If formula has to be made up with water at >70 degrees, then why

(64 Posts)
IdaClair Sun 05-May-13 13:39:44

does the packet I just bought say 40-50 degrees and to mix, then feed immediately?

And can you also explain those powder dispenser things that people add to cold/room temp water?

I'm starting to mix feed 8mo DD and it's really confusing.

working9while5 Fri 10-May-13 09:01:29

"I was absolutely not being 'flippant' when I said mothers can become anxious and distressed about any aspect of their babies' care - the opposite is true. You are right - we don't know each other and you don't have the first notion of why I could not possibly be flippant about this truth, but my words don't even suggest flippancy unless someone is unfairly inclined to read them in the wrong way! "

Look, it's just the nature of language. We all respond to the words as we respond to them, there's nothing fair or unfair about it. In real interactions, we have nonverbal communication to help guide our interpretation of someone's intentions but we don't have that here so it is what it is. Words and phrases will resonate differently with different people based on their experiences. One person's "affronted" is another person's barbed.. the same words can seem different depending on who reads them and in what context. I'm not being unfair to you and you're not being unfair to me because we read and respond differently based on our own interpretation of language.

In the same way, I don't need to know the personal details of your suffering to understand that you will have had your own challenges - I sort of assume that like all of us you have had your struggles and your suffering and that it doesn't define you or what you do because that's the nature of the human condition. It happens in different ways to different people - the content may differ but the theme is the same. We all know what it is to feel pain, anxiety and distress: some of us just get labels or see people we love get labels. Nobody gets to live without pain though, despite what Hollywood would have you believe... everyone has their dark night of the soul and there is no "closure" or "happy ending" in which that's somehow undone or unwritten, it's always a part of who you are.

I digress a bit here but I'm just saying, this isn't and never was a battle with you and please take the way I write lightly - we're all having a conversation with ourselves really.

Best wishes.

ALittleBitOfMagic Thu 09-May-13 23:48:26

Ida please please read the UNICEF leaflet on making formula it is sooooo much more informative than anything else nhs midwives family friends - no one gave me clearer advice than this leaflet it's fool-proof smile

tiktok Thu 09-May-13 23:46:01

working, I am sure I am as human and prone to human weakness and mixed motives, conscious and unconscious, as anyone. However, I'm not really 'affronted' when people disagree with me - if I was, I'd tell myself to get a life, I think! I can be a bit barbed and snarky - never to women experiencing a feeding concern - but it's not 'cos of being 'affronted'.

I was absolutely not being 'flippant' when I said mothers can become anxious and distressed about any aspect of their babies' care - the opposite is true. You are right - we don't know each other and you don't have the first notion of why I could not possibly be flippant about this truth, but my words don't even suggest flippancy unless someone is unfairly inclined to read them in the wrong way!

I agree, feeding issues do appear to have particular and strong links with mental and emotional difficulties, but they don't have a monopoly on this.

Yes, the guidelines are somewhat tough. My point was (and maybe I wasn't as clear as I though) that the guidelines at least have the merit of being specific and clear, not that they are always super-easy to follow.

I am going to cease engaging here - I believe in your goodwill around this whole topic, and hope you will simply accept the same for me.

working9while5 Thu 09-May-13 21:10:45

Tiktok, I really don't know what to say to you. I have seen you on these boards over three years and I think you can be really supportive and I know that many women feel a lot of gratitude to you for the inordinate amount of time you put into sharing the information you have learned in a more professional context.

I don't think, however (any more than any other Mumsnetter) you always are supportive.. and sometimes I have had the thought that you can seem surprisingly affronted at anyone who disagrees with you or holds a different opinion particularly if you feel it challenges the facts that you hold to be most important at the time. Posts such as above (with the smiley face) demonstrate you are just as human and potentially catty/unsupportive as the rest of us.

I am struggling to think how to put this without using "hey, it's just words on a page" because that's not what I really think.. I suppose an easier way to put it is that the conversations on internet forums are really conversations with ourselves as each of us who posts has no specific interest in the person we are addressing. It's a means of discussing things that you value and care about and certainly, I have no intention of causing hurt which is why I try my best to avoid sarcasm and personal comments.

You can resent how I interpreted you words if you choose to. I could choose to resent the flippancy of "but mothers in distress may become anxious/depressed/guilty/obsessive about any aspect of their babies' care" given what and how I have spoken about my own experiences but it seems a little bit silly. We don't know eachother.

I will say however as Horry put it above, infant feeding has an importance above a lot of other aspects of care for many women and can be directly implicated in causing distress as opposed to being symptomatic of it. Infant feeding is also often where a lot of other obsessions begin as it is often the first thing that a woman finds difficult that perhaps she didn't expect to and also the first thing that causes outside intervention and measurement of how well she is doing via weighing etc. I think there are few other areas of care where this is true. I can't speak for every "mother in distress" but I do know that there is pretty strong research evidence that troubles with breastfeeding in particular are implicated in PND - of which I am sure you are aware.

My posts are not about you because I don't know you. My posts were about the categorisation of risk in this context and I still feel as I felt about it. I don't personally think the guidelines are easier. I think they're actually pretty tough. My mental health care team certainly felt this about these particular guidelines in relation to my care. I don't think you can say that they are easier in any sort of generalised way, research review or not. It's too complicated and personal an issue. They may be easier for some women, they may not be easier for others. Not every woman needs or wants rules, that isn't going to be the particular mechanism driving distress for all women. That's probably as much as can be said.

I find the obsession with research in our current culture difficult if I am honest because I know - as anyone who has ever done research does - that it is only ever a snapshot of a very particular finite point of reality, even more so if it is qualitative e.g. what's easier/what's not. It's important from my point of view to share perspectives and experiences and these are not readily "undone" with reference to specifics or discussion about whose research review was better. We're not lab rats in the end of the day and there is no ultimate truth when it comes to this sort of thing.

I suppose what I feel from reading your post is: well yes, you feel resentful and you still really want to prove to me how you are right and I am wrong. What's all that about? Do you know what is driving you to focus on that in terms of what I've written?

I posted on this thread initially because it struck a chord in me. I think I've been pretty clear as the discussion has progressed about precisely what that was about and I think my relationship to the discussion has evolved. I still don't see what is so important about proving that the risk is really really high or how my interpretation of the advice is so problematic that you want to continue on discussing how yours is superior. Does it really matter? Is it that important? What difference will it make? I don't know. I thought I was just sharing my opinion and experience and querying whether the risk was really that high.

Again, I will listen to your responses with an open heart and an open mind.

tiktok Thu 09-May-13 09:11:11

catherine, the guidance on making up formula is not law, and the manufacturers are not legally obliged to ensure their instructions follow it. Their view is that some ingredients in the formula are damaged by being mixed with hot water. Other views - based on research - say these other ingredients are of no benefit to the product. However, HIPP probably want to keep what they see as a distinction between themselves and other products on the market.

working, I come from a research background and am actively involved in other parts of my life with research and reviews into research. I can read and evaluate research papers. There are a number of reviews, based on research, which support giving parents clear instructions on the preparation of powdered infant formula. I am well-aware of and have had close experience of the distress that arises when mothers become focussed on Getting Things Right - but mothers in distress may become anxious/depressed/guilty/obsessive about any aspect of their babies' care.

In fact, with feeding, clear guidelines are easier to follow for mothers in this situation, because the 'rules' are there (whereas they are not, in other aspects of care eg sleep, wake, is my baby hot/cold/bored/unhappy/resentful, am I a good mother, does my baby love me...etc etc).

There are several studies of samples of formula - i just picked one, because it was handy! - which indicate a high risk of contamination of formula....but as I keep saying, the risk of contamination leading to infection or other harm to the baby is low (actually, very low) if the rules are followed. I think if this is communicated calmly and without others muddying the waters about what they did then no one need fear the message is doing more harm than good.

I resent your suggestion that I have some sort of sneaky (pro-breastfeeding?) agenda - you cannot have been round these boards very long or perhaps you have not read many of my posts , but I champion women's rights to clear information about formula and formula feeding, and support their decisions in infant feeding.

5318008 Wed 08-May-13 18:19:55

Catherine, at the risk of repeating myself, HIPP are contemptuous of guidance for parents from the Do H and WHO link here and actively discourage parents from preparing their infant formula safely

catherine19 Wed 08-May-13 17:18:50

Follow what it says on the tin. They wouldn't be allowed to sell a harmful ff

Good post.

It is easy for those further from "new baby" days to say "if you use formula do it properly" completely forgetting how loaded that question is.

And it sounds like you agree with me that too much choice isn't helpful.

working9while5 Wed 08-May-13 15:17:13

I agree with you Horry. It is tricky isn't it. I'd never actually read the formula prep guidelines before this thread because I didn't need to - I always primarily breastfed (still do) and so cartons were a bit of a no-brainer based on cost etc. Nothing to research, no complicated steps to make it happen, no careful measurement or double checking. I know I would struggle with this, as it is it took me a long time to be able to actually use the steriliser because I was so bloody afraid of doing it wrong, dh had the honour (and I am lucky I had that option, as I know all too well). It seems quite lengthy and very tricky to pull off in practice.

It is, from my point of view, about balance. I remember really well what it was like to be that emotionally vulnerable woman. Breastfeeding didn't just click for me, not even second time round... it was very, very stressful and it took a lot of work (and I mean therapy as well as breastfeeding intervention) to get to a point where I wasn't completely exercised by anything that suggested that what I had been told/was doing/believed was wrong. The contradictions were immense. Every single health professional gave a different point of advice and these boards (and others like them) were actually extremely difficult.

Like all mothers, I was desperate to do the "right thing" and I know that there are thousands if not hundreds of thousands of women who feel bewildered, confused and upset by health professionals, forums, other women in playgroup, relatives etc who all seem to be saying a different thing which is The Absolute Truth. I remember sitting by the laptop crying my eyes out having realised I had damaged my baby's "virgin gut" hmm and it was because I clearly hadn't tried hard enough. The Alpha Parent who is wickedly dismissive of women who use formula strangely describes a similar situation and it always makes me wonder why discussions need to become heated. It's hard to be objective, it's true.. but is it important to always be right? That is a slightly different question.

I am all for research and I would wish for all infants to have the best possible start in terms of their nutrition. However, the wide ranging impact on women for whom breastfeeding does not come easy either because of physical or cultural reasons or just plainly being advised poorly (or with too many contraditions by too many people) is important.

It's all too common to see sneering about the "happy mummy, happy baby brigade" but I share DW Winnicott's opinion that "there is no such thing as a baby" - that mother and baby are inextricably connected in the first year after birth and their welfare impacts upon one another. Again, I am not advocating that huge risks should be taken... but I also think there is very limited need to suggest that any slight deviation from the "official guidance" is going to be extremely dangerous. From my point of view, it's a cost-benefit sort of thing. The listeriosis advice in pregnancy doesn't really have the same sort of quality of life impact on women and their children as the idea that formula contains dangerous contaminants which might at any moment steal their precious infant from them may. It's also very easy to follow while the at-the-point-of-feeding pasteurisation patently isn't that easy all the time for the reasons you mention.

If PND, OCD and associated mental distress were rare and unusual in the postnatal period, I would take a different view. They are sadly not. PND represents one of the gravest threats to women's health in this period of their lives and by extension to their children. Women will always share information with eachother about how to raise their children and that's fine. However, the pseudo-scientific hand wringing about the necessity of getting it Absolutely Right At All Costs is pretty heavily implicated in maternal mental distress.

I'll be honest. I have limited qualifications either by virtue of profession or personal experience to advise anybody on breastfeeding. I pretty much suck at it. It took 20 weeks into my second outing with my boobs to realise my darling boy was wasting away in front of me: I thought it was going okay. The panic that ensued was, well, extremely tough at the time, especially as it was laid on top of generalised panic.

I am pretty much alright at reading health research though, because I do have training in this area. Yet it was this that ended up contributing most heavily to the development of OCD as my natural, normal fears about becoming a new mother and fearing I wouldn't measure up became something pathological - the issue wasn't that I was worried (all new mothers are), the issue was that I thought this worry meant that something was wrong and that I had to Do Something About It. The issue was that what I thought I Had to Do was research every possible decision about infant feeding excessively. I spent hours and hours reading research which is kind of why I can partake in these sorts of discussions. Now I'm fairly rational about it because I am no longer living under the cloud wherein my ability to read research was, in my mind, directly related to my ability to keep my baby alive. I just don't buy into it.. but I know many others may do and I have some feeling for the desperation this can invoke.

I learned through therapy that trying to apply this objective and scientific approach to working out what was Absolutely Right in terms of infant feeding brought about the distress that took over my life great cost to myself and my family. I had six months of having CBT weekly with the therapist kindly and repeatedly saying: but you can't problem solve something hypothetical, there will always be risk, there will always be anxiety, making the right choice won't protect your baby, there will always be a leap of faith, it's okay to make mistakes, you're highly unlikely to kill your baby because you didn't know the most up to date research on [insert risk factor here].

I consider I have been very lucky indeed that I had the benefit of timely intervention. Very, very few women access the level of support I did... yet as one mental health worker said to me, she was AMAZED when she became a mother herself and realised the women she medicated were matched in their droves by apparently "well" women who were tearing eachother apart over minor points on how to do it all right and suffering hugely as a result of their participation in these narrow verbal communities where "facts" are bandied about as evidence of doing it right/getting it wrong.

I think actually most women (especially first-timers) are "a bit postnatal" and it is only what you come across during this period of time and how seriously you take it that keeps it at a "typical" level or pushes it over into what we term mental illness.

Ultimately we are all connected in this small universe of ours and I like the acronym "think" for internet posts: is it true, is it helpful, is it inspirational, is it necessary and is it kind. Motherhood is not a scientific profession and we can all only do our best. Our best might not always include following every bit of government guidance exactly but this is not the same as being irresponsible or needing to feel crippling guilt.

I don't think that quite made sense. I'll try to summarise:

I agree that it is pretty much impossible to think objectively about feeding your own baby, because there is too much else going on.

In some ways I think "choice" only serves to add pressure.

No, your position is very clear.

Unfortunately it is the point we always reach, and represents an impasse IMHO.

Objectively, there is a clear hierarchy of infant feeding methods, which places powder ff below carton ff, for example. But infant feeding is such a fundamental thing - after all, it is one of very few things infants actually need, and typically the only measurable thing - that any relative value placed on one method over another, no matter how objectively true, loads guilt on to people who are already emotionally vulnerable.

It is monstrous really that a new mother - and typically it is her, however equal a couple - has to cope with a newborn who almost certainly doesn't do quite what the baby next door or the baby in the book does, and can't explain what's wrong or even give a hint, whilst at the same time suffering the physical and hormonal recovery from childbirth, and sleep deprivation on top. It's a wonder anyone with a newborn isn't completely doolally quite frankly.

FF is a pain to prepare - either it is a bit faffy or expensive - but I wish nobody ever suggested shortcuts ("tap water is fine" "you don't need to sterilise really" etc) because I genuinely think if there were one agreed method that minimises risk without being unachievable, people would just do that, and not second-guess themselves or overthink matters.

But with infant feeding in the real world you always have best practice competing against personal experience. If your sister never had a problem using water at room temperature, why would you follow the guidelines and have to jiggle a screaming baby for half an hour while the water cools enough?

working9while5 Wed 08-May-13 08:58:38

Incidentally, in case it isn't crystal clear, my intention in contributing to this thread is to be clear that while important and worth paying attention to, the infant feeding guidance is that: feeding guidance about minimising risk, not eliminating it and it is certainly not about narrowing focus to the discussion of the "dangers" of formula in a way that can be frightening and confusing for women who are concerned for their babies.

If you want to explain to me what it is that you find difficult about my interest in and concern for women's mental health based on my own experience and reading of research, I will listen with an open heart and an open mind.

working9while5 Wed 08-May-13 08:53:31

One article doesn't constitute "evidence". It is a piece of evidence, much like a fingerprint in a crime scene investigation. I would say the WHO document carries more evidentiary weight in terms of evidence based medicine. My understanding of evidence based medicine is that it is about careful and critical analysis of a wide range of research and not isolated quotation from particular abstracts or articles. Good EBP will always be characterised by balance e.g. the WHO document states clearly that the cooling of boiled water to 70 degrees or higher appears at present to be the best means of decontaminating any potential contaminants in formula but also states that this carries its own risks (scalding, potential activation of bacterial spores). Risk calculation is not about eliminating all risk or making sweeping statements. All good research also is equivocal - may/might/potentially etc - unless there is an extremely broad and established evidence base to suggest otherwise.

I'm really unsure as to what you are finding controversial here. I am suggesting that the first "best fit" based on evidence (and I am drawing mainly from the WHO guidance on infant formula here, which is certainly probably the most respectable in the context of this discussion given that it is the basis of the guidance in the first place!) is the use of sterile cartons, the second is to supplement powdered infant formula prepared as per the guidelines with cartons if there are times that the process seems too arduous, third is to prepare infant formula as per the guidelines and that all of this should be done with the awareness that the risks are not that high, but it is worth making the best evidence-based decision because the potential outcome could be catastrophic although, like with listeriosis, it is still a rare outcome and not worth worrying unduly about.

Somehow, you appear to think that makes me "sound like an arsehole" and that it should provoke sarcastic comments, though I don't know why: it's pretty much about reading the evidence and connecting the dots confused. Not sure about the intention of your comment about sarcasm with the smiley face either.

tiktok Tue 07-May-13 23:29:51

I'm assuming Betterbet's praise is sarcastic, BTW smile

tiktok Tue 07-May-13 23:28:58

working, you say "However I suspect from your choice of quote and study Tiktok that your desire to point out the Very High Risks of not preparing infant formula exactly as set out in the guidance is not entirely apolitical and may not be purely about providing support to someone with a baby of eight months who is confused by contradictory guidance."

The study is from the March 2010 issue of the Journal of Pediatrics. I am at a loss to understand why this is not respectable. Peer reviewed journal, long-standing, international....what's wrong? The quote from the same study? I chose it because it is relevant!

I have offered support to the OP - I suggested she called the manufacturers and got an explanation from them. If she did not want to go against their guidance (or felt it was contradictory) I suggested she used a different brand, or ready-to-feed.

Betterbet Tue 07-May-13 22:54:58

working, I just want to say that I think your style of writing and analysis is brilliant. you have put your argument really well without being an arsehole. totally impressed and thank you for the insight into this complicated issue.

working9while5 Tue 07-May-13 22:33:35

Oh come off it Tiktok. That is an almost meaningless sentence in terms of actually dealing with my point about serious risk to children's lives and health. The WHO guidance which explains carefully each step of the decision to alter guidance on infant food preparation is fairly clear that risks are predicted and are to some extent unknown but that best evidence suggests these are ways of minimising risk.

I agree that what stresses a lot of women out is the assertions that are made by other women about how to do things, particularly those which are superior ('I will never understand why convenience trumps infant welfare') or are backed up by spurious links to small scale studies that masquerade as being about infant welfare when mostly they are just about sounding clever.

I wouldn't mind if I were saying ignore all guidance. I'm not. I'm just saying that actual risk in terms of mortality is low. As for guidance being straightforward, it isn't really, now, is it. It is basically calling for at home pasteurization at point of making up a feed with calls to check and double check temperatures in a process that takes about thirty minutes when keeping bottles isn't advisable either. This is going to be hard for many to achieve with a screaming baby and possibly other children to attend to.

I know that for me, as a pretty risk averse person for whom breastfeeding was difficult and having had two children fail to thrive despite following all advice given to me, cartons are the obvious safest option. However I also know that if the risk were as high as some make out, the very many women who do not slavishly follow these newish guidelines would have seriously ill or dying babies. They don't.

However I suspect from your choice of quote and study Tiktok that your desire to point out the Very High Risks of not preparing infant formula exactly as set out in the guidance is not entirely apolitical and may not be purely about providing support to someone with a baby of eight months who is confused by contradictory guidance. The obvious evidence based response is to buy cartons but as many people who are pro-breastfeeding are so offended by the existence of formula companies (who I agree have beyond-dodgy ethics and are capitalist, commercial ventures not interested in woman or child welfare) it is more palatable to respond to a request for information with information on the Very High Risks of powdered infant formula to the lives of infants. I just don't buy it.

Themobstersknife Tue 07-May-13 17:23:40

I think the thing that stresses mothers out is the conflicting 'advice' given by their own mothers, friends, midwives with out of date information, health visitors with out of date information, GPs with out of date information - you get the picture. I don't understand why guidelines which suggest a straightforward method of minimising the risks of feeding formula would cause anxiety. I think it is more likely the people who suggest they are somehow doing it wrong, or being too cautious. But it is not my specialist subject.
OP - I hope you are ok? Please don't worry. If I were you, I would either use cartons or follow the WHO guidelines as that would seem to be the safest approach.

tiktok Tue 07-May-13 17:12:07

I agree it depends on your definition of 'high'.

When discussing the presence of clostridia bacteria, the study reported on in my IBFAN link shows "78% of samples of market-purchased formula contained several other species in the genus, notably Clostridium sporogenes and Clostridium butyricum."

Is that not 'high'?

The point is that while the risk of contamination may be 'high', the risk of infection is definitely 'low' ....if the preparation rules are followed.

working9while5 Tue 07-May-13 16:44:36

That's just the problem though ItsAllGoingtoBeFine. One of the first things any therapist dealing with a woman with postnatal depression or anxiety will talk about is how anxiety is maintained by the perceived probability/awfulness of a threat - so this type of anxiety is directly maintained by the same sorts of discussions we have about infant health.

It really doesn't take an awful lot for guidance to lead to obsessions and compulsions in women. I should know. I was one of them. In my case I had a particular obsession about water temperature and I could easily spend up to an hour checking and rechecking the temperature of my baby's bath and even more checking and rechecking the temperature of the baby's room. Hours. Hours and hours and hours.

There is published evidence about scalding of babies and of higher room temperatures leading to death - these are definitely actual real risks out there in the world. However, they don't really warrant the level of vigilance that I and the thousands of other women who are suffering postnatal mental illness apply to them.

Unfortunately, when it comes to babies and published research, if you rigorously apply the formula

Consequence = death
Probability = low

and you factor in the need for a caretaker to be "responsible enough" to "never take the chance", it really doesn't take an awful lot for clinical behaviours to take root. I had no history of this sort of thing, many women don't. Our culture is incredibly risk averse to the point that it is easy to believe based on what you read that if you only do everything "right" that you will eliminate risks. You won't. Ever. If it's not infant formula it might be roller blinds or scalds or accidents on the stairs/with the windows/in the bath/in the car. It's easy to pretend that the tendency to tip over into obsessing vs worrying is about the individual but when you see how we talk about these very small risks, it's clear to me that the verbal community we live in actually initiates and maintains a lot of unhelpful psychological behaviour.

Does that mean that you shouldn't take sensible precautions? Of course not. However, it's best to just be realistic about what you are going to do (if you know you are going to find it hard to follow the guidelines as you are already on edge and this sort of thing might really get to you in your deprived state, use the bloody cartons) and also to remember that it is just guidance and there will be people who are actually doing terribly dangerous things whose babies will be safe and people doing terribly safe things whose babies may sadly suffer harm.

I just hate, hate, hate when I see people talk about "high risk" of low probability outcomes because frankly, there's enough pressure out there in terms of becoming a parent in a world with limited support systems for many women. Salmonella is awful. I'd hate my baby to get it... but I have learned with the benefit of time and therapy that slavishly following guidance is no guarantee of safety and a sensible, balanced approached to anxiety is to find out what to do and just get on with it avoiding all Dr. Google/Mumsnet scare stories along the way.

ItsAllGoingToBeFine Tue 07-May-13 16:11:23

Risk = consequence x probability.

Contaminated baby milk
Consequence = high (death)
Probability = low
Risk = ?

working9while5 Tue 07-May-13 16:05:30

Neither of those links says that risk is high. They say there is a risk. I'm not really sure where you're getting the idea that the risk is high. There does appear to be consensus that there may be pathogens in powdered infant formula and that formula is not sterile but it appears from both these links and the WHO information that it is far from clear cut that this leads to serious health consequences in all cases. When it does, it's awful and so it is worth avoiding but this is not really a "high risk".

Perhaps you have a different understanding of or tolerance of risk to me. I think of something "high risk" as something that is very likely to happen if you don't take action e.g. there is a "high risk" that if you continually pull out of your driveway without looking in your mirrors, you will be involved in an accident or a "high risk" that if you repeatedly miss mortgage repayments you will damage your credit rating and may lose your home. I would consider something that was 1 in 100,000 to be pretty low risk though I would still take action in cases such as this one where the potential outcome was serious: I just would do so realising that the overall relative risk was low. This is why we avoid listeria prone foods in pregnancy. The actual likelihood of getting listeriosis is actually minute but it is easy to avoid so therefore it makes sense to do so. I didn't have soft ice cream in pregnancy or blue cheeses as many women don't but if I had accidentally eaten a food, I wouldn't have been crying my eyes out about it.

As it happens, what's under discussion is the introduction of the guidance to use boiling water at point of making up bottle and let it cool to 70 degrees before use which arose from the document I linked to and not many of the other actions required to make up formula safely e.g. appropriate water source, preparation at point of feeding, discarding formula after use, properly storing formula etc.

If you can provide evidence that the water cooling is 100% crucial to the point that not doing it will seriously increase the risk of serious harm or death to a baby e.g. make it pretty likely indeed which is based on data as opposed to predicted risk calculation, fair enough. There appears to be a number of correlations being made and the authors seem fairly explicit about it and the fact that it is actually hard to know exactly what's happening.

Again, I'm really not telling anyone to dismiss or ignore the guidelines. Just pointing out again that making a mistake with the formula preparation guidance is overall unlikely to lead to death or serious physical harm coming to an infant of over six months who is being combined-fed. It would certainly be far more dangerous to take a child in a taxi without a car seat which is not even against the law.

I would also point out again that if you are going to be getting into the nitty gritty of it and are worried about the precise temperatures involved, sterile cartons are always going to be your best option.

I really don't think there is anything "unwise" about what I am saying nor do I believe I'm representing a devil may care attitude to infant health. Just a sensible one. I agree the facts are important but I don't see the categorisation of this risk as "high" as being a fact.

tiktok Tue 07-May-13 10:30:38

working, the risk is only 'low' if the formula is prepared according to guidelines. The risk of contamination with salmonella and chronobacter and clostridium is high:

cid.oxfordjournals.org/content/46/2/268.long

www.ibfan.org/how_widespread.html

There is a lot of published data, with varying results depending on the samples tested, but you're not looking properly if you say the data is not there.

It's unwise to confuse the two risks - high risk of the presence of contamination, low risk of transmitted infection....if prepared correctly.

The best way to support women who - I agree - may stress unnecessarily about this, is just to give the facts. The guidance ensures safe preparation, which is important because of the high risk of contamination. If you use powdered infant formula, make it up safely and you are protecting your baby effectively. Or, you can use ready-to-feed.

shufflehopstep Tue 07-May-13 10:13:00

I second the poster who says use the cartons. I struggled with bf at first and was topping up with formula and we just bought the cartons. They last for a while and we used them when we started weaning on cereal and in any recipe that needed milk. If you're only using them for a couple of feeds a day, they are by far the best and quickest option in my opinion.

working9while5 Tue 07-May-13 10:05:27

It was in an article in the Scottish Chronicle which for the life of me I can't find now though I am using "Scottish Chronicle" and "infant feeding guidelines" as a search term as I was yesterday - both an NCT policy adviser and an RCM person said that the risk was really very low except for premature and other high risk babies.

I can't find any evidence that the risk of contamination is high though, merely that there is no ability to guarantee that powdered milk is sterile due to how it is manufactured. I've been looking at the WHO guidance and it would appear that the water cooling advice (to 70 degrees) is recommended as one of a range of controls (making up milk at point of use and discarding it after feeding) which is predicted through risk to reduce contaminants significantly. However, the WHO document does remind us that all figures are approximate as there is a lack of published data.

I've gone through the main document from the WHO and it would appear that the intuition here that the risk reduces as a baby gets older is sound with very young babies being at more risk and risk decreasing quite a lot from age 6-12 months. There isn't really a lot of data as far as I can see though some old figures suggest the rate in the US to be 1 in 100,000 (2002).

The key finding actually is that use of cartons is to be recommended where possible as this presents the least risk. This makes sense and particularly for someone mix-feeding an eight month old is surely the most sensible advice to offer. I've had a look at the NHS guidelines on making up powdered milk and I think they are just highly unlikely to be followed by all people at all times and the WHO document says that if it is used for only 80% of feeds the reduction in risk halves. It seems like a really difficult process and one I would worry about vulnerable women (young single mothers/those with physical or mental health issues etc) being able to commit to. It also encourages a lot of checking which I always find problematic.

The reality is that the risk of PND and obsessive compulsive type symptoms in the perinatal period is quite high. 98% of women will experience some "scary thoughts" about their ability (or lack of ability, more accurately) to care for their baby without causing them harm e.g. will worry about dropping/scalding/walking on/smothering their baby. This suggests that it's probably evolutional to worry in this way. For up to 6% of women this will become OCD. For up to 10% it may become PND.

In real terms, there is a much, much higher risk of a mother in the postnatal period believing and experiencing significant distress over what they perceive to be a high probability risk to their baby with the potential for catastrophic outcomes than there is of a feed not prepared to laboratory-tested standards causing irreparable harm to an infant. As such, I think it's important to give sensible and careful advice that doesn't fixate on very low probability outcomes.

My advice to the OP or anyone in her situation would be:
- If you want to keep combined feeding going, try not to miss breastfeeds
- Use cartons for the feeds that are formula as at this age, there won't be that many and it is easier and less faff all around with the bonus being that the milk is sterile and there aren't complicated procedures to follow in terms of preparing the food
- If you want to use powdered milk, follow NHS guidelines but have cartons on hand for when you really can't be arsed you have other things to attend to or are travelling/out and about and can't really follow the guidance.
- If you occasionally mess up on following the guidance as you are learning or simply just being human don't stress about it unnecessarily - the risk isn't so great that you need to put yourself through the mill. Just do your best.

Further info from WHO here

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