Infants At-Risk From Formula “Stretching”

Improved screening methods help doctors identify families with hunger issues

Tuesday, January 17, 2012

Despite receiving supplemental food benefits, some families cannot afford enough infant formula and resort to the dangerous practice of formula “stretching” – watering down formula – to feed their babies, according to a Cincinnati Children’s Hospital Medical Center study conducted at urban pediatric clinics.

Motivated by this and other findings, the research team launched a separate quality improvement project to help doctors better identify families with hunger issues. This new study was just published online in the journal Pediatrics.

The first study, published in the journal Clinical Pediatrics, found that families receiving public assistance remain at high risk of food insecurity – defined as the inability to afford enough food to meet basic nutritional needs. Approximately 30 percent of families in the clinics reported food insecurity, a rate that is roughly twice the national average.

“We were surprised to find one in three families worried about putting food on the table,” said Andrew Beck, MD, MPH, a general pediatrician at Cincinnati Children’s and one of the study’s authors. “Food insecurity tends to be an invisible problem, forcing families to make difficult choices between nutrition and other essential needs.”

Two-thirds of the families in the federal Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program – which provides nutrition basics for low-income women with children – reported running out of WIC-supplied formula toward the end of most months. Among food-insecure families, 27 percent reported watering down formula or reducing feedings, a practice that can have serious health consequences for babies’ developing brains, leading to cognitive, behavioral and psychological issues.

In 2009 WIC decreased the amount of formula provided to infants over the age of six months.

“We’re seeing the effects of those changes in our urban clinics, highlighting that WIC is truly a supplemental program,” said Mary Carol Burkhardt, MD, lead author of the study. “I would venture to say that cities with similar demographics and poverty levels are seeing some of the same behaviors found in our study.”

The study, led by Dr. Burkhardt, Dr. Beck, Melissa Klein, MD, and Robert Kahn, MD, was conducted at two urban health centers in Cincinnati: The Pediatric Primary Care Center (PPCC) and the Hopple Street Health Center. The centers see roughly 45,000 patient visits per year from underserved neighborhoods.

Better Screening to Identify Families at Risk

The study being published on Jan. 16 in Pediatrics has helped doctors better identify food-insecure families. Preliminary research suggested that roughly 30 percent of clinic households were food insecure. But, during face-to-face, routine health screenings, pediatric residents were identifying just two percent of families with the problem.

“Families are sometimes reluctant to report food insecurity because of the stigma,” said Dr. Kahn. “We made a number of improvements, including training our pediatric residents to ask about hunger issues in a more sensitive manner.”

“It was clear that we needed a more effective and reliable way to identify these families before we could implement interventions,” added Dr. Klein.

The doctors’ identification of food-insecure families climbed to 11 percent following training, according to the study.

The two studies sparked the creation of a collaborative effort in which the PPCC partnered with the Freestore Foodbank to provide formula and education for families facing hunger issues. Since it began in March 2011, the program has distributed infant formula to hundreds of families in need.

About Cincinnati Children’s

Cincinnati Children’s Hospital Medical Center ranks third in the nation among all Honor Roll hospitals in U.S. News and World Report’s 2011 Best Children’s Hospitals ranking. It is ranked #1 for gastroenterology and in the top 10 for all pediatric specialties – a distinction shared by only two other pediatric hospitals in the United States. Cincinnati Children’s is one of the top two recipients of pediatric research grants from the National Institutes of Health. It is internationally recognized for improving child health and transforming delivery of care through fully integrated, globally recognized research, education and innovation. Additional information can be found at

Contact Information

Jim Feuer, 513-636-4656,