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Formula shortage is worst for low-income families, high-risk infants

Empty shelves at a Target store in Albany, Calif., on Tuesday. (David Paul Morris/Bloomberg)
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The baby formula shortage has put the medical community on alert, from pediatricians screening infants for anemia to specialists struggling to replace the carefully calibrated recipes that keep high-risk youngsters alive.

“This is a crisis,” said Mark Corkins, a pediatric gastroenterologist at Le Bonheur Children’s Hospital in Memphis, who chairs the American Academy of Pediatrics committee on nutrition.

What to do if you can't find baby formula

The most vulnerable children have been hardest hit, including those whose parents are unable to spend hours searching for formula online or in person, and preemies and medically complex babies who require specialized nutritional support. Doctors say that deficiencies caused by diluting or using alternatives to formula can in some cases be catastrophic, prompting imbalances that can lead to seizures, coma and even death.

“These are not small risks. They are big risks,” said Kimberly Giuliano, a primary care pediatrician affiliated with Cleveland Clinic Children’s Hospital. She recalled a single mother who didn’t have a car describing going on foot to five supermarkets on a fruitless search before social workers were able to find some formula for her.

Tiffani Hays, director of pediatric clinical nutrition education and practice at Johns Hopkins, has spent months at the center of a logistical juggle involving daily calls and regular meetings to assess formula inventories in different locations, consolidate them and redistribute them where they were most needed.

One of the biggest challenges, she said, has been helping complex-care babies, some of whom have trouble swallowing or malformed bowels and receive tube feeding at home. They often don’t tolerate a different brand, said Hays, who described pulling dietitians out of clinics to coordinate with prescribers and try out new products and recipes.

Despite the efforts, two babies had to be admitted to the hospital. One newborn’s discharge was delayed.

The shortage, which began in February after contamination at an Abbott Nutrition production plant in Michigan, has been exacerbated by pandemic-related supply chain problems. While many healthy, full-term babies can switch easily from brand to brand, for others a change could be a life-or-death decision. Babies with a disorder known as galactosemia, for example, are unable to digest lactose, the main sugar found in milk-based formulas and breast milk.

Le Bonheur recently admitted a toddler and a preschooler with a medical condition known as short bowel syndrome that requires an amino acid-based formula. When that wasn’t available, doctors tried a peptide-based product. The children became dehydrated and ended up needing intravenous fluids and hospital care. One was discharged after about a week; the other remains in the hospital.

“This is not what we signed up to do,” Corkins said. “We’re not giving the best care we can give.”

U.S. baby formula shortage is worrying parents. Here’s what to know.

Katie Lockwood, a primary care pediatrician at Children’s Hospital of Philadelphia, is always on the lookout for the signs of iron deficiency among infants at the south Philadelphia clinic where she works: Pale skin. Fatigue. And a heart that beats too fast.

But what used to be a tip-off that families were saving money by making their own formula could now signal another scourge: parents diluting short supplies or substituting cow’s milk, which doctors discourage for children younger than 1.

“All they are trying to do is feed their babies,” Lockwood said.

The AAP said this month that in a pinch parents can feed babies 6 months and older cow’s milk “for a brief period of time until the shortage is better.”

Pediatricians say parental anxiety has grown in recent weeks as the shortage has become more acute, prompted by a mix of panic buying, allegations of price gouging and fears of what the future holds.

Those worries seem well-founded. In the first week of May, the product analytics company Datasembly estimated the out-of-stock rate at 43 percent among U.S. retailers. Abbott and the Food and Drug Administration came to an agreement Monday to fix safety issues and resume production, but it will take weeks to get additional formula on shelves. The government also launched a website with advice for parents, while encouraging states to take advantage of waivers that allow easier distribution of formula to low-income parents.

While government data shows that most families use formula at some point in an infant’s development, the shortage is hitting economically disadvantaged communities and communities of color hard in part because they rely heavily on formula, according to data from the Centers for Disease Control and Prevention. Half of the nation’s formula — much of it sourced from Abbott — is purchased by recipients of a food assistance program for mothers and babies known as WIC. More than 1.7 million infants are in the WIC program.

“It’s a systemic problem,” said Gabrina Dixon, a hospitalist at Children’s National Hospital in Washington who said that African American mothers often contend with a lack of structural support at home and at work to feed their babies breast milk.

While the AAP recommends that babies are breastfed until age 1 or longer, many women are unable or unwilling to breastfeed for a variety of reasons, including trouble latching, inadequate milk supply or a lack of breastfeeding support at home or work.

Post Reports: The baby formula crisis

Black infants are less likely to ever be breastfed than Hispanic and White infants, while more than 90 percent of Asian babies are breastfed. Infants who receive WIC are also less likely to be breastfed than infants who are ineligible for the program.

Lockwood, in Philadelphia, said the women she sees often face substantial barriers to breastfeeding. Many new mothers’ work schedules involve spending hours away from their infants, often without the privacy to pump or a place to refrigerate their milk. Now they are also facing ill-informed criticism for not breastfeeding, she said.

“Unfortunately, some people don’t understand that women can’t just start breastfeeding months later,” Lockwood said.

The Agriculture Department last week echoed President Biden’s message of support for low-income families, urging more states to take advantage of the waivers the USDA has been offering in the WIC program, allowing participants access to a broader range of sizes and brands of formula. The FDA said this week it would approve new types of formula from foreign and domestic sources on a case-by-case basis.

“We’re acutely aware that the ongoing recall has left many parents and caregivers concerned about access to formula and how they will feed their babies,” Agriculture Secretary Tom Vilsack said in a statement.

Help can’t come quickly enough for Crystal Sandoval of Houston. Son Armando has been a fussy and unpredictable eater, prone to spitting up the precious formula she provides.

“I would drive from WIC store to WIC store,” Sandoval said, visiting Walmarts and Targets in hopes of keeping a few extra bottles on her shelves. She refrigerates half-consumed bottles, determined never to waste a drop. And whenever she runs low, “The scare starts to set in,” Sandoval said. “I never really know if he will end up on the last can.”

Maria L. Marquez, a pediatrician and administrative medical director at Mary’s Center, a community health center that serves nearly 60,000 people in and around Washington, said she is focused on educating parents, telling them to call ahead before spending time and gasoline on hopeless trips to pharmacies and advising on substitutions.

“It’s a lot of extra work,” Marquez said, “guiding them through when it’s okay to take the formula that is available.”

Kate Breznak, nutritionist in the neonatal intensive care unit at St. Christopher’s Hospital for Children, a safety-net facility in North Philadelphia, said she has maintained adequate supplies for inpatients, though she sometimes had to switch infants from one formula to another during their hospital stay to make sure they get the higher levels of calcium, phosphorus, protein and calories that preemie formula provides. These days, once the babies leave the NICU, her search continues on behalf of new parents who may not be so digitally savvy.

“I try to Google and find places where Mom might be able to get formula,” Breznak said.

Some desperate parents are trying anything they can to feed their infants. Colette Acker, who runs the nonprofit Breastfeeding Resource Center in Abington, Pa, said she has recently helped a mother try re-lactation, an arduous effort to stimulate her breasts to produce milk again.

Another client, Michelle Galanek, developed mastitis, a breast infection, followed by an abscess shortly after her second child was born.

When Galanek had to supplement her reduced milk supply with formula, the baby developed a rash, indicating a cow’s milk allergy that sent them to urgent care. Her husband, with their 2-year-old in tow, went in search of hypoallergenic formula, which they eventually received from a pediatrician.

Since then, Galanek has relied on online searches and a network of friends and family members to scan shelves and find the type of Enfamil her baby needs, while she keeps working with Acker to boost the breast milk production.

“It’s funny — if it wasn’t for what is going on with formula I would probably stop [breastfeeding],” said Galanek, describing a painful and time-consuming process. “But with not knowing how to find formula or if it is available consistently, it’s the lesser of two evils.”

Parents’ individual efforts to find formula are multiplied many times over in a huge institution like Hopkins. The cost in extra hours and having to pay retail prices to purchase off-contract products will be enormous, Hays said. What’s more, some parents are “rolling the dice again,” she said, having to switch a second time as alternatives are not consistently available.

“I really didn’t think anything like this could happen in the U.S.,” Hays said. “That’s shocking to me.”

Laura Reiley contributed to this report.