Preparing Infant Formula – Safe Water Guidelines

Mixing with HOT water

Mixing with HOT water

While writing this I am making a few assumptions first.

First and foremost, I am assuming you know your baby, your body and your situation best.  I am assuming that you are knowledgeable about your choices for feeding your infant.  I also assume that:

1. You know that your breastmilk or donor human milk is the optimal and normal food for your full term infant.

2. You have made the decision with information from your child’s health care provider.

3. You have informed yourself of the risks of using artificial formula vs. human milk.

4. You have or are seeking support you need from an International Board Certified Lactation Consultant or other breastfeeding or lactation person.

When I discuss with friends or with families who contact me for support regarding using infant formula for supplementation one thing that strikes me is the varying degree of information they have regarding how to safely prepare infant formula and the array of information and guidelines around the globe regarding water.

This is not a post on the how or why for supplementation but specifically a post on preparation of artificial baby formula in countries where water supply is considered “safe”.

This is a small snapshot – I have not researched all of the countries around the globe – you can imagine there are some variations in and between countries or locations where water is not at all drinkable or safe but one thing I was struck by is my own country’s guidelines and warnings in the U.S.A. and what doctors’ and formula industry guidelines are.

In one of my posts, I mention that we did add artificial baby milk to our feedings for Z, although I do mention how we flash heated donated human milk, I didn’t mention what we did to prepare Z’s infant formula.

First a short explanation to backtrack, we were working as a team as we figured out why Z wasn’t gaining well… I had support from La Leche League Leaders, more than one IBCLC, a nutritionist and early intervention specialist, pediatrician and an occupational therapist as well as my husband; who washed pump parts and bottle fed while I pumped.

We were covering all the bases and we came up with a minimum and maximum amount of supplement that we were all happy with.  The pediatrician wanted me to supplement for weight gain while I knew from my reading and lactation support that I wanted to mainly supplement with my own pumped milk and didn’t want supplementation to interfere  or risk lowering my supply further.

You can find more on supplementation of the breastfed baby in the book The Breastfeeding Mother’s Guide to Making More Milk.  It is a wonderful resource.

I would boil water in a kettle and then add the hot water to a glass measuring container for preparation.  This way I could measure the proper amount of water and then add infant formula to the container while it was still very hot. It is extremely important not to over add water which will make the formula less nutritious. It is also important not to have too little water as it may create dehydration while putting your baby’s kidneys and digestive system at risk.

We were using a Supplemental Nursing System and Lact-Aid at the breast and to finger feed in the early weeks and then bottles in the later weeks.  I didn’t want to have the plastic melt but wanted to be sure that the formula was mixed with piping hot water so we used metal and glass. (158 degrees Fahrenheit or 70 degrees Celsius)

Many people often believe that the reason for boiling water is to kill bacteria or virus in the water.  While this may or may not be true in different locations throughout the U.S. or your part of the globe, my reason for doing this was because I had read the guidelines from the World Health Organization regarding killing anything that may be IN THE FORMULA itself.

Several things concern me about the information I found.  For one, most guidelines are similar except the International Formula Council’s.   Another concern is that most parents don’t know this information and use powdered infant formula as an “on-the-go” beverage.  Either they don’t have the information that infant formula is not a sterile product or don’t understand the seriousness of it.

Of course, this is very concerning in emergencies when breastfeeding is not happening or is not at an optimum level… when the power goes out, there is not only a concern for access to clean water but to have the ability to sterilize the baby formula as well.

Below I have some of the quotations I found and have included the links so that you can read the information in its entirety at your convenience.

** American Academy of Pediatrics: Are you preparing your baby’s bottles correctly? 

If your tap water is safe, simply mix powdered formula with room temperature tap water, and the bottle is ready to use.

If your tap water is not safe or if you are unsure, use bottled water or bring cold tap water to a rolling boil for no longer than one minute. Avoid boiling for more than one minute because it could increase the concentration of impurities in the water. Allow the water to cool to room temperature for 30 minutes, but do not leave the water out longer than half an hour to avoid bacterial contamination.

However, this is concerning to me when looking my at neighboring Canada or what UNICEF suggests.  Here it is suggested that you boil water and let it cool… the wording suggesting to parents or guardians that they only looking at the safety of the water and not the formula itself.  I found that the U.K, Canada and Australia as well as the U.S. CDC all have stricter guidelines for preparing baby formula that includes the directions to add HOT water.

** Centers for Disease Control and Prevention: Cronobacter Illness and Infant Formula

  • Keep powdered formula lids and scoops clean (be careful about what they touch)
  • Close containers of infant formula or bottled water as soon as possible
  • Use hot water (158 degrees F/70 degrees C and above) to make formula
  • Carefully shake, rather than stir, formula in the bottle
  • Cool formula to ensure it is not too hot before feeding your baby by running the prepared, capped bottle under cool water or placing it into an ice bath, taking care to keep the cooling water from getting into the bottle or on the nipple
  • Before feeding the baby, test the temperature by shaking a few drops on your wrist

** National Health Service United Kingdom: Making up infant formula

To reduce the risk of infection, make up each feed as your baby needs it, using boiled water at a temperature of 70ºC or above. Water at this temperature will kill any harmful bacteria that may be present.

In a booklet created by UNICEF, The Baby Friendly Initiative, and Start 4 Life the risk of infection and using boiling water at a temperature of 70/158 is also discussed.  The booklet informs families on baby’s immune system and includes both drawings and photographs to help parents as they prepare formula bottles.

** Health Canada: Preparing and Handling Powdered Infant Formula

Bring the water you’re using for preparing the powdered infant formula to a rolling boil for 2 minutes. After cooling the water to 70°C (this takes about 30 minutes), pour the required amount of water into a sterilized bottle and add the formula powder according to the instructions on the label. You should make sure that the temperature of the water does not go below 70°C during the mixing period. You can use a clean, digital food thermometer to make sure.

** U.S. Food and Drug Administration Safe Infant Formula Preparation

  • Formula preparation. In most cases, it’s safe to mix formula using ordinary cold tap water that’s brought to a boil and then boiled for one minute and cooled. According to the World Health Organization, recent studies suggest that mixing powdered formula with water at a temperature of at least 70 degree C—158 degrees F—creates a high probability that the formula will not contain the bacterium Enterobacter sakazakii—a rare cause of bloodstream and central nervous system infections. Remember that formula made with hot water needs to be cooled quickly to body temperature—about 98 degrees F—if it is being fed to the baby immediately. If the formula is not being fed immediately, refrigerate it right away and keep refrigerated until feeding.  
  • Bottles and nipples. The Mayo Clinic says you may want to consider sterilizing bottles and nipples before first use.  After that, you can clean them in the dishwasher or wash them by hand with soapy water.
  • Water. Use the exact amount of water recommended on the label. Under-diluted formula can cause problems related to dehydration.  Over-diluted formula will not provide adequate nutrition, and, if fed for an extended period of time, may result in slower growth.
  • Bottled water. If consumers use non-sterile bottled water for formula preparation, they should follow the same directions as described for tap water above. Some companies sell bottled water that is marketed for infants and for use in mixing with infant formula. This bottled water is required to meet general FDA quality requirements for bottled water. If the bottled water is not sterile, the label must also indicate this. Water that is marketed by the manufacturer as sterile and for infants must meet FDA’s general requirements for commercial sterility.

** Food Safety.Gov – U.S. Government – U.S. Department of Health and Human Services

What can I do to make sure that formula is safe for my baby?

Here are a few basic steps that you can follow to ensure that formula is safe from bacteria that can cause illness.

  • Prepare safe water for mixing: Bring tap water to a roiling boil and boil it for one minute. If you use bottled water, follow this same process unless the label indicates that it is sterile. Then, cool the water quickly to body temperature before mixing the formula.
  • Use clean bottles and nipples: You may want to sterilize bottles and nipples before first use. After that, it’s safe to wash them by hand or in a dishwasher.
  • Don’t make more formula than you will need: Formula can become contaminated during preparation, and bacteria can multiply quickly if formula is improperly stored. Your best bet: prepare formula in smaller quantities on an as-needed basis to greatly reduce the possibility of contamination. And always follow the label instructions for mixing formula.

** World Health Organization: Safe preparation, storage and handling of powdered infant formula GUIDELINES 2007

1. Clean and disinfect a surface on which to prepare the feed.

2. Wash hands with soap and water, and dry using a clean cloth or a single-use napkin.

3. Boil a sufficient volume of safe water. If using an automatic kettle, wait until the kettle switches off; otherwise make sure that the water comes to a rolling boil. Note: bottled water is not sterile and must be boiled before use. Microwave ovens should never be used in the preparation of PIF as uneven heating may result in ‘hot spots’ that can scald the infant’s mouth.

4. Taking care to avoid scalds, pour the appropriate amount of boiled water, which has been allowed to cool slightly, but not below 70 °C, into a cleaned and sterilized feeding cup or bottle. The temperature of the water should be checked using a sterile thermometer.

a.         If making a batch in a larger container: the container should have been cleaned and sterilized. It should be no larger than 1 litre, be made from food-grade material and be suitable for pouring hot liquids.

5. To the water, add the exact amount of formula as instructed on the label. Adding more or less powder than instructed could make infants ill.

a.         If using feeding bottles: assemble the cleaned and sterilized parts of the bottle according to the manufacturer’s instructions. Shake or swirl gently until the contents are mixed thoroughly, taking care to avoid scalds.

b.         If using feeding cups: mix thoroughly by stirring with a cleaned and sterilized spoon, taking care to avoid scalds.

c.         If preparing a batch in a larger container: stir formula using a cleaned and sterilized spoon to ensure even mixing. Immediately pour into individual feeding cups or bottles, taking care to avoid scalds.

6. Cool feeds quickly to feeding temperature by holding under a running tap, or placing in a container of cold water or iced water. Ensure that the level of the cooling water is below the top of the feeding cup or the lid of the bottle.

7. Dry the outside of the feeding cup or bottle with a clean or disposable cloth and label with appropriate information, such as type of formula, infant’s name or ID, time and date prepared, and preparer’s name.

8. Because very hot water has been used to prepare the feed, it is essential that the feeding temperature is checked before feeding in order to avoid scalding the infant’s mouth. If necessary, continue cooling as outlined in step 6 above.

9. Discard any feed that has not been consumed within two hours.

What concerns me is that the formula council and the AAP are not in line with all the other guidelines I found.  (If you have an updated version of the AAP guidelines, please do share them with me.)

Why do YOU think that is?

** International Formula Council: Infant Feeding and Nutrition Bottle Prep and Safety Guidelines

Parents should check with their baby’s doctors about the need to boil water for powdered formula preparation. If sterilizing the water is necessary, the water should be boiled for one (1) minute at a rolling boil to sterilize it and then cooled. Bottled water, including distilled water is not sterile unless boiled.”

 Always use HOT water

FOR FURTHER READING:

KellyMom What Should I Know About Infant Formula

http://kellymom.com/nutrition/milk/infant-formula/

Just One Bottle Won’t Hurt Or Will It? Supplementation of the Breastfed Baby by Marsha Walker, RN, IBCLC

http://www.health-e-learning.com/articles/JustOneBottle.pdf

The Do’s and Don’ts of Safe Formula Feeding by Teresa Pitman

http://www.todaysparent.com/baby/healthy-babies/the-dos-and-donts-of-safe-formula-feeding

United States Breastfeeding Committee Statement on Infant/Young Child Feeding in Emergencies

http://www.usbreastfeeding.org/Portals/0/Position-Statements/Emergencies-Statement-2011-USBC.pdf

UNICEF: A guide to infant formula for parents who are bottle feeding 2010

http://www.unicef.org.uk/BabyFriendly/Resources/Resources-for-parents/A-guide-to-infant-formula-for-parents-who-are-bottle-feeding/

http://www.unicef.org.uk/BabyFriendly/Resources/Resources-for-parents/Preparing-a-bottle-feed-using-baby-milk-powder/

National Alliance for Breastfeeding Advocacy: Recalls of Infant Feeding Products list

http://www.naba-breastfeeding.org/images/Formula%20Recalls-W.pdf

Centers for Disease Control and Prevention Overview: Infant Formula and Fluorosis

http://www.cdc.gov/fluoridation/safety/infant_formula.htm

United States Environmental Protection Agency

http://water.epa.gov/drink/index.cfm

Safe Drinking Water Foundation

http://www.safewater.org/

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This entry was posted in Bottles, Breastfeeding, Formula, Milk Supply, Water. Bookmark the permalink.

9 Responses to Preparing Infant Formula – Safe Water Guidelines

  1. I do trust all of the ideas you’ve offered on your post. They’re very convincing and can definitely work. Nonetheless, the posts are very brief for beginners. Could you please prolong them a bit from subsequent time? Thanks for the post.

  2. Michelle says:

    I think it’s important to also make a distinction between bottled water and bottled still/flat mineral water. The mineral content of bottled/boxed waters varies greatly so it’s important for parents to check with their paediatrician or family doctor or other HCP to see if the one they are using (or planning to use) is safe for use with infants or older babies.

  3. naomia2z says:

    Thanks Michelle,
    I found this comparison study for the USA. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495189/

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