions due to the coronavirus disease 2019 (COVID-19) pandemic and restrictive import tariffs have exacerbated the situation.
By the end of May 2022, several states had run out of formula. The shortages disproportionately affected poorer communities and infants on special diets. The government introduced Operation Fly to bring in imported formula in partnership with other nations.
Unsafe feeding practices include using diluted formula, making formula at home, giving your baby cow’s milk before one year, and using human milk from untested sources. Previous research has shown that among parents in low-income groups, almost 50% adopted one or more of these practices versus <10% prior to this period.
Untested human milk was used by more than a quarter during the shortage, compared to 5% before it. Likewise, ~30% used diluted formula versus 2% prior to this period.
The current study was performed retrospectively on a cross-sectional population from middle- to high-income communities. The aim was to identify potential improvements in regulatory policies and programs to ensure that infant feeding systems can easily recover from such crises.
About the study group
All participants registered for the Bobbie Infant Formula (USA) list and participated in an online survey. All had babies six months of age or younger in May 2022 and used formula to varying degrees before the shortage.
There were almost 180 participants from 37 US states, with 93% of respondents being women. Most were white – 77%, and nearly 90% had a college degree. Over half of them had an annual household income of $150,000 or more.
Almost 90% of the babies were born at term, and the average age at the time of the study was ten weeks. About 70% of them were the first babies born to their mothers.
About 6% had been enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) at some time within the year immediately prior to their participation in the study.
How have baby feeding practices changed?
Breastfeeding initiation rates were high, with 96% of mothers reporting that they breastfed or fed their infants expressed breast milk (EBM). One in five parents said their babies needed special formula in May 2022 for reasons such as metabolic disease, allergies, colic and more.
Surprisingly, while 80% of infants were initially on their mothers’ own milk (MOM), this decreased to 76% in May 2022. Conversely, ~84% of infants were on formula before, but 93% during of the shortage.
Unsafe practices for infants remained at 2% before and throughout the shortage period, although other milk foods increased slightly as one-seventh of infants started solid foods earlier than planned.
Use of American brand formula decreased by 2% during the shortage, while use of imported formula increased from 2% to 7%. Use of cow’s milk formula more than doubled during the shortage, from 18% to 39%, but preterm milk declined from 33% to 9%.
How did the parents cope?
During the formula shortage period, 10% of parents turned to social media to get their hands on the formula, up from 3% before. Free samples from medical professionals have halved from 40% before the shortage. However, family and friends in the US became more instrumental in providing formula, with 25% during the period versus 11% during the shortage.
Over 80% of parents switched formula brands at that time, with almost 90% because they couldn’t find their usual formula. Over a third switched brands or types 3-5 times during this period. A fifth of parents stockpiled four weeks or more of baby food at home in May 2022.
Almost 30% of parents said they visited four or more stores within 24 hours to get formula. Again, more than a quarter said they drove more than 20 miles for the same reason, and a seventh said they used Operation Fly.
While 80% of parents perceive ready-to-use infant formula as safe for babies, 90% support powdered formula. Only 65% favor the concentrated liquid formula.
Over a fifth reported inadequate infant feeding in May 2022. While 80% worry about feeding their babies if they stop breastfeeding, 90% worry about whether their babies will take another formula.
How did parents get support?
About half of parents received support or guidance on infant feeding during this time from social media and their healthcare providers. Relatives and friends offered help in over 40% of cases. They were rated as most helpful with seven or more points on a scale of 10.
Lactation specialists helped in 30%. Other sources, including health authority websites, the media, breastfeeding support groups, and blogs or sites maintained by formula companies, contributed 20% or less of the cases. They were rated 6.5 or less.
Most medical sources recommend switching to formula, while 25% of parents received free samples. One in seven said they had been told about breastfeeding practices.
How did babies develop?
The most affected group are infants on special formula foods, with problems such as vomiting when changing formula foods.
What future measures might help?
Parents wanted more formula brands and unlimited choices available through WIC. They also wanted full insurance and Medicare support for formula brands.
Parents also said they needed good online information about specialty formula brands, as well as location-based brand availability data. Breastfeeding support before and after birth is also expected to be very helpful.
What are the consequences?
The findings do not fully support those of earlier studies, perhaps because this is a higher-income group. Paradoxically, the increased use of formula milk during a period of scarcity may be due to the help of family and friends.
Other reasons include online purchases through social media and Operation Fly. Stockpiling formula at home, against the recommendation that no more than two weeks’ worth of formula should be purchased at a time, may also have contributed.
The failure to breastfeed exclusively in almost 90% of women who intended to do so underscores the need for lactation support. Factors included include “lack of federal paid family and medical leave policies, insufficient flexibility and privacy for mothers to breastfeed or pump while at work, to barriers to providing or accessing prenatal breastfeeding education and postpartum breastfeeding support that do not are part of standard care.”
The results of this study may inform changes in legislation covering policy, health and workplace systems to ensure better infant nutrition. Monopolistic systems and protective tariffs disproportionately affect people living in poverty and those babies who need more food. Donor milk banks should be promoted through proper inclusion in public health policies and regulations allowing equitable and reliable access to this source of nutrition for infants.
“The future of individual, community and societal health relies on optimal early nutrition that is sustainable and equitable for all.”
