The effects of infant formula shortages on breastfeeding rates, knowledge gaps among advanced practice registered nurses (APRNs) about breastfeeding, and access to breastmilk for critically ill infants in the pediatric cardiac intensive care unit (PCICU) were among the many issues covered at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida.

When news broke of infant formula shortages in 2022, Annie Imboden, DNP, APRN, CPNP-PC, and colleagues at a private pediatric practice in a rural and medically underserved area in southern Illinois prepared to assess how this shortage, which was spurred by a recall of Similac formula, would affect breastfeeding rates.1

Using electronic medical record (EMR) data, researchers observed 326 infants aged 0 to 2 months prior to the shortage from March to August 2021, and 318 infants in the same age group after the shortage from March to August 2022. These sample populations did not include infants in foster care or infants with complex medical conditions, such as cardiac or metabolic disorders.1

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More mothers decided to initiate breastfeeding after the shortage: overall 65.6% (n=198) initiated BF before the shortage compared with 76.3% (n=233) after the shortage.1 At age 2 months, more children were still breastfed after the shortage than before (Figure).

Figure. Rate of infants given any breastmilk before and after the formula shortage. Source: Imboden et al.

The formula shortage disrupted parental behavior in 2 ways: first, the lack of access to formula, even if parents felt it was safe for their child, was a barrier to choosing formula feeding. Second, since the Similac formula was recalled because of instances of infant illness and death, public perception shifted and some parents viewed formula as an unsafe feeding option, choosing to breastfeed instead.1

“In an effort to collect and disseminate data as quickly as possible, and based on the natural timeline of the formula shortage, our study did not calculate breastfeeding continuation beyond two months of age,” Dr Imboden said. The researchers hope to investigate if there was an increase in the duration of breastfeeding in infants born during the formula shortage in a future study.

“Longer duration of breastfeeding is tied to improved health outcomes in infants, and therefore the implications could be far-reaching,” Dr Imboden said. Duration of breastfeeding will also indicate whether breastfeeding is sustainable for this population. Furthermore, exploring whether attitudes and perceptions of formula and breastmilk have changed compared to preshortage will be interesting.”

Primary care providers such as NPs and PAs need to understand what factors influence parental feeding choices, Dr Imboden noted. These providers should aim to create a breastfeeding-friendly environment whenever possible and learn ways to support all families, regardless of feeding type, Dr Imboden concluded.

Breastfeeding Basics Lacking in Nursing Programs

Knowledge about safety and accessibility of infant feeding options is not only crucial for parents, but for clinicians as well. According to a convenience sample of 304 APRNs who practice in primary care settings and were recruited through email and social media, 77% reported that their graduate nursing program did not prepare them well to support and educate patients who breastfeed, and 40% reported not receiving any breastfeeding-related education in their graduate nursing program at all.2

The most common source of knowledge about breastfeeding outside of the graduate nursing program was personal experience (76%), meaning that either the respondent or their partner breastfed, according to Diana Cartagena, PhD, CPNP-PC, and colleagues. Continuing education programs also accounted for some breastfeeding knowledge among 62% of respondents.2

Breastfeeding issues are a common patient concern for some respondents; 29% indicated that they had seen 10 or more patients with breastfeeding problems over the past 3 months.2 “Graduate nursing programs should include innovative and competency-based breastfeeding education essential to equip APRNs with the tools to support lactating women and eliminate breastfeeding disparities,” Dr Cartagena said.

Breastmilk Is Preferred in the PCICU

Breastfeeding is considered the gold standard infant feeding option for newborns1 but can be even more important for infants with congenital heart disease. Prior to the implementation of a quality improvement (QI) project, 27% of infants aged less than 1 year received any amount of breastmilk in the PCICU at the Children’s National Hospital.3 After the intervention, nearly all infants received some amount of breastmilk.

The PCICU is an inherently stressful postpartum environment and lactation support is limited during the critical early weeks of breastfeeding initiation. At baseline, staff at the study site did not regularly order lactation consultation, provide formal breastfeeding education, or oral immune therapy (OIT; ie, colostrum/breast milk absorbed oropharyngeally).3 The primary aim of the QI project was to increase the percentage of infants in the PCICU who received any amount of human milk within their first 30 days of life.

“CHD infants are at high risk for developing feeding difficulties and malnutrition due to structural and cardiopulmonary differences,” explained coinvestigator Skyler Coelho, RN, BSN. “They have a combination of impaired oxygen delivery, increased energy expenditure, increased metabolic demand, and typically insufficient caloric intake that place them at risk for feeding-related morbidity and mortality.”

The study authors implemented several interventions at the 26-bed PCICU, including formal pre- and postnatal lactation education, distribution of lactation support bags, and a revise newborn admission order set that specified human milk OIT and lactation consultation.3

Post QI implementation, 96% of infants received some amount of breastmilk during their first 30 days of life, and 65% of infants received OIT, though OIT was reported as a single occurrence of administration due to EMR constraints.3

All mothers at the PCICU received a lactation support bag and postnatal lactation education; 60% of mothers received a lactation consultation within 5 days of their child’s admission to the PCICU.3

This QI project was limited by the lack of a unit-specific lactation consultant and limited lactation consultant coverage on nights, weekends, and holidays. However, the results of this project indicate that it is possible to improve breastfeeding rates in pediatric intensive care units even amid staffing shortages.3

Mothers self-reported that providing breastmilk and OIT made them feel part of their child’s medical care and gave them a sense of purpose.3

“Most infants in the PCICU are not able to directly breastfeed so lactation consultants will need to focus on supporting mothers with the initiation of pumping as well as establishing and maintaining their milk supply,” Coelho said. “Mothers of infants with no health issues are able to directly latch baby to their breast, provide skin to skin, and hold their baby as much and as often as they would like. Depending on the severity of illness, many mothers in the PCICU are not able to have this typical maternal-child bonding and many have separation from their child shortly after birth. This can be a barrier to establishing and maintaining maternal milk supply and should be considered by lactation consultants who care for this population.”

Breastfeeding is a complex undertaking for new mothers, and advanced practice providers have an opportunity to connect parents to lactation consultants or other educational resources, especially when the clinician themselves is educated about breastfeeding.

Visit Clinical Advisor’s meetings section for more coverage of NAPNAP 2023.


1. Imboden A, Sobczack B, Kurilla N. Did breastfeeding increase as a result of the infant formula shortage? Presented at: NAPNAP national conference; March 15-18, 2023; Orlando, FL.

2. Cartagena D, Linares AM, Higgins K, et. al. Infant feeding and breastfeeding knowledge and practice of advanced practice registered nurses (APRNs). Presented at: NAPNAP national conference; March 15-18, 2023; Orlando, FL.

3. Coelho S, Simone S, Riley C. Promoting human milk use in the pediatric cardiac intensive care unit. Presented at: NAPNAP national conference; March 15-18, 2023; Orlando, FL.