For months, Chloe Banks has struggled to do something that used to be straightforward - buy baby formula.

CHLOE BANKS: It's incredibly stressful. It's endless, where you don't know where, you know, your next can of formula's going to come from.

CHANG: Across the country, formula is in short supply, especially specialized formula, like the kind her 11-month-old son Teddy needs. He has a milk and soy protein allergy.

BANKS: Everything that we want to do is to take the best care of our children. And we're between a rock and a hard place because it's not like we have other sources.

CHANG: The CDC says three-quarters of babies depend on formula for at least some of their food by the time they're 6 months old. So we're talking about millions of families.

MIKI FARRIS: We're not panicking, but we're nervous that if it goes on longer than 10 weeks, we'll have a problem, too.

CHANG: That's Miki Farris, the executive director of Infant Crisis Services in Oklahoma City. They serve mostly lower-income families who need baby food, diapers or formula. She says clients are coming in droves right now. And just like her families, she's running into trouble buying formula.

FARRIS: We buy from the distributor, and they don't have any more right now.

CHANG: The consequences of all this for parents who can't find the formula they need are huge, says pediatric gastroenterologist Dr. Benjamin Gold.

BENJAMIN GOLD: It is a real crisis, and in many cases potentially life-threatening.

CHANG: The FDA this week announced a strategy to get more formula on the shelves, but it'll take weeks, at least, before parents see relief at the grocery store. In the meantime, Chloe Banks and her husband will continue to spend hours looking for formula that works for their son.

BANKS: And then you have, of course, in the back of your mind, there are other families who are doing the same thing. Are you taking this from a child who needs it as well? Try not to be too greedy, but then if you're not greedy, you don't have enough for your child. It's just a really vicious cycle.

CHANG: And some experts say this crisis is compounded by a system that makes breastfeeding a privilege.

ALISON STUEBE: Many women in America can't breastfeed because of a man-made crisis. Only 1 out of 4 folks have access to paid leave. And it's really hard to breastfeed a baby if you're not with your child.

CHANG: CONSIDER THIS - a baby formula shortage is exposing how a perfect storm of supply chain tangles, federal policy and structural inequity threatens parents' ability to do their most important job - feed their children.

CHANG: From NPR, I'm Ailsa Chang. It's Wednesday, May 18.

It's CONSIDER THIS FROM NPR. So the spark that ignited this whole crisis was a safety recall.

UNIDENTIFIED PERSON #1: Abbott Nutrition is expanding its recall of baby formula.

CHANG: Several babies got very sick, and two died after being fed formula that was manufactured at a plant in Michigan run by Abbott Laboratories.

UNIDENTIFIED PERSON #2: It involves powdered infant formula sold under the name Similac, EleCare and Alimentum.

CHANG: That plant reportedly produced as much as one-fifth of all the infant formula in the country, and it shut down in February.

CHANG: By the beginning of May, measures of available formula on store shelves were looking pretty grim. The FDA cited a 20% out-of-stock rate. A retail analytics firm called Datasembly estimated that number to be 43%. Compare that to the first half of 2021 when the rate peaked at just 8%.

This week, the FDA announced a plan to reopen that formula plant in Michigan, one of a series of emergency measures designed to relieve this crunch. Here's Frank Yanez, the FDA's deputy commissioner for food policy and response.

FRANK YIANNAS: We're focused on getting as much product as possible on store shelves, and we won't rest until the infant formula market gets back to normal.

CHANG: But how did we get to such a precarious position in the first place? My colleague Mary Louise Kelly spoke to NPR chief economics correspondent Scott Horsley about that.

MARY LOUISE KELLY, BYLINE: The FDA has now cleared the way for that plant to reopen. There will be new safety measures. But it's kind of mind-blowing how a single plant can have such a huge role to play in feeding the nation's hungry babies.

SCOTT HORSLEY, BYLINE: It really is. And this episode has highlighted just how concentrated the baby formula industry is. Abbott Laboratories is one of just four companies that control about 90% of the U.S. formula market. And in some ways, the federal government has contributed to that.

HORSLEY: One example is the Agriculture Department's WIC program, which provides low-income families with baby formula and other food. The way it works is each state signs an exclusive contract with one of the formula manufacturers. So the government gets a big price break, and in exchange, the company gets a captive market. And because WIC is such a big customer, it has an outsize impact on the whole formula industry. You know, whichever company has the WIC contract in a state tends to get the most shelf space at the grocery store and the most recommendations from pediatricians. Claire Kelloway, who's with the Open Markets Institute, says that really crowds out the competition and helps the big players get even bigger.

CLAIRE KELLOWAY: Because the WIC program is such a large purchaser - it buys about half of the formula on the market - once a company has an exclusive deal to service a state, competitors don't have a financial incentive to compete in that state.

HORSLEY: Abbott, the company with the shuttered plant, has the WIC monopoly in about two-thirds of all the states. And the administration has asked states to temporarily relax those monopoly rules so that WIC recipients can use any brand of formula they can find.

KELLY: Another piece of this is the FDA is also opening the door to importing more formula from other countries. How is that going to change things?

HORSLEY: Ordinarily, the U.S. brings in almost no formula from other countries, and that's because there are steep taxes and regulatory barriers that make it very difficult to bring formula in. Those barriers are ostensibly designed to protect the safety of infants, but they also protect the domestic suppliers.

And this illustrates a larger point. You know, some people have argued the best way to bulletproof supply chains is to bring manufacturing inside the United States. But we've basically tried that here with baby formula. And as Mary Lovely at the Peterson Institute for International Economics says, you can see the results.

MARY LOVELY: This shows that just having one or two, you know, factories in the U.S. - or suppliers in the U.S. - is not the way to be resilient. In fact, it's a recipe for being vulnerable.

HORSLEY: Lovely says what you really want is a bunch of suppliers, so don't put all your eggs in one basket - or all your baby formula in one bottle.

KELLY: Meanwhile, if you have a baby and you're worried - how am I going to feed this baby? - this is really urgent. How soon will these moves make a difference?

HORSLEY: Not overnight - authorities say it's going to take weeks to restart production at the Abbott plant and weeks to bring imported formula into the U.S. In the meantime, the administration is working to get existing formula where it's needed most. You know, these emergency fixes are designed to be temporary in nature, but FDA commissioner Robert Califf says longer-term concentration in the formula industry is also worth a look.

ROBERT CALIFF: The question of whether we need more diversity in terms of the overall supply is one that I think will be much discussed and needs to be considered in light of the levers we have to make that happen.

HORSLEY: And the government does have some important levers as both a regulator and a customer.

CHANG: That was NPR chief economics correspondent Scott Horsley talking to my colleague Mary Louise Kelly.

CHANG: Until the FDA's emergency measures start chipping away at this formula shortage, many parents still will face a daily challenge to feed their babies. That was already a stressful issue for a lot of mothers. The decision about whether to breastfeed or use formula or use both can be a really complicated one, often loaded with shame or guilt.

Dr. Alison Stuebe works with parents in this situation as an OB-GYN and lactation specialist at UNC Health. And she says there's a lot more to understand about why, for so many parents, feeding their babies with formula is simply necessary. And she says, people on social media are misguided when they suggest right now that parents should just try breastfeeding as a solution to the formula shortage.

STUEBE: Many women in America can't breastfeed because of a man-made crisis, and that's that we're the only, quote-unquote, "civilized country" without paid parental leave. Only 1 out of 4 folks have access to paid leave. And it's really hard to breastfeed a baby if you're not with your child.

And then, in addition to that, not every single person has body parts that work 100% of the time. We don't say to people with Type 1 diabetes, if you just squeeze your pancreas a little harder, you won't need that insulin; these medicines are silly. And so there's this assumption that if you just power through, you can make this work. And that's simply false.

CHANG: OK. So a lot of reasons out there why people choose not to breastfeed. And yet, there is a lot of pressure on new mothers to breastfeed. Like, organizations such as the American Academy for Pediatrics say that babies should be breastfed until they are at least a year old. I'm just curious, like, what are you hearing now from parents you work with about how this particular baby formula shortage crisis is exacerbating that pressure to breastfeed?

STUEBE: So I want to start with, weirdly, something somewhat positive about all of this. I was chatting today with some of my colleagues in our lactation office, and one of the women said - you know, she's on several a mom group. She herself has a young baby. And she said that people who are breastfeeding are saying, well, I'm going to pump so I can donate my milk to other moms because this is a crisis. And women who have stopped or cut down on their breastfeeding are working on bringing back up their milk supply and then seeing how they can help others.

And she said that at least in the community here, it's not a question of, well, you should have breastfed and you wouldn't have this problem, but babies need food - what can I do? And how can I help? So I do think we're seeing moms respond to this crisis by banding together, as moms have for all of human history, to help each other out so their babies can eat.

What we really need, though, is for our society and our systems to band together so that a woman who wants to breastfeed can breastfeed because, right now, if you are privileged and you have access to paid leave and you have access to support that you can spend your own money on, it's pretty possible to breastfeed. But if you don't have those things, it's really not a right right now, it's a privilege. And when we make a medical recommendation to do something but that's impossible, we are only widening the gap between those who have privilege and resources and those who do not. And I think that's what's really being exposed so tragically right now.

CHANG: Well, at the moment, the shortage is still going on. So what immediate recommendations do you have for families who are struggling to find formula for their babies at this moment?

STUEBE: So I think that one of the key resources is the WIC program, which provides - pays for about half the formula in the country. Most formula is paid for by this federal program for folks living in poverty. And so folks should reach out to their local WIC office as a resource to find out how they can find formula in their communities.

I think for women who are breastfeeding or have breastfed, continuing to breastfeed and taking steps to try to increase the proportion of feeds that are breast milk makes sense at this moment in time simply because we know that there's a shortage.

But it's really, really important that families not dilute powdered formula because the concentration of water to formula that's in those instructions is what's safe and healthy for babies. And when you dilute that, it's actually very dangerous for the child. And so folks need to be really careful not to either dilute formula or to sort of make something ad hoc because cow's milk by itself is really potentially harmful to infants under the age of 1.

CHANG: So for those parents out there who may have been made to feel guilty or ashamed because they have chosen not to breastfeed their babies during this time and then were hit by this baby formula shortage, what message do you have to them if they're wrestling with feelings of guilt or shame right now?

STUEBE: Mothers want the best for their babies. Mothers love their babies. Mothers want to do the things they can to take care of them. And each mother is uniquely qualified to understand in the context of her life and her challenges and her lived experience what is the thing that is going to work to feed her baby. And the context has changed, right?

You know, six months ago, it was very reasonable to say, I'm going to formula feed, and I'm going to buy formula because it was available. And I would encourage people to say, I made the best decision I could with the information in front of me. And now this is hard, and I'm going to reach out to my community and resources to get through it. But I'm going to recognize that I made the best decision I could with what I knew at the time.

CHANG: That was Dr. Alison Stuebe, a professor at the University of North Carolina's Gillings School of Public Health. She's also an OB-GYN and medical director of lactation services for UNC Health.

In our show notes, you can find a link to advice from the Academy of Breastfeeding Medicine. It has guidance for parents struggling through this baby formula shortage.

And at the top of this episode, you heard additional reporting from NPR's Joe Hernandez and producer Eliza Dennis.

It's CONSIDER THIS FROM NPR. I'm Ailsa Chang.

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