The Curious Case of Baby Formula in the United States in 2022: Cries for Urgent Action Months after Silence in the Midst of Alarm Bells

Food Safety Research and Extension Needs for the U.S. Low-Moisture Food Industry

Historically, low-moisture foods were considered to have minimal microbial risks. However, they have been linked to many high-profile multistate outbreaks and recalls in recent years, drawing research and extension attention to low-moisture food safety. Limited studies have assessed the food safety research and extension needs for the low-moisture food industry. The objectives of this needs assessment were to explore the food safety culture and education needs, identify the food safety challenges and data gaps, and understand the barriers to adopting food-safety-enhancing technologies in the U.S. low-moisture food industry. This needs assessment was composed of two studies. In Study 1, food safety experts from the low-moisture food industry upper management participated in online interviews and a debriefing discussion session. In Study 2, an online anonymous survey was disseminated to a different group of experts with experience in the low-moisture food industry. The qualitative data were analyzed using deductive and inductive coding approaches, while the quantitative data were analyzed via descriptive analysis. Twenty-five experts participated in the studies (Study 1: n = 12; Study 2: n = 13). Common commodities that participants had worked with included nuts and seeds, spices, flour, and dried fruits and vegetables. A food safety culture conceptual framework was adapted, which included three main components: infrastructure conditions (foundation), individual's food safety knowledge, attitudes, and risk perceptions; and organizational conditions (supporting pillars). Major barriers to establishing a positive food safety culture were identified to be limited resources, difficulties in risk communication, and difficulties in behavioral change. For continual improvement in food safety performance, two major themes of food safety challenges and data gaps were identified: cleaning, sanitation, and hygienic design; and pathogen reduction. Participants perceived the main barriers discouraging the low-moisture food industry from adopting food-safety-enhancing technologies were: (1) budgetary priorities, (2) operation constraints, (3) technology validation, (4) consumer acceptance, and (5) maintaining desired product characteristics such as quality and sensory functionality. The findings of this needs assessment provide guidance for the food industry, academia, and government agencies about the direction of future research and the development of targeted extension programs that might help improve food safety in the low-moisture food industry.

Impact of the 2022 national formula shortage on clinical decision-making of healthcare providers in switching amino acid formulas for infants with cow's milk protein allergy: a survey-based study

Background

In 2022, the United States experienced a national shortage of infant formula due to a global supply chain crisis and a large-scale domestic formula recall. The existing literature on healthcare providers' (HCPs) clinical decision-making during formula shortages is limited. This study aims to analyze the factors influencing pediatric HCP clinical decision-making when switching between amino acid formulas (AAF) for managing cow's milk protein allergy (CMPA) in infants under 24 months of age during an unprecedented national formula shortage.

Methods

The study included pediatric HCPs with experience managing CMPA in infants and toddlers under 24 months during the formula shortage from January 2022 to November 2022. A de-identified survey comprising 26 questions examining driving factors used in clinical decision-making was administered to pediatric HCPs using a real-time mobile data collection tool.

Results

Among the surveyed pediatric HCPs (n = 75), the factors most frequently considered as "extremely important" when switching to another AAF included safety (85%), tolerability (73%), and efficacy (83%). No statistically significant differences were found in HCP ratings among the listed examined factors of the four AAFs. The availability of specific formulas was the only factor that exhibited a statistically significant difference in perceived performance among pediatric HCPs when comparing the four AAFs (p < 0.05).

Discussion

This study elucidates the crucial aspects that influenced pediatric HCPs' selection of AAFs for CMPA management during the 2022 formula shortage. The findings highlight the significance of safety, tolerability, efficacy, and availability in the pediatric HCP decision-making processes.

Cross-Sectional Analysis of Infant Diet, Outcomes, Consumer Behavior and Parental Perspectives to Optimize Infant Feeding in Response to the 2022 U.S. Infant Formula Shortage

In May of 2022, millions of U.S. parents encountered uncertainty in safely feeding their infants due to the infant formula shortage.

METHODS

An anonymous, electronic, cross-sectional, retrospective survey was used.

RESULTS

U.S. parents (n = 178) whose infants were ~10 weeks old during the shortage completed the survey. Of parents, 81% switched formulas during the shortage, 87% switched because they could not find the formula they typically used, 34% switched 3-5 times, 29% of parents visited ≥4 stores/24 h and 26% of parents traveled >20 miles/24 h to purchase formula. Use of infant formula increased (p < 0.01); in infants requiring specialty formula, use of intact cow's milk formula increased (p < 0.05) and use of premature infant formulas decreased (p < 0.05). Infants relying on specialty formulas experienced at least one undesirable outcome compared with non-specialty users. Parents used social media, relatives/friends and healthcare providers for support during the shortage, but their helpfulness scores were suboptimal. Parents reported the need for greater infant formula availability, free prenatal lactation education and postpartum lactation support.

CONCLUSIONS

Government, regulatory and healthcare policy oversight are needed to protect the infant feeding system, including more commercially available products, access to banked donor milk and lactation support.

WIC Participation and Coping Strategies Adopted by Families During the Infant Formula Shortage Crisis

BACKGROUND

Availability of benefits and expanded flexibilities to obtain formula, granted by the US Department of Agriculture shortly after the onset of infant formula shortage in February 2022, could have mitigated adverse experiences related to the shortage in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) families.

OBJECTIVE

To examine association of household WIC participation with formula shortage experiences and coping strategies adopted by families using Household Pulse Survey data.

DESIGN

Cross-sectional.

PARTICIPANTS

The current study utilized Phase 3.7 of the Household Pulse Survey with the following data collection periods: December 9 through 19, 2022, January 4 through 16, 2023, and February 1 through 13, 2023. The primary analytic sample (N = 1,542) consisted of households with income ≤185% of the federal poverty level and children younger than age 18 months.

MAIN OUTCOME MEASURES

Experiences and coping strategies during the formula shortage.

STATISTICAL ANALYSES

Logistic regression examined associations of WIC participation with odds of being affected by formula shortage and difficulty in obtaining formula during the past week. Among those affected by the shortage, association of WIC participation with odds of utilizing coping strategies was examined.

RESULTS

No statistically significant differences were observed in the rates of being affected by formula shortage and having difficulty in obtaining formula during the past week between WIC participants and income-eligible nonparticipants. However, among those affected by the shortage, WIC participation was related to significantly lower odds of using suboptimal practices as a coping strategy (odds ratio 0.38, 95% CI 0.20 to 0.71; P = 0.003). WIC participants also had significantly higher odds of solely changing formula type, brand, or method of receipt (odds ratio 2.63, 95% CI 1.20 to 5.73; P = 0.02).

CONCLUSIONS

Findings from this study suggest that WIC participants may have utilized more optimal coping strategies during the infant formula shortage compared with income-eligible nonparticipants. Additional research is needed to determine whether or not these findings could be attributed to expanded flexibilities to maximize formula access among WIC participants during the shortage.

Navigating formula shortages: associations of parental perspectives on transitioning to alternative infant formulas for cow's milk protein allergy during the 2022 national formula shortage

The COVID-19 pandemic led to supply chain disruptions causing a severe shortage of infant formula. The shortage impacted parents of infants with cow's milk protein allergy (CMPA) who rely on specialized formulas. However, research on parent perspectives during formula shortages is limited. We aimed to understand the factors guiding parents' decisions when transitioning to alternative amino acid formula (AAF) or extensively hydrolyzed formula (eHF) during the national formula shortage. We conducted a survey using the ZSMoments platform and found that before the shortage, parents valued safety (83%), tolerability (78%), and reputability (78%) as primary factors in selecting eHFs and AAFs. Post-shortage, formula tolerability (86%), assurance (84%), and safety (80%) gained more importance. Among those switching eHF (n = 54), health care provider recommendations (81%), reputability (78%), taste (78%), and tolerability (78%) were rated as "extremely important." Among those switching AAF (n = 26), top factors included tolerability (77%), assurance (73%), safety (73%), cost-effectiveness (73%), and formula trustworthiness (73%). These data suggest that parents carefully weigh various factors when managing their child's CMPA and transitioning to different AAF or eHF options.

Infant feeding practices and parental perceptions during the 2022 United States infant formula shortage crisis

BACKGROUND

In May of 2022, parents living in the United States experienced a dramatic infant formula shortage caused by supply chain issues and the recall of several infant formula products over contamination concerns.

METHODS

An anonymous, electronic, cross-sectional survey was designed to understand infant feeding practices, parental experience and perceived support during the crisis.

RESULTS

Ninety-nine parents that lived in the U.S. and fulfilled study criteria completed the survey. 66% of respondents were female, and 75% of respondents were recipients of the Special Supplemental Nutrition Program for Women Infant Children (WIC). Parental mean age was 30.0 years, and the mean infant age was 26.8 weeks. The number of individuals that used at least one unsafe infant feeding practice increased from 8% before the infant formula shortage to 48.5% during the shortage (p < 0.001). 79% of parents fed their infants U.S. infant formula brands and 39% of parents fed their infants imported infant formula brands before the shortage which were significantly reduced during the shortage to 27% (p < 0.005) and 11% (p < 0.005), respectively. The percentage of parents that reported infant feeding practices before and during the infant formula shortage significantly increased from 2 to 28% for banked donor milk use (p < 0.005); 5-26% for use of human milk from informal sharing (p < 0.005); and 2-29% for use of watered-down infant formula (p < 0.005). The resources that parents reported as most helpful in navigating the crisis differed by parental sex and WIC recipient status and included other parents, friends, and family; lactation consultants; healthcare providers; and WIC.

CONCLUSIONS

Our study found that feeding practices in response to the infant formula shortage may pose health risks to infants including nutrition and food insecurity. These data suggest the need for policy changes within regulatory and the healthcare system to provide families with clinical prenatal and postnatal lactation support, access to pasteurized banked donor milk, and access to more commercially available products.

Coping with the 2022 infant formula shortage

To estimate the proportion of US consumers who sought formula during the shortage, what coping mechanisms they used, and public support for formula policies, we conducted an online survey of approximately 1,000 US consumers in August 2022 via Qualtrics. Approximately 35% of consumers attempted to purchase formula during the shortage, for their own household or on behalf of someone else, and the most common coping mechanisms were focused on searching different outlets (e.g., multiple stores, online). During the shortage public health agencies published recommendations for consumers - some were highly utilized (e.g., searching multiple stores), however, some were utilized less frequently (e.g., brand switching, breastfeeding). Additionally, despite warnings, some consumers still attempted to make their own formula. Understanding what coping mechanisms were and were not utilized, and their related risks has important implications for improving public health outreach in the future. Finally, we find considerable public support for regulation to ensure adequate supply of formula in the future, in particular regulation allowing imported formula and increased government involvement in the number of firms producing formula.