A straightforward solution to the formula crisis

Adopt Canadian guidelines for older babies

The FDA and Abbott Laboratories reached a deal yesterday to reopen the shuttered baby formula factory whose lost production has been the proximate cause of the formula shortage that’s been causing enormous distress to America’s parents in recent weeks. Unfortunately, the timetable they worked out here still means we’ll be about two weeks from reopening and that “could translate to more formula on shelves in six to eight weeks.”

That’s good news, though in baby time 6-8 weeks is like a lifetime so for the short-term we still need to wrestle with the crisis. It directly implicates a number of big-picture failings related to trade policy and the functioning of our regulatory agencies, and I think these are policy discussions we need to have.

But people tend to lead themselves astray with a desire to drag every news event back to their longstanding hangups. If we want to actually address the short-term crisis in a specific way, it’s good not just to look at deep underlying causes but at more superficial issues. And I believe there is actually a very superficial solution to this crisis: have many American kids who are nine months old and who are not being breastfed start drinking cow’s or goat’s¹ milk instead of formula, complemented with iron-rich baby foods.

Now to be clear, I am not a medical doctor and I do not know the specific circumstances of your family. No doubt there are particular children — especially preterm babies and babies who already have a documented history of iron deficiency — for whom continuing with official formula is vital. There are also picky kids who may have trouble with anything other than a particular type of formula. I am not saying that it is easy or appropriate in all cases for families to make an early transition off formula.

What I am saying is that precisely because formula is so important for many families and because supplies are so limited right now, one of the best and most constructive things we could do is switch the kids for whom it is safe a little bit sooner than we normally would — bringing American pediatric practice into line with the recommendations used by our neighbors up north in Canada.

WHO guidelines on infant feeding in an emergency

Cow’s milk and human milk are different in a number of ways, but the most important one is the iron content. If you just feed a human infant cow’s milk, she will not get enough iron and very bad things will happen.

Because human babies are also tiny, pediatricians really want to make sure that they fill their tiny bellies up with the nutrients they need — nutrients that are in human breastmilk and that are required by the FDA to be included in infant formula. They tell you very sternly not to give a kid under one-year-old any cow’s milk not because lightning bolts will come down from the sky and strike your baby down, but because they don’t want you to crowd out nutritionally-complete formula. This is the same reason why they are currently enjoining people not to try stretching their formula supply with water.

But the presumption in all of this is that formula is readily available. The WIC program has tons of problems (including program designs that created oligopolistic features in the formula market), but one of its virtues is that it ensures even the poorest families can have a steady supply of infant formula. But when you see parenting documents warning that giving your kid cow’s milk will lead to nutritional deficiencies, the assumption is that there is formula available for the cow’s milk to crowd out. Starving a child does not prevent iron deficiency.

This comes up in practice during international humanitarian emergencies.

The World Health Organization’s pamphlet “Infant Feeding in Emergencies” is overwhelmingly focused on breastfeeding advice. But it also contains the advice that in an extreme emergency, you can mix 1/3 of a cup of boiled (for sterilization purposes) water with 2/3 of a cup of boiled (again for sterilization purposes) cow’s milk plus one level teaspoon of sugar.

They also state that in this kind of emergency you may want to introduce solid foods before six months old.

This is fairly extreme, and the good news about the United States of America is that we don’t need to do it. Even with the one large Abbott plant offline, we are producing plenty of formula for America’s kids who are that young.

But these emergency guidelines are a reminder that our typical child development guidelines — no solid food before six months, no cow’s milk before 12 months — are meant as easy-to-remember rules for normal times. A child who is 178 days old and one who is 187 days are not radically different from the standpoint of nutritional needs just in virtue of being on opposite sides of the six-month line. And the same is true of the one-year line. To ensure an adequate supply of formula for the kids who really need it, we should encourage kids over nine months old who are already eating some solid foods to switch to animal milk and make sure they are eating iron-rich foods.

Worthwhile Canadian Initiative

The WHO emergency guidance is for extreme scenarios.

But consider Health Canada’s official nutrition guidelines for infants, which says:

If you are making the transition to cow milk as your child’s main milk source, wait until your baby is between 9 and 12 months old. Start with homogenized cow milk (3.25% M.F.). Do not offer skim or partly skimmed milk (1% or 2% M.F.) before 2 years of age."

Is human biology radically different in Canada? Obviously not. Canadian officials and American officials have, for whatever reason, decided on slightly different rules of thumb. In America they say don’t introduce cow’s milk until the kid is 12 months old, whereas in Canada they give you a 9-12 month age range.

Here’s how the Province of Alberta’s official health guidelines explain it:

When your baby is 9 to 12 months old and eating a variety of iron-rich foods, he or she can start to drink pasteurized whole-fat cow's milk. Limit cow's milk to no more than 3 cups (750 mL) per day for children 9 to 24 months old. If you are not breastfeeding and do not want to give your child cow's milk, give your child soy infant formula until your child is 2 years of age. After age 2, you can serve low-fat milk or fortified alternatives.

Or consider the views of the Canadian Paediatric Society, which says, “If breastfeeding is not an option, use a store-bought iron-fortified infant formula for the first 9 to 12 months.”

Why do the guidelines differ so much north and south of the border? Gerald Butts, who used to be Justin Trudeau’s top political advisor, alleges that the American government is captured by nefarious baby formula interests with regard to international trade policy. Perhaps the same dynamic is at work in the pediatric guidelines. What I’ve learned over the past couple of years of Covid reporting, though, is that American medical authorities have a strong preference for unambiguous rules over accurate information.

In many cases, I find this to be annoying and wrongheaded. I will say that as a parent, in this specific case, I do see where the American doctors are coming from. The US rule “formula until one and then switch” is a lot clearer and more psychologically reassuring than “do it sometime during this three-month span.” That said, it is clearer and more reassuring in a world where infant formula is widely available in stores. Since infant formula is currently not widely available in stores, it seems like switching to the Canadian guideline — “animal milk is fine starting at nine months, the important thing is to start eating iron-rich solids” — would be a lot more helpful and reassuring.

A rapid solution to the crisis

Kids aged between 9 and 12 months old represent roughly one-quarter of America’s formula-eating population. And they constitute over 25 percent of actual formula consumption because they are physically larger² than tiny babies and because a larger share of newborns are breastfed.

Under the current circumstances, I think advising parents of older babies that they can switch to animal milk would both give them peace of mind and also (more importantly) help resolve the underlying crisis. Consumption would rapidly fall by 10-30 percent, which would allow shelves to be restocked. That would reduce the incentive of parents with time and money to burn to stockpile or hoard formula, which would further alleviate shortages.

Note here that I am not a crazy person, the American Academy of Pediatrics has even added a little infobox to their document about why you can’t give babies cow milk that concedes you actually can give them cow milk.

In other words, the American and Canadian pediatricians do not seem to actually disagree about the underlying medical science. They simply disagree about which guideline it is most socially constructive. Reasonable people can, I think, disagree about who is right during ordinary times.

But amidst an acute national shortage of baby formula, I don’t think this is a close call. The message that cow’s milk is okay for older babies shouldn’t be lurking in a weird footnote on an American Academy of Pediatrics website; it should be a headline in all parenting-focused media. The head of the AAP should be on the Today Show talking about this and they should be flooding the zone of local television news stations to push out this message.³

Now more than ever

In terms of bigger picture policy issues, it’s worth noting that the extreme vulnerability of the American formula market to the shutdown of one plant reveals some very bad underlying trade policy.

Allowing more formula imports can only alleviate, not solve, the crisis and I think would have less short-term impact than my solution. But it’s an important reminder that proponents of economic nationalism have often made dubious arguments about less trade improving our economic resilience. It’s true that heavy reliance on imports from a country we’re likely to have foreign policy conflicts with can be bad. But in general, global trade creates more resilience in supply chains and more robustness to particular disruptions.

My larger “now more than ever” hangup, though, is that we once again need a public health community that is more nimble, more operationally-minded, more open to cost-benefit analysis, and less invested in the role of armchair social psychologist.

Parents of young kids are tired and stressed out and it really is helpful to give them clear, unambiguous guidelines rather than long lectures about child development. But by the same token, having tired and stressed-out parents spend tons of extra time driving around town trying to find a store that has formula in stock is really bad. It’s bad for parents’ fatigue and stress levels. It generates traffic congestion and pollution externalities. People (including babies brought along for the ride) will die in car crashes. And that’s all assuming nobody actually goes malnourished.

The public health authorities themselves should remember that the actual medical science is more nuanced than their guidelines. The day that the plant in Sturgis was shut down would have been a good time to kick the tires on everything formula-related and start easing off the twelve-month rule as a good alternative to creating a national panic. Or if they thought was a bad option, they should have come up with an alternate means of increasing formula supply. I take everyone at their word, though, that the latter is difficult to do on short notice. It’s really easy to understand why the people in charge would be reluctant to switch to the Canadian guidelines and it’s also easy to understand why they want to be cautious with regard to the plant they shut down. But in the absence of a Strategic Formula Reserve (which we should maybe have), you can’t just kneecap supply of a vital product without a plan.

Of the available options, disseminating information about the most iron-rich purées while encouraging parents of older babies to switch to animal milk seems by far the best.

1. Goat milk and cow milk have different nutritional properties with some sources seeming to indicate that goat milk is better for kids (because it may increase the bioavailability of iron), while others indicate that it’s worse (because there are fewer folates). I was hoping to come to a firmer conclusion about this but there doesn’t seem to be direct experimental evidence.

2. Again, though, the existing medical wisdom is that older babies’ formula needs vary based on their solid food intake.

3. Obviously the other thing that works here is if more people breastfeed, but the level of pro-breastfeeding propaganda from the medical community is at such a constant fever pitch that I don’t think there’s any way for them to amp this up. For the record, in normal times the breastfeeding hype is massively overstated relative to the evidence, but in the middle of a national formula shortage the convenience upside of the bottle is reduced so the calculus changes.