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

Practice changes and infant health risks during the 2022 infant formula shortage: Results of a US healthcare provider survey

BACKGROUND

In February 2022, an infant formula recall and closing of a major manufacturing center exacerbated a nationwide shortage initiated by COVID-19-related supply chain disruptions. The effects were far-reaching, impacting families and healthcare providers across the US.

METHODS

A 19-item web survey was developed to better understand how the infant formula shortage impacted healthcare provider practices, resources needed and those already used, and patient health, including malnutrition. Subjective data on providers' experience were also collected.

RESULTS

Two hundred forty-one providers responded, primarily registered dietitians (94%) practicing in inpatient/academic hospitals in urban and metropolitan areas. Practice adjustments included increases in patient education (100%), communication with pharmacies/durable medical equipment companies (65%), and visit durations (28%). Feeding adjustments by caregivers included new infant formula (99%), toddler (55%) or homemade (23%) formula, cow's milk (46%) or milk alternatives (32%), formula dilution (41%), and early food introduction (14%). Providers indicated an increase in malnutrition (33%), related diagnoses (including failure to thrive [31%] and deceleration in z score [27%]), and associated symptoms. Of the providers who reported malnutrition and related diagnoses, 93% also reported caregiver feeding practices that are generally not recommended.

CONCLUSION

Providers made practice adjustments to mitigate the consequences associated with formula unavailability and misuse yet saw an increase in malnutrition and related diagnoses or symptoms. Subjectively, providers reported frustration that greater workloads did not result in improved outcomes, contributing to burnout. These data underscore the essentiality of supporting healthcare providers as they guide families in safe infant feeding practices.

Impact of the 2022 Infant Formula Shortage on Neonatal Intensive Care Units

Objective: The aim of this study was to examine effects of the 2022 infant formula shortage as experienced by neonatal intensive care units (NICUs) in the United States, a previously unreported perspective. Methods: A mixed-method approach was utilized. Data were collected using an online survey of NICU medical directors. Quantitative data were analyzed with descriptive statistics and Student's t test. Thematic analysis was utilized to make sense of patterns within the qualitative data. Results: Responses from 139 medical directors were received. Both academic (41.7%) and community (58.3%) NICUs were represented among respondents. Thirty-nine percent of NICU medical directors reported an impact on their unit by the infant formula shortage. Within the qualitative data four themes were revealed as follows: alterations to discharge planning, policy modifications, suboptimal solutions, and extraordinary measures. These themes may inform strategies for mitigation of future infant formula shortages. Conclusions: NICUs were significantly impacted by the infant formula shortage with likely lasting effects. From the reported experiences, clear recommendations have been formed to minimize effects of future infant formula shortages.

SPOOC (Sensor for Periodic Observation of Choline): An Integrated Lab-on-a-Spoon Platform for At-Home Quantification of Choline in Infant Formula

Choline is an essential micronutrient for infants' brain development and health. To ensure that infants receive the needed daily dose of choline, the U.S. Food and Drug Administration (FDA) has set requirements for choline levels in commercialized infant formulas. Unfortunately, not all families can access well-regulated formulas, leading to potential inadequacies in choline intake. Economic constraints or difficulties in obtaining formulas, exacerbated by situations like COVID-19, prompt families to stretch formulas. Accurate measurement of choline in infant formulas becomes imperative to guarantee that infants receive the necessary nutritional support. Yet, accessible tools for this purpose are lacking. An innovative integrated sensor for the periodic observation of choline (SPOOC) designed for at-home quantification of choline in infants' formulas and milk powders is reported. This system is composed of a choline potentiometric sensor and ionic-liquid reference electrode developed on laser-induced graphene (LIG) and integrated into a spoon-like device. SPOOC includes a micro-potentiometer that conducts the measurements and transmits results wirelessly to parents' mobile devices. SPOOC demonstrated rapid and accurate assessment of choline levels directly in pre-consuming infant formulas without any sample treatment. This work empowers parents with a user-friendly tool for choline monitoring promoting informed nutritional decision-making in the care of infants.

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.

Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

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.

Global lessons for strengthening breastfeeding as a key pillar of food security

Breastfeeding is identified as a central pillar of food security by the World Health Organization, however globally significant challenges remain in achieving breastfeeding targets for early initiation, exclusive breastfeeding for 6 months, and continued breastfeeding for 2 years and beyond. Inadequate support in health systems, poor maternity protections and workplace policies, and insufficient regulation of commercial milk formulas, among other barriers, continue to undermine this key pillar across nations. This paper highlights the central importance of breastfeeding for food security across diverse global settings by examining three case studies: Honduras, Pakistan and the USA. The cases highlight the complex layering and intersections of key challenges that threaten breastfeeding in the era of pandemics, the climate crisis, conflict and global inequality. Lessons drawn from these case studies, combined with additional insights, reinforce the importance of multisectorial collaboration to scale up investment in creating equitable, enabling environments for breastfeeding. These structural and systems approaches can successfully strengthen the breastfeeding ecosystem to ensure greater first food system resilience in the face of global crises, which compound maternal and infant vulnerabilities. Additionally, the cases add urgency for greater attention to prioritizing breastfeeding and incorporating IYCF-E protocols into disaster preparedness and management into the policy agenda, as well as ensuring that first food security is considered in energy policy. An integrated approach to policy change is necessary to recognize and strengthen breastfeeding as a pivotal part of ensuring food security across the globe.