Water temperature and storage guidance for formula(20 Posts)
the leaflet also says how to prepare when you dont have boiling water.3
It would be interesting though to know the relative risks of infection from milk, bottles, preparation, storage. I think that info would take some deeper reading, if available.
I've seen advice elsewhere that beyond six months you don't need to sterilise everything. It would seem silly to be rigorous about one aspect of hygiene while not bothering about another.
That leaflet is essentially the same as the DoH one and says that formula should be prepared with water no cooler than 70c. The advice about storing is also the same.
I'm amazed that doctors in a SCBU would disregard DoH advice in that way, especially as they'll be dealing with some of the highest risk patients. Powdered formula is not a sterile product. Both DoH and WHO are clear on that. Cases of infection could arise from the powder, the preparation, or storage. Not being able to demonstrate that it is definitely from one of these sources is not the same as being able to demonstrate that it is definately not from that source.
The risk of intection is tiny but the consequences, if infected, are very, very serious. I choose not to take that risk.
well they had normal tubs of fomula just like you buy in the shops... i asked them about it and they said the doctors there had looked into it and decided it wasnt necessary to make it with 70 degree water as the actual numbers of babies effected by bacteria in milk was so tiny and there was no research to suggest that these cases werent caused by bottles not being washed/sterlised properly. We were also give this leaflet from the world health organisation when we left scbu - which gives a couple of ways of making it up and suggests you can store it in the fridge if needed.
Oops, avoid using 'boiling' water, not boiled, it will be boiled!
I'm also going to get out a thermometer and see what the water temp actually is and, work out the best proportion of boiling to boiled, cooled, to achieve just over 70.
So I'm sticking with 70c+ but will avoid using boiled water as, though I haven't looked into this yet, I accept that this could damage some useful components of the formula (e.g. I know vit c is destroyed by boiling). I've bought some ready-made, sterile bottled formula for night feeds (though I will store made-up, cooled formula in the fridge for a few hours).
DD gets plenty of bacteria from putting everything into her mouth, is not in the highest risk groups but is under a year. Given the severity of the consequences if this particular infection affected her though, it's not a risk I'm going to take.
DD spent a few days in hospital from 5 days, as had lost too much weight. The formula available on that paed ward was all the ready-made sterilised bottle type.
A temperature spike on admittance meant she was treated as a precaution for infection, with a lumbar puncture to test for meningitis and three types of powerful antiobiotics for almost three days before test results confirmed no infection. That was unpleasant enough for us (and at times very painful for her) while knowing she was almost certainly not infected (temp returned quickly to normal, all other signs fine). The experience did highlight the very horrible practical consequences of that very tiny 'what if'.
I've talked to friends with similar age babies who've used formula from the start. They are doing all sorts of different things and have been given different advice by health care workers, including, from a HV, that using stored, cooled, boiled water to make up formula is fine - very worrying as that is blatantly wrong, dangerous and against DoH guidelines.
The risk of infection is so low that most people's experience will be that they and everyone they know did whatever and got away with it - which is not the same as it being safe.
I've been looking up a few things to understand the significance of 70c and the level of risk from the bacteria that may be present in formula. Haven't got far on the benefits or otherwise of pro-biotics as that seems of secondary importance. May be a bit long and repeat stuff you know but thought I might as well share.
The main issues are how prevalent the harmful bacteria are, how infectious, how harmful an infection is and whether the bacteria will be killed at 70c.
1) The relevant bacteria are Salmonella and Cronobacter sakazakii (formerly Enterobacter sakazakii). Formula is not allowed to contain salmonella but some does. C. sakazakii is widespread and, as formula is not sterile, is often present in the powder and also in our kitchens and everywhere else.
2) Infection rates are very low but babies under 1 year are most vulnerable. One literature review found only 48 such cases in 42 years (a US report gace an infection rate of 1 in 100,000 babies) but under-reporting is likely.
3) Infection is very harmful, causing meningitis, enteritis, 20->50% death rate and long-term complications. Early, immuno-compromised and newborn babies are at greatest risk.
4) 70c should kill the bacteria, or most of them, but because they are everywhere they can get into the milk and grow. The 'use in two hours' or 'cool and refrigerate at <5c' guidelines are about minimising opportunity for growth. Optimal growth conditons (for bacteria generally) are 5-63c.
Dept of Health guidelines do say you can make up formula, cool rapidly and store at <5c for up to a day.
The are clear that you must not use cooled, boiled water, the water MUST be at least 70c to kill the bacteria in the powder. (see guidance and Q+A right at the end):
WHO Q+As on Cronobacter sakazakii:
HiPP are flouting the DoH guidelines, doing everything as carefully as possible to minimise risk, hoping babies' carers do too and hoping for the best.
Their response to a question on this:
Baby Milk Action's view of HiPP's stance:
fairi, I don't know what hospitals do - they may have access to special resources that can sterilise the powder before they use it - but I'm certain that making up bottles 'cold' doesn't kill the bacteria in the powder straight from a commercially available tub.
the formula companies don't explain it in instructions as they don't really like to publicise the fact that formula powder isn't sterile.
i saw it mentioned on another thread that it was the vitamin content that was damaged by using boiling water - not sure if i imagined this?
being that the scbu made up powdered formula with room temperature sterile water, i personally have been filling bottles with boiling water, sealing and adding powder as and when needed, so the same as when dd was in special care
I only know because I was listening to a radio 4 thing about it a day or two ago. They were interviewing someone from Hipp who was saying that they recommend the water to be only 50 degrees - and Hipp's big thing is the pre- and pro-biotics, apparently. The Dept of Health person was saying that as there's no evidence that those make any difference, their advice is sticking with 70 degrees to ensure that the nasties in the powder are killed off.
Interesting. I'd have thought if they do work, the probiotic elements would be more important for first-stage formula than follow-on. Will look this up and see what's to be found.
There's no current evidence on whether there are benefits to having the pro-biotics in formula (because if there were clear benefits then it would be mandatory to have them in there and it's not) so I wouldn't worry too much about killing them off.
The 70 degrees thing is both really precise (for best use of powder) and really approximate ('up to half an hour'). I bet few people use water that is bang on 70. I'd like to know which side to err upon.
It could be that faecal coliform bacteria need to be boiled to die but the particular bacterium that's a problem in formula is killed at a lower temperature. That does sound like a 'hope for the best' compromise otherwise. In which case, at some point, a baby will be affected by the formula bacterium despite the manufacturer's instructions having been followed to the letter.
So I could boil water, leave some to cool in a sealed bottle and mix that with boiling water to achive an instant 70.
Interesting about pro-biotic elements. I wonder what the maximum temperature they can be exposed to is. That would give a safe range of 70-X
I don't see that information on the tubs, company web-site or other obvious places. I appreciate the manufacturers are trying to keep things simple with this half an hour rule but even that is 'up to half an hour', so giving a temperature range of 99-70. As well as the faff, I find instructions without explanation infuriating.
1 - just boiled water is too hot, it will destroy some of the nutrients in the formula
2 - water must be boiled to kill any bacteria that may be in your tap water (unusual, but you do get water alerts from time to time due to faecal coliform contamination of water supplies). Heating to 70 degrees is not considered sufficient (bit of a contradiction/compromise here, as 70 degrees is accepted as being just about hot enough to kill anything in the formula powder without damaging the nutritional quality)
3 - I usually ignored this one for exact reasons you said and kept bottles in fridge for up to a day, but technically, technically, you are not making up the milk under sterile or aseptic conditions so bacteria could grow in it and cause tummy upsets. At age of 7 months, I'd imagine risk of severe illness would be much less.
4 - every time you boil water you increase the salt concentration in the water; if boiled too often salt concentration may be too high for babies' kidneys to process (reason why you don't add salt to their food or feed them salty crackers etc)
I used to boil the water, use a small amount to rinse out a clean (sterilised when babs was teeny tiny) jug with lid and then leave it to cool in that - we are a big family of tea drinkers!
Use a thermometer a few times to establish the right proportions, then stick with that?
I've never used formula so clearly know nothing! But I understand from other threads that if you added boiling water it would kill the pro-biotic stuff in the formula.
At six months plus, when children are having tap water anyway, I can't see why you couldn't mix boiling water and cold water though - although how would you know what mix made 70 degrees?
DD is seven months and we're moving from ebf to follow-on formula (why is beside the point). Preparing formula is faffier than I expected, I feel I must be missing some obvious tricks and I'd appreciate your wisdom to help clarify a couple of points and perhaps reduce the faff level.
I understand that the formula has to be made with water at, at least, 70 degrees c, to kill any potentially harmful bacteria in the formula. I am aware of no reason why tap water needs to be boiled before being offered to a baby (though there seems to be much guidance about cooled, boiled water for babies, so I'm clearly missing something). Guidance is to boil water, then cool for up to half an hour, make formula, then use the milk within two hours. Ok but:
1) Why not use boiling water to make the formula, then cool?
2) Why not turn the kettle off just before it boils and use near-boiling water, or, mix cold and boiling water in the bottle to achieve at least 70c and use that?
3) If the formula is made, cooled rapidly then stored in the fridge, it's life must be longer than two hours, I'd guess up to a day. How long can it be kept there?
4) Why must the water not be re-boiled? The potential harm is in the powder, not the water, so what is this about?
Anticipating need by half an hour and putting the kettle out of use while the water cools adds much complication in the day and doesn't work at night when she wakes hungry.
Any advice much appreciated!
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