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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.

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

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

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.

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.

HorryIsUpduffed Wed 08-May-13 12:41:55

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?

HorryIsUpduffed Wed 08-May-13 13:43:42

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.

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.

HorryIsUpduffed Wed 08-May-13 16:57:35

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.

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

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

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.

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 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.

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

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.

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