For months now, the US has been experiencing a severe shortage of infant formula due to supply chain issues, product recalls, factory closures and limits on imports. As a result, stores have struggled to keep their shelves stocked with formula: the latest data indicates that out-of-stock rates are currently at 43% nationwide.1 The families hardest hit are those with exclusively formula-fed infants under six-months-old, for whom this is their sole source of nutrition, and infants who need specialist formulae for certain nutritional or metabolic needs.
Breastmilk or formula should be the only source of nutrition for infants under six-months-old and should remain their primary source of nutrition from 7-12 months as solids are introduced.2 Formula is designed to mimic breastmilk as closely as possible, as an alternative for those infants who cannot breastfeed. Although most US babies begin nursing at birth (84%), by three-months-old more than half receive at least some supplemental formula,3 meaning that many infants are reliant on its availability.
There are reports of parents diluting formula to make it go further, but this can lead to malnutrition and electrolyte imbalances4 and is not safe. Others may be tempted to substitute with cows’ milk, however, it is contraindicated in babies under 12 months5: the higher protein and mineral content can stress developing kidneys, and the type of protein can also irritate the gut lining, sometimes leading to blood loss and iron-deficiency anemia. Cows’ milk also lacks iron and other essential nutrients, increasing the likelihood of deficiencies, and it has lower fat content than breastmilk, essential for babies’ brain growth. This is more problematic the younger the infant.
Families might consider DIY formula recipes found on the internet. Under most circumstances we would promote homemade food over processed alternatives, but this is one area where that might not be advisable. Most of these recipes use cows’ milk as a base, the issues with which were outlined above. The additional ingredients added to compensate for the nutrient shortfalls may be expensive and hard to source, leading some parents to omit them, and the recipes can be complicated to follow.
Some recipes advocate using unpasteurized cows’ milk, which is difficult (and, in many states, illegal) to source, plus it can pose health risks, especially to underdeveloped immune systems. Other DIY recipes include a liver-based formula with levels of preformed vitamin A that exceed the TUL for infants, and vegan recipes which lack so many essential nutrients that they cannot be considered a substitute for breastmilk. It is worth remembering that the tight FDA regulations governing formulae production are to ensure that it approximates the composition of breastmilk as closely as possible, because it serves as the primary source of nutrition for the full first year of life.
What to do, by age of infant
For pregnant women and new mothers, establishing successful breastfeeding may be the best option, getting as much support as necessary to achieve their breastfeeding goals: 60% of mothers don’t breastfeed for as long as they’d like to, and the reasons given for stopping early could be resolved with more support from lactation consultants and other healthcare providers.6
For premature infants and newborns with medical need, donor breastmilk is an option: the Human Milk Banking Association of North America distributes pasteurized human milk to babies in hospitals and home settings. There has recently been an increase in donations, so they may be able to bridge the gap for families in the general public needing assistance (contact your local milk bank to donate or apply).
Many infants under six-months-old are consuming both breastmilk and formula – it may be possible to increase maternal milk supply with the assistance of a lactation consultant or nutritionist. Pediatricians can also put parents in touch with local WIC programs or may have formula samples available in their office. Ordering formula online is an option for some, but be sure to purchase known brands from reputable websites only.
For older infants (7-12 months-old), cows’ milk can be given occasionally or temporarily (1-2 weeks): whole milk is best, ideally with A2 proteins only as these are more like breastmilk and less irritating to the GI tract7; purchase organic and grass-fed if possible. DIY formulae may also be appropriate for some older infants, in consultation with a trained healthcare provider. And, although babies start exploring some solids at this age, it isn't appropriate to use these foods in place of formula feedings - they aren’t an adequate nutritional substitute. After their first birthday, babies can transition to other milks (e.g. cows’ or goats’ milk, enriched plant milks); toddler formulae are not nutritionally necessary.
1 Datasembly Releases Latest Numbers on Baby Formula. Datasembly website. https://datasembly.com/news/out-of-stock-rate-in-april-2022/. Published May 10, 2022. Accessed May 31 2022.
2 Kleinman, RE. American Academy of Pediatrics Recommendations for Complementary Feeding. Pediatrics (2000) 106 (Supplement_4): 1274. https://doi.org/10.1542/peds.106.S4.1274a
3 Breastfeeding Data and Statistics. https://www.cdc.gov/breastfeeding/data/facts.html. Published August 21, 2021. Accessed May 31 2021.
4 Abrams, SA. How to Safely Prepare Baby Formula With Water. American Academy of Pediatrics Website. https://www.healthychildren.org/English/ages-stages/baby/formula-feeding/Pages/How-to-Safely-Prepare-Formula-with-Water.aspx. Published May 17, 2022. Accessed May 31, 2022.
5 Zeigler, EE. Adverse effects of cow's milk in infants. Nestle Nutrition Workshop Series: Pediatric Program. 2007; 60:185-199. doi: 10.1159/000106369. https://pubmed.ncbi.nlm.nih.gov/17664905/. Accessed May 31, 2022.