P3C137: Got Milk? A Review of the Systemic Inequities for Highlighted by the 2022 Formula Shortage

Introduction: The United States (US) infant formula shortage was catalyzed by the food-safety-related closure of a single formula factory in February 2022. This case aims to 1) elucidate the underlying multisystem factors that set the stage for the shortage, 2) describe disparities in formula access exacerbated during the shortage, especially for recipients of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program, and 3) identify potential advocacy opportunities.

Case Description: A Black preterm infant was born to a non-English-speaking mother during the formula shortage. His NICU stay was complicated by necrotizing enterocolitis and feeding intolerance requiring hydrolyzed formula. At 3 months old, he was medically ready for discharge, but there were several logistical difficulties in establishing a safe discharge plan. First, his hydrolyzed formula was in extremely low supply. Additionally, his mother needed family shelter placement. Caught in a catch-22 situation, she was unable to confirm family shelter placement without a discharge date, which could not be finalized until an available formula was identified. After a comprehensive search, the medical team secured WIC specialty formula via a DME supply company, but only after discharge was delayed by a week.

Discussion: The case demonstrates how systemic shortcomings leading to the formula shortage had disparate downstream impacts on families. Consolidation of the US formula market leading to dominance by only three manufacturers, along with strains on safety inspection systems during the COVID-19 pandemic, set up the conditions for the shortage. Because WIC’s state-based sole-contract system limits WIC recipients’ choice of brands for formula purchases, families enrolled in WIC were particularly vulnerable to the effects of the shortage. Due to structural racism leading to poverty and food insecurity, a disproportionately large percentage of WIC recipients identify as Black or Latinx as compared to the general population, including our case patient. These historically marginalized populations have also faced cultural, social, and structural barriers to breastfeeding, making them more dependent on formula. Notably, WIC-enrolled infants consume more than 50% of domestically-produced formula. Furthermore, the shortage magnified pre-existing hurdles at individual, community, and institutional levels in enrolling and accessing WIC benefits to purchase formula. Some of these challenges include language barriers, transportation difficulties, and limitations in where and how WIC can be utilized. These systemic inequities should prompt advocacy for WIC reform, such as through The Healthy Meals, Healthy Kids Act (H.R. 8450), and for broader efforts to promote equitable access to formula and human milk.

Conclusion: The 2022 formula shortage highlighted systemic inequities in formula access, particularly for families in WIC. To ensure equitable access to nutrition for our youngest patients, pediatricians should advocate for WIC reform and policies to address structural barriers to both breastfeeding and affordable formula access.