Infant feeding practices, health and quality of life outcomes during the 2022 infant formula shortage

By Dr. Liji Thomas, MDMar 12 2024Reviewed by Danielle Ellis, B.Sc.

The occurrence of a large and widespread shortage of infant formula in the US during May 2022 focused attention on the need to ensure a stable infant feeding system. A recent study published in Nutrients examined infant formula use, difficulties, support resources, and potentially beneficial measures for the future in a sample of US parents.

Background

The crisis was triggered by a recall of infant feeding products from Abbott Nutrition, coupled with the closure of its large production facility in Michigan. This company supplies 40% of infant formula to the nation. Supply chain disruptions due to the coronavirus disease 2019 (COVID-19) pandemic and restrictive import tariffs worsened the situation.

By the end of May 2022, several states were out of infant formula stock. The shortage affected poorer communities and infants on specialty formulas disproportionately. 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 the infant cow’s milk before one year of age, and using human milk from non-vetted sources. Previous research showed that among parents in low-income groups, almost 50% adopted one or more of these practices vs <10% before this period.

Non-vetted human milk was used by over a quarter during the shortage, vs 5% before it. Similarly, ~30% used diluted formula vs 2% before this period.

The present study was performed retrospectively on a cross-section of the population of middle- to high-income communities. The aim was to identify potential improvements in regulatory policies and programs to ensure infant feeding systems can rebound easily in such crises.

About the study group

The participants all signed up for the Bobbie Infant Formula (US) listserv and took part in an online survey. All had babies who were six months or younger in May 2022 and used infant formula to varying extents before the shortage.

There were almost 180 participants from 37 US states, with 93% of respondents being female. Most were Whites, at 77%, and nearly 90% were college-educated. Over half of them had annual household incomes of $150,000 or higher.

Almost 90% of the infants were born at term, and the mean age at the time of the survey was ten weeks. About 70% of them were the first babies born to their mothers.

About 6% were on the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) at some time within the year immediately preceding their participation in the survey.

How did infant feeding practices change?

Breastfeeding initiation rates were high, with 96% of mothers reporting they had nursed or fed expressed breast milk (EBM) to their infants. One in five parents said their infants required a specialty formula during May 2022 for reasons like metabolic disease, allergies, colic, and the like.

Surprisingly, while 80% of babies were initially on their mothers’ own milk (MOM), this went down to 76% during May 2022. Conversely, ~84% of babies were on infant formula before, but 93% during, the shortage.

Unsafe infant practices remained at 2% before and throughout the period of shortage, though other dairy foods were slightly increased because a seventh of infants were started on solid foods earlier than intended.  

American formula brand use declined by 2% during the shortage, while imported formula use went up from 2% to 7%. Cow’s milk formula usage more than doubled during the shortage, from 18% to 39%, but premature formula went down, from 33% to 9%.

How did parents cope?

During the period of formula scarcity, 10% of parents resorted to social media to obtain the formula, vs 3% before it. Free samples from medical professionals went down by half from 40% before the shortage. However, family and friends within the USA became more instrumental in supplying formula, at 25% during vs 11% during the shortage.

Over 80% of parents switched formula brands at this time, almost 90% being because they could not find their usual formula. Over a third switched brands or types 3-5 times in this period. A fifth of the parents stockpiled four weeks or more of infant feed at home in May 2022.

Almost 30% of parents said they had visited four or more stores within 24 hours to get formula. Again, over a fourth said they drove over 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 infants, 90% support powdered formula. Only 65% supported concentrated liquid formula.

Over a fifth reported inadequate infant feeding during May 2022. While 80% worried about feeding their infants if they stopped breastfeeding, 90% were concerned about whether their babies would accept another formula.

How did parents obtain support?

About half of parents obtained support or guidance for infant feeding during this time from social media and their healthcare providers. Relatives and friends offered help in over 40% of cases. These were rated as most helpful, at seven or over, on a scale of 10.

Lactation specialists helped out in 30%. Other sources, including websites by health authorities, media, breastfeeding support groups, and blogs or sites maintained by infant formula companies, contributed to 20% or less of cases. These were rated at 6.5 or less.

Most medical sources recommended switching formulas, while 25% of parents received free samples. A seventh said they were told about breastfeeding practices.

How did the babies thrive?

The most affected group were infants on specialty formulas, with problems like vomiting while switching formulas.

What future measures might help?

Parents wanted more formula brands and unrestricted choices to be available through the 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 locality-based brand availability data. Breastfeeding support before and after childbirth was also expected to be very helpful.

What are the implications?

The findings do not fully corroborate those of earlier studies, perhaps because this was a higher-income group. The paradoxically increased use of formula during a period of shortage might be due to the help of family and friends.

Other reasons include online purchases via social media and Operation Fly. The stockpiling of formula at home, against the recommendation that no more than two weeks of formula should be bought at a time, could also have contributed.

Failure to exclusively breastfeed among almost 90% of women who intended to do so underlines the need for lactation support. Factors involved 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 in affording or accessing prenatal lactation education and postpartum lactation support which are not part of standard care.”

The results of this study may justify changes in policy-spanning legislation, healthcare, and workplace systems to ensure better infant feeding. Monopolistic systems and protective tariffs unequally affect people experiencing poverty and those infants who need more nutrition. Donor milk banks must be promoted by proper inclusion in public health policies and regulations, allowing fair and reliable access to this source of infant nutrition.

“The future of individual, community and societal health relies on optimal early life nutrition that is resilient and equitable for all.”