2026/05/05 by Luis Seoane Estruel, Tatiana Andreyeva · 1 voice
Health Professions · Medicine · #Breastfeeding Practices and Influences #Consumer Attitudes and Food Labeling #Food Security and Health in Diverse Populations
paper · doi:10.1542/peds.2025-075813
openalex publication_date 2026/05/05 · openalex created_date 2026/05/06 · openalex updated_date 2026/06/26
Breastmilk is the ideal source of nutrition for most infants, with health benefits for mothers and children.1 Despite recent improvements, breastfeeding initiation disparities persist by income, education, and race and ethnicity.2 In 2022, a major recall and the shutdown of Abbott Nutrition’s Michigan facility triggered severe nationwide infant formula shortages.3 In response, breastfeeding initiation increased by nearly 2 percentage points (pp), with larger gains among groups historically reliant on formula.4 As formula supplies normalized in 2023 and 2024, this study examines whether breastfeeding initiation gains persisted and among which population groups.We analyzed restricted national birth certificate data from 2016 to 2024, covering 47 states and the District of Columbia (n = 26 789 278) (Supplementary Table 1). Bayesian structural time-series models estimated changes in breastfeeding initiation trends, which were defined as any breastfeeding exposure, and linear probability models tested for population group differences. We defined a control period (January 2016–January 2022), a shortage period following Abbott Nutrition’s recall and plant shutdown (February–December 2022), and a post-shortage period (January 2023–December 2024) marked by restoration of aggregate US formula availability, as reflected in national in-stock rates returning to pre-crisis levels and recovery in overall sales volume.3 The data set and methods are described elsewhere.4 The University of Connecticut Institutional Review Board deemed the study exempt (protocol #23-274-910).In the post-shortage period (January 2023–December 2024), breastfeeding initiation remained above pre-shortage levels, averaging 85.43% (Figure 1). Previous analyses of the 2022 shortage estimated an adjusted increase of 1.96 pp (95% credible interval [CrI] 1.68–2.23).4 In 2023 and 2024, initiation rates remained 1.25 pp above pre-shortage levels (95% CrI 0.58–1.77), with similar annual increases in 2023 (1.19 pp; 95% CrI 0.64–1.65) and 2024 (1.31 pp; 95% CrI 0.49–1.93) (Figure 1).During the shortage, breastfeeding initiation gains were largest among groups with historically lower breastfeeding rates.4 In 2023 and 2024, larger gains persisted among mothers with less than a high school diploma, Medicaid coverage, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation, whereas maternal race/ethnicity and county population size were no longer associated with additional changes in initiation. Subgroup estimates are presented only for maternal characteristics that differed significantly from the reference group, defined as first-time non-Hispanic white mothers with a college education, living in counties with more than 100 000 residents, covered by private insurance, and not participating in WIC. Among first-time mothers meeting our definition of socioeconomic disadvantage, defined as less than a high school diploma, Medicaid coverage, and WIC participation, breastfeeding initiation increased by 4.22 pp (95% CI 3.43–5.02). This increase is similar in magnitude to that observed during the 2022 shortage for the same group (4.38 pp; 95% CI 3.75–5.01). No significant changes were observed for the reference group (Figure 2).The effects of the 2022 infant formula shortage on breastfeeding initiation have persisted beyond the immediate disruption, particularly among less advantaged subpopulations.Several mechanisms may explain these patterns. Peer effects may have played a role because increased exposure to breastfeeding during the shortage could have reduced stigma and shifted social norms.5,6 Heightened risk salience following the recall may have increased perceptions of breastfeeding as a safer option.7Economic and policy factors8 may have reinforced these behavioral changes. Baby food and formula prices outpaced overall inflation following the shortage,9 potentially strengthening incentives to breastfeed. Although paid family leave was implemented during our study period in several states, post-shortage gains were larger when those states were excluded (1.61 vs 1.25 pp), providing no support for this mechanism. Breastfeeding initiation rates remained stable at 85.4% from January 2023 to December 2024, suggesting no detectable increase after the implementation of the Providing Urgent Maternal Protections for Nursing Mothers Act and the Pregnant Workers Fairness Act; however, the absence of maternal employment information limits our ability to assess their effects. Stronger gains among WIC recipients may reflect June 2024 revisions to the WIC food packages that introduced a partial breastfeeding option from birth, either encouraging partial breastfeeding or increasing participation among women intending to partially breastfeed.This study has several limitations. Breastfeeding initiation data were unavailable for California, Michigan, and Utah; potential confounding from contemporaneous events cannot be ruled out; and universal data on breastfeeding continuation, exclusivity, and harmful infant feeding practices are still needed to assess long-term health effects.Overall, the findings indicate that the 2022 infant formula shortage had lasting effects on breastfeeding initiation in 2023 and 2024, with the most durable gains among less advantaged mothers. At the same time, the partial decline in initiation rates underscores the persistence of structural barriers, including aggressive formula marketing; during the recall, the affected formula products could not be marketed, but such marketing has since resumed, alongside inadequate paid family leave, and limited workplace support for lactation, all of which continue to contribute to disparities in breastfeeding.10 Policy attention remains warranted to reduce breastfeeding barriers and better understand mechanisms that sustained initiation gains among less advantaged mothers.