This is a complicated answer with a complex history.

The most recent factor contributing to the formula shortage is COVID-19 and the pandemic’s effect on supply chains. With the start of the pandemic, people began stockpiling supplies from toilet paper, bottled water, to formula. Concurrently, birth rates decreased due to fear of the virus and its unknown effects on pregnant patients, fetuses, and newborns. Formula consumption was low, decreasing demand and production. Formula companies thus had a hard time predicting future needs.

When families began purchasing again, there was a parallel uptick in birth rates, exponentially increasing the demand for formulas past what companies had predicted. The pandemic had also rapidly decreased breastfeeding rates due to limited support and no support at all in some areas. Lactation services, including group classes, lactation consultants, and pediatricians who had to triage in-person care, were thwarted. Declining breastfeeding rates increased reliance on formula. Economically, the demand exceeded supply.

The first infant formulas were developed in the 1860s as an alternative to wet nursing. Since these early formulas were so expensive, homemade formulas became popular. By the early 20th century, most babies who were not breastfed received homemade formula. Commercial infant formula began to gain acceptance in the 1960s and the U.S. market for formula surged in 1972 with the creation of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). A new industry was born and, through aggressive marketing, convinced health care professionals and parents that commercial formula was superior nutrition to breast milk. Breastfeeding rates for newborns reached a low of 25 percent in the mid-1970s.

Although breastfeeding rates have since increased, baby formula is still a 2.1 billion dollar industry in the U.S. The “Big Four” companies are U.S.-based Abbott (Similac), U.K.-based Reckitt-Benckiser (Enfamil), Swiss-based Nestle (Gerber), and Perrigo (store brand). Though WIC is federally funded, each state’s WIC program negotiates a time-limited contract with only one of these formula companies. This is why some states were affected more than others.   Analyses have shown that there is a direct correlation between a state’s WIC contract and the sales of that brand of formula throughout the state. Specific contracts and sales create a false narrative that certain baby formulas are “superior.” In reality, almost all infant formulas are exactly the same outside of hypoallergenic versions.

In 1981, the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes (the Code), regarded as a landmark public health agreement “to protect the general public and mothers from aggressive marketing practices by the baby food industry that negatively impact breastfeeding practices.” The Code is meant to “protect, promote, and support breastfeeding.” In the Spring of 2018, at the World Health Assembly in Geneva, these were the exact words that the Trump administration aimed to remove. After several political and economic punitive threats to Ecuador, the country bringing up more secure breastfeeding measures, Russian delegates supported and passed the resolution to support breastfeeding.

Referred to as the mother’s milk of politics, lobbying money to support formula companies’ interests has dominated the cultural war against breastfeeding. Collectively, the big three formula companies, Abbott Laboratories, Nestle, and Reckitt Benckiser, have spent $60.7 million dollars lobbying U.S. lawmakers and officials in the last decade (MapLight analysis). However, following the money is difficult because these companies are designated as corporations with the formula being a subsidiary. For example, Similac producer Abbott Nutrition is a division of Abbott Labs. Abbott labs produces rapid COVID-19 tests, medical devices, and adult nutrition Ensure. In 2021, Abbot spent $4.3 million dollars ranging from issues around medical devices, patent reform, and nutrition. Similarly, Reckitt Benckiser funded opiate abuse legislation.

Regardless of direct lobbying for formula, formula companies have a massive presence at the U.S. Capitol and lawmakers, funding $4 million dollars in campaign funds. Their influence might also be thwarting European formulas entering the market. All formulas sold in the U.S. have to be approved by the Food and Drug Administration (FDA), and thus all formulas produced in the U.S. Currently, FDA has only approved seven formula production sites, and with one site down, the ripple effect is evident in this current shortage.

Experts cite that U.S. infant formulas still follow standards outlined by the Infant Formula Act of 1980 without any progressive updates to add support to European formulas. In contrast, E.U. standards are regularly updated. For example, the fatty acid DHA imperative in infant brain development is mandatory in every E.U. formula while it is optional in U.S. formulas. The science behind DHA has been present for over 40 years.

Breastfeeding is one way some parents can provide food security for their infants. However, systemic barriers exist, creating this decision complex. From lack of knowledge/education amongst health care providers to abysmal parental leave policies and inconsistent family, community, and societal support for breastfeeding parents, breastfeeding becomes challenging. While some families may not be able to breastfeed or may choose not to do so, many parents wish to breastfeed and are not reaching their goals. Prior to the pandemic, research has shown that 85 percent of mothers describe intending to exclusively breastfeed for at least three months, but at three months, only 32 percent are achieving those goals. Concrete measures such as providing prenatal education, advocating for skin-to-skin time after any delivery, including C-section, empowering parents in cue-based feeding, rooming in, and early assistance with latch and positioning both in the hospital and home have demonstrated increasing initial rates.

During the current formula shortage, parents who initially started with or transitioned to formula may be an option to re-lactate if the parent opts. Relactation, though achievable, does take significant time, energy, and weeks prior to having results. Frequently latching, pumping, and medications are needed to promote the return of milk. During this public health emergency, if a parent desires relactation, the family’s physician should facilitate activation of short-term disability (if the parent has it) to allow the necessary protocols to promote re-lactation.

All families deserve support as they welcome home a new infant. The history behind infant feeding, breastfeeding vs. formula, is long and complicated, with many players directly marketing and influencing choices, accessibility, and support. The current formula crisis unearths the many hidden issues (ability to breastfeed and continuation, access to quality breastfeeding services, formula company production practices, government regulations, lobbying, lack of paid family leave, poor employer and community support, and marketing practices) families encounter in a simple decision of newborn feeding. We must provide support to families to reach their feeding goals both during the current public health emergency and in the long term. No parent should face a future in which baby nutrition is a commodity.

Michelle Haggerty and Nithya Natrajan are family physicians. Jessica Madden and Sonal Patel are neonatologists. 

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