The national shortage of baby formula in the U.S. that began in February of 2022 cast an urgent spotlight on the difficulties parents can face in meeting basic nutritional needs of their babies.
The COVID pandemic triggered severe strains in formula supply chains. These were further exacerbated when Abbott Nutrition recalled formulas and closed a major Michigan formula production plant. The crisis not only raised questions about the regulation and market structure of the formula industry but also prompted calls for broader reliance on breastmilk and to increase supports available to breastfeeding parents, especially given the gap between recommendations and practice.
WATCH: Despite all efforts to increase the supply of baby formula, it is still very scarce
For example, less than a quarter of U.S. infants meet the American Academy of Pediatrics’ recommendation of exclusive breastfeeding for the first 6 months of life.
However, a narrow focus on formula supply or AAP recommendations for infant formula does not reveal the full range of economic tradeoffs families make when deciding how to best provide nutritional health for their infant.
Facts
Long-term consequences can be caused by deficiencies in nutrition early.
It is recommended that infants should only consume either breastmilk or formula during the first six months of life, with health authorities including the World Health Organization and the U.S. Centers for Disease Control and Prevention, strongly favoring exclusive breastfeeding during this time. Breast milk has unique nutritional properties, such as the ability to transfer maternal antibodies, and studies suggest multiple infant and maternal health benefits; however, the direct causal link between breastfeeding and children’s early health in a developed country context such as the U.S. is challenging to identify.
Nevertheless, some recent evidence from the United Kingdom shows that breastfeeding improves cognitive development among infants of mothers with lower levels of education. Food security during children’s earliest years of development matters to subsequent infant health risks with early nutritional deficiencies and malnutrition potentially having irreversible, lifelong consequences for children’s subsequent neurodevelopment and cognitive functioning. Infant formula is designed to imitate human milk in order to provide important macro-, and micronutrients.
Breastfeeding is a popular choice for many mothers in the United States. However, breastfeeding rates drop over time and vary widely by socioeconomic status.
The majority of mothers (or 84%) report having ever breastfed, according to the most recent survey data. The AAP guidelines are not always followed by all mothers. Only about 25% of mothers reported exclusive breastfeeding during the first 6 months. (See chart). Lower rates of breastfeeding are associated with higher levels of poverty: Only 40% of mothers who live below the poverty line report that they have ever breastfed in 6 months.
According to CDC data, around 70% of mothers whose incomes are more than six times that of poverty report some breastfeeding at 6 month. Mothers who are less educated, are not married, or have a younger child are more likely to report that their infants are receiving breastmilk at six months.
In the U.S., financial and social support for breastfeeding are mixed and inconsistent.
Although breastfeeding was the norm in the 19th century it has changed drastically in the United States between 1880s to 1940s. This led to a wide acceptance of medically-directed infant feeding.
Breastfeeding rates reached their lowest point in the 1970s and rates have been rising since then; however, this means that many women do not have mothers or relatives who they can turn to for breastfeeding advice as people did back in the 18th and 19th centuries for example. Breastfeeding support, counseling and equipment are covered under many health insurance plans but even for women with a primary care physician or pediatrician, the supply of skilled lactation consultants is low.
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There are an estimated 5.1 Internationally Board Certified Lactation Consults (IBCLCs) per 1,000 live births in the U.S., falling below the recommended standard of 8.6 per 1,000 live births, and many pediatricians report feeling ill-prepared to provide breastfeeding support to lactating parents.
Access to professional lactation support can be critical; many mothers stop breastfeeding earlier than intended due to lactation difficulties and concerns about milk supply. Hospitals play an important role in establishing infant feeding practices. However, the U.S. does not adhere to international standards on formula marketing, enabling formula companies to use aggressive marketing strategies, such as encouraging healthcare workers to distribute free samples to parents.
Slightly over a quarter of all U.S. births occur in hospitals designated “Baby-Friendly,” which is viewed as the gold standard for infant feeding practices. Inequities persist in hospital offerings; Black infants are more likely to be introduced to formula during their hospital stay and maternity facilities that follow baby-friendly practices are less prevalent in neighborhoods with a higher percentage of Black residents.
Formula may be costly, but breastfeeding is not “free”
Advocates for breastfeeding cite the high cost of formula, with saving of up to $1,500 in direct infant formula costs. This argument doesn’t take into account the opportunity cost of breastfeeding. These include the possible loss of wages from breastfeeding breaks, the time investment to breastfeed, pump, or breastfeed, as well as the special storage bags and clean, food grade containers that can store pumped milk.
For the first few weeks, infants breastfeed 8-12 times per day. If an infant breastfeeds 20-40 minutes each feed, it would cost a breastfeeding parent $588 to $11,176 for the first month.
Many American mothers are faced with tough decisions about breastfeeding or working for a living.
Mothers who return to work full-time and/or shortly after giving birth are less likely to plan to exclusively breastfeed, have lower rates of breastfeeding initiation, and have shorter breastfeeding durations.
On the other hand, increased paid family leave has been shown to increase breastfeeding duration and the likelihood of breastfeeding for at least 6 months, yet only about 50 percent of U.S. mothers who are working at the time of birth report taking some paid leave. Lactating parents who return to work and breastfeed are often met by a lack of professional support.
READ MORE The industry’s long-standing weaknesses are exposed by the current shortage of baby formula
Provisions from the 2010 Patient Protection and Affordable Care Act amended Section 7 of Fair Labor Standards Act (FLSA) that requires employers to provide “reasonable break time” and “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public” for employees to express breast milk excludes an estimated 9 million workers of childbearing age who are exempt from Section 7 of the FLSA, which includes the majority of salaried employees.
Recent legislative efforts such as the PUMP Act would have expand protections to salaried employees failed to pass the Senate in June 2022 during the height of the formula shortage; a similar bill – the Pregnant Workers Fairness Act – remains sitting in the Senate.
Formula can be an important part of infant nutrition. However, it is not always available or affordable.
A recent Econofact podcast examined the supply side factors that contributed to the infant formula shortage, including market consolidation (four producers – Abbott, Mead-Johnson, Perrigo, and Nestlé – control approximately 90 percent of the formula market), high tariffs on imported formula leading to a reliance on domestic producers, and ongoing supply chain issues due to COVID-19. These factors contributed to increasing formula prices and out of stock percentages prior the shutdown of Abbott’s Sturgis, Michigan plant in February 2022, which substantially exacerbated these issues.
The shutdown of the Sturgis plant demonstrated the fragility of the formula market to supply shocks: formula prices increased by an average of 11 percent between March 2021 and May 2022 and shortages spiked to over 74 percent nationwide at the end of May 2022, with ten states having shortage levels of 90 percent or greater.
At the same time, the industry’s profit margin increased by 2.6 percentage points. Congress passed legislation temporarily suspending tariffs on infant formula, and, more recently, legislation suspending tariffs on formula-based power used in formula manufacturing in the U.S. to address the shortage. Both laws expire on December 31st 2022. It is not known what the long-term effects of Cronobacter contamination on infant formula and the shortage of infant formula will be. The Cronobacter sakazakii bacteria that led to the Sturgis plant shutdown is one of the few organisms that can survive in powdered formula and can cause severe meningitis. The infant formula industry is still vulnerable to possible outbreaks and shut downs due to the lack of a comprehensive method for diagnosing or investigating Cronobacter infections.
The shortage also had negative implications for infant’s health as some families turned to rationing supplies or creating homemade formula to deal with the crisis.
Federally funded Women, Infant and Children (WIC), can help to ensure that formula is available in all states and influence the feeding of low-income infants.
WIC is a very successful early intervention nutrition support with high use and proven benefits to infants, young children and their families. Breastfeeding promotion is a central goal of the WIC program, with state and local agencies required to create procedures to ensure breastfeeding support for beneficiaries, staff trained on breastfeeding promotion, and more generous food packages offered to fully or partially breastfeeding moms.
The White House recently announced testing of telehealth initiatives to provide virtual breastfeeding support and one-on-one counseling through the WIC program. However, breastfeeding rates among WIC participants remain below the national average, with participants citing lack of support at home, need to return to work, and lack of time as barriers to breastfeeding. As such, approximately half of all infant formula sold in the U.S. is purchased with WIC benefits. WIC has sole-source contracts with formula producers, receiving rebates that lower costs. This not only allows WIC to reach more eligible families, but also limits the type of formula beneficiaries WIC can receive.
In response to the supply crisis, Congress passed legislation that waives restrictions on the type of formula WIC recipients can purchase and on the maximum monthly allowance for formula during a product recall or supply chain crisis.
What does this mean?
Children who don’t get the micronutrients they need early in their lives could be at risk of poor development.
While the nutritional value of breastmilk is high and mothers seem to have internalized the “breast is best” mantra, this recommendation is wildly in conflict with policy support available for mothers (and, families more broadly), and also not aligned with industry drivers for the production and marketing of infant formula.
WATCH: Nationally, parents are struggling with a critical shortage of baby formula
Many working families don’t have parental leave. There are few protections that allow lactating mothers to express their milk at work. The availability of lactation consultants is not universal. Although hospitals account for more than 90% of all births, hospitals also offer support for breastfeeding in mixed circumstances. Low-income mothers with low incomes are often limited in their options for infant feeding. This may be due to the inequalities in breastfeeding rates based on socioeconomic status and race.
Most U.S. baby formula is used to provide their nutritional needs. However, the recent crisis highlights the need for further action to protect the product and ensure market resilience to future supply shocks.
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