Characterizing Physician and WIC Staff Experiences During the 2022 Infant Formula Shortage in Oregon

Introduction

A national infant formula shortage began in the United States in February 2022. This shortage was the culmination of several factors, including a recall and halt of supply production by Abbott Nutrition that exacerbated pandemic-related supply chain issues, and resulted in access challenges for families across the country. ¹ Millions of U.S. families rely on formula to feed their infants, toddlers, and children with complex medical needs. ² In 2018, Women, Infants, and Children (WIC) infants consumed approximately 56% of formula in the United States. ³ Recent data show that an estimated 39% of infants in the country were served by the Special Supplemental Nutrition Program for WIC in 2022. ⁴ Both medical providers and WIC served as resource points for families experiencing the effects of the shortage. The roles of WIC and pediatricians and their interaction during this stressful time have not been examined; therefore, this study sought to address that gap in knowledge.

Methods

This study was completed with providers working in Oregon. The Institutional Review Board (IRB) approval for survey distribution and data analysis was granted from both affiliated institutions. Surveys were developed for physicians caring for infants (pediatricians and family practitioners) and WIC staff to examine shortage-related perceptions, impacts on families, and interprofessional communications. Cognitive interviews were conducted with a group of physicians to refine the survey questions. Survey participants were recruited via email listservs and newsletters to complete the survey online. Responses were anonymous and stored on the Qualtrics XM platform.

Qualitative analysis of the responses was performed using inductive methods. Three independent investigators analyzed de-identified survey responses. Women, Infants, and Children staff and physician responses were reviewed independently initially to identify repeating concepts. These concepts were shared between investigators and grouped into themes and subthemes. Demonstrative quotes were identified for each subtheme.

Results

Our survey received 17 physician responses and 35 WIC staff responses. Physician responses were captured from 10 Oregon counties, of which 50% are designated as rural, and various practice sizes including small clinics (4-5 physicians), an academic center, and large medical groups (100+ physicians). Women, Infants, and Children staff responses represented 18 Oregon counties, of which 70% are designated as rural (Figure 1). Among WIC staff respondents, most were certifiers, coordinators, or dietitians.

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Figure 1.

Practice locations of physician and WIC respondents demonstrating representation of both urban and rural practitioners.

On review of responses, 5 themes were identified, with corresponding sub-themes to capture further nuance: heightened emotions (anxiety, frustration), access (WIC emergency expansion, challenges for rural/frontier populations, challenges for specialty formula), response/actions (flexibility, reassurance, questions, workload), communication (WIC-physician, with families, information sources used by families, updates about shortage), and alternative feeding strategies (developmentally appropriate, developmentally inappropriate, breastfeeding) (Table 1). There were similar themes and subthemes between the physicians and WIC staff, demonstrated by representative quotes for each. However, there were notable differences in the impact of the shortage on workload and communication between the 2 groups. Women, Infants, and Children staff experienced a greatly increased workload given that most of their families were impacted by the formula shortage, while physicians shared the increased workload across multidisciplinary staff. In most Oregon counties, there was unidirectional communication about the shortage from WIC to patients and medical groups. While most WIC staff reported that their office had put out formal communications to their families about the formula shortage, less than a quarter of physicians reported that their office had put out such communications.

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Table 1.

Summarization and comparison of themes and subthemes found in WIC staff and physician survey responses.

Theme	Definition	Sub-theme	Representative quote—WIC	Representative quote—physician
Heightened emotions	Emotional responses to limited formula access.	Anxiety	“It cause[d] lots of stress and anxiety to families as they feared how they would feed their baby.”	“. . . the formula shortage brought a lot of anxiety to families with both a medical need for formula/specialty formula or choosing to formula feed their infants”
		Frustration	(1) “People are struggling to get to another town for their formula, trying other formulas just to get by. Families are frustrated, and it’s still out of our control.”(2) “Clients have been very frustrated with all the changes and confusion and often take this out on staff.”	“The shortage made families anxious, worried and frustrated.”
Access	Changes in how formula was accessed during the shortage and challenges to access.	WIC emergency expansion	“Review and revise state and national exclusive bid process for formulas. State was responsive to add different formulas and container sizes.”	“WIC expanding coverage was the best asset for making sure that infants could get some kind of formula.”
		Challenges for rural/frontier	“Our rural town in Oregon is still struggling with getting formula back on the shelves! Why is this, when a larger town a few short 30 miles away the stores are stocked. People are struggling to get to another town for their formula, trying other formulas just to get by. Families are frustrated, and it’s still out of our control.”	(1) “Why doesn’t Amazon or Walmart accept WIC for mail orders? For rural and frontier counties this would be a life saver.” (2) “The shortage has impacted families in that certain brands have been impossible to get within our county and families have had to travel extensive distances to access the type of formula their baby requires.”
		Challenges for specialty formula	“Infants with sensitive stomachs were impacted more because they required specific formula and switching between formulas had more of a negative effect on their digestion.”	“Children with more complex medical conditions were more impacted, as were kids who required specialized formulas. Some infants truly cannot tolerate most formulas, and those were especially difficult cases during the shortage.”
Response	Reaction to the formula shortage: public messaging, workload	Flexibility	“Looking at formula brand alternatives that are equitable to what they usually use, looking at other store options out of the local area when possible, increasing breastfeeding (if parent is using both formula and breastmilk) and working on milk production”	“Fed baby is better than not fed baby. Work with WIC and use whichever covered formula is available. When availability gets back to normal, go back to your covered formula of choice.”
		Reassurance	“To assure them that we would find a formula that would work for their infant”	“I tried to reassure as best as possible that for most babies having to make a change due to unavailability of their preferred formula was likely going to be okay.”
		Questions	“Can we get anything other than Similac formula? The trust was really low. How do I find formula? Can I give my baby anything else besides infant formula?”	“Are all formulas interchangeable?”
		Workload	(1) “It has made the job harder and much more time consuming. Countless hours have been spent on the phone and texting clients with questions, concerns, changes.” (2) “More interactions with clients to educate, alleviate fears, correct misinformation, find product etc. A lot of realigning how time spent to accommodate needs. Still fielding questions about formula choices and why changes.”	(1) “I relied on my staff a LOT to make calls and help families find formula, so this definitely increased their workload. I also spent a good deal of time during appointments helping families figure out substitute formulas, especially formulas covered by WIC.” (2) “Many came for in person help, straining our capacity to see sick kids and wellness checks.”
Communication	References to communication, either between WIC and providers, WIC and families, families and providers, or other	WIC-physician	(1) “We had a letter that was sent out to all of our providers that let them know the measures WIC was taking to get safe formulas available for our families, and the list of formula that were approved by WIC” vs (2) “Little to none except to correct MDFs (medical documentation forms). Unfortunately did not have time.”	(1) “No direct communication, told parents to contact them, tried calling WIC” vs . (2) “Our county WIC program is embedded in our Community Health Center, so we are in daily communication.”
		With families	“I think most families received the most information from WIC as they would often call us first when unable to find their formula.”	“Phone, MyChart and visits”
		Info sources used by families	(1) “Social media, word of mouth from friends, store staff when they find the shelves empty.” (2) “Text/call, Social Media posts, and mailed information to the families specifically receiving formula”	(1) “Social media or friends/family” (2) “Physician office, news, WIC”
		Updates about shortage	“Sent hardcopies by mail, and sent emails to all the medical offices about what WIC could provide during the shortage.”	(1) “AAP” (2) “WIC”
Alternative feeding strategies	Mention of switching between formulas or other feeding options (eg, breastfeeding, cows milk, etc).	Developmentally appropriate switch	“Looking at formula brand alternatives that are equitable to what they usually use, looking at other store options out of the local area when possible, increasing breastfeeding (if parent is using both formula and breastmilk) and working on milk production”	“In children 10 months and older who did well with solids, I would have families switch to entirely solids, although I did not recommend starting milk earlier than 12 months.”
		Developmentally inappropriate switch	“I heard from many parents trying to make their own infant formulas, diluting formula, and switching to alternative milks or cow’s milk before 12 months”	“Diluting formula happened with a couple of parents. As did early start for whole cow’s milk.”
		Breastfeeding	“I always advocate for breastfeeding/milk but I find that slightly more moms bring up the fact about ‘giving breastfeeding more of a try’ because of the uncertainty of formula in the future. Moms are worried about contamination or shortages again in the future so are more invested in breastfeeding/milk their baby.”	(1) “Most of the newborns in my practice breastfeed, so it was a small # of patients impacted.”(2) “It has further resolved my commitment to breastfeeding promotion, education and support.”

Discussion

Our study demonstrates the effects of the national infant formula shortage on families and reveals some of the differential impacts felt by WIC and medical providers in supporting families. The disproportional burden of information sharing from WIC highlights the lack of robust communication pathways between WIC and clinicians. The American Academy of Pediatrics asserts that pediatricians should work collaboratively with state and local WIC agencies. ⁵ The Accreditation Council for Graduate Medical Education states that pediatrics residents must demonstrate an understanding of the complexity of health systems and be able to coordinate care “across the healthcare continuum.” ⁶ To improve collaboration with WIC and facilitate coordinated care, the ACGME could incorporate a required competency regarding WIC services by the conclusion of a pediatrics residency. Recent studies have highlighted how WIC-enrolled families may have used more effective strategies in navigating the shortage and that these individuals benefited from the flexible strategies employed by WIC, strategies which could have been shared with non-WIC families with improved physician-WIC communication.^7,8 Strategies such as increasing physician competency around WIC, co-locating WIC and medical offices, and aligning messaging between the 2 spheres may help to reduce the anxiety and frustration felt by families, WIC staff, and medical providers should similar crises emerge in the future. Furthermore, improved communication and cooperation between WIC and medical providers would likely facilitate streamlined coordination of care even outside times of crisis and be beneficial to daily clinical care.

Author Contributions

SD: Contributed to conceptualizing and designing the study, collecting data, carrying out the analyses, drafting the initial manuscript, and critically reviewing and revising the manuscript.

MA: Contributed to conceptualizing and designing the study, collecting data, carrying out the analyses, drafting the initial manuscript, and critically reviewing and revising the manuscript.

JR: Contributed to conceptualizing and designing the study, collecting data, carrying out the analyses, drafting the initial manuscript, and critically reviewing and revising the manuscript.

AF: Contributed to conceptualizing and designing the study, collecting data, carrying out the analyses, drafting the initial manuscript, and critically reviewing and revising the manuscript.

EL: Contributed to critically reviewed and revised the manuscript and helped develop figures for the manuscript.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.