Evidence

[FunnysInTheGarden]

Tabouleh, what evidence/ statistics have you got which show that making up Formula at less than 70 degrees causes harm to a baby in the UK?

I am intrigued, since although you have posted an awful lot about the dangers, I have yet to see any hard evidence that making formula in this way actually translates into any hard factual evidence.

tbh tabouleh i wouldn't bother wasting your time with this. If funny could be arsed she would find evidence that 70 degree water does not reduce bacteria to safe levels. As it is, she clearly hasn't even read what you have posted.

Funny would you be happy if you found out a baby in the uk had died from incorrectly prepared milk? Or would it take five? Ten? Your own?

Stop bullying tabouleh and pick your fight with the who. At the same time you might want to get some help cause you clearly have a lot of issues around this.

Surely the point is that there is only a very small chance that the formula is actually contaminated in a way that could cause a serious problem, and even then, it would be more of a problem for a newborn than an older baby? And the risks would be higher for formula not used immediately (as it would have time to grow etc).

I thought it was 2 babies in Belgium that died and IIRC they were newborn - when my DD and DS were small we all made up formula the old way, and I don't know anyone whose baby was ill.

The risk can't be so high or SMA wouldn't sell its staydown formula which has to be made up with cold water.

FWIW if I was FFing a newborn I'd definately make sure the water was at 70c. I'm going to move onto formula at 6 months and when on the go will mix it with cool water use immediately and take the risk.

MFM how odd of you. Bullying? Issues? I am merely asking a sensible question in order that I may assess the actual risk for myself. I have read an awful lot about the risks, but nothing so far which translates into evidence of harm.

The WHO statement and advice

I'm confused. If there is evidence of a risk, why would you need evidence of actual harm? The two things don't necessarily equate. If there is evidence that shows that there is a risk of illness arising from bacteria in formula, even if no baby in the UK actually falls ill, that doesn't mean that there is no risk does it? It just means that everyone dodged the bullet.
If we all went out now and ran across the M25 there is a chance that we would all make it safe to the other side, thus avoiding harm. That wouldn't mean that there wasn't a risk and that the next person to come along and try the same thing wouldn't be harmed.
Granted, if the risk never manifests itself, then you can probably conclude that it is a low risk and carry out your own personal risk-assessment on that basis, but the risk doesn't disappear.

excellent post anne.

Thank you QOFE that was useful. So it seems that the only statistical evidence available shows that between 1961 and 2003 there were 48 cases. Less than one a year. I would conclude that constitutes a low risk.

Thanks annec555 I do understand the basics of risk assesment.

FunnysInTheGarden

Not got much time just now and just seen your questions was intrigued by the "evidence" title. .

I guess my starting point is - there are UK guidelines - these are based on the WHO guidelines.

Formula powder is not sterile - tests on batches show that it sometimes contains bacteria.

Many people do not know that.

Most I think would think formula is sterile.

I am sort of taking you through the process that I went through when I found this out.

There are a small number of documented cases of fatal and serious illness related to Enterobacter sakazakii in babies. (Google this).

Various things I have read suggest that there are probably more cases which are not identified as being due to this bacteria.

There are also cases of salmonella in FF babies who are not yet weaned onto food and whose family members have not bee effected.

More FF babies contract D&V and are admitted to hospital - there are the risks of the unsterile powder, contamination through poor hygiene etc, milk being left for extended periods, babies more susceptible as they are not getting the BF antibodies.

I have seen a case of Enterobacter which was in Scotland.

The formulas are a global product and made in the same way so personally I feel that cases anywhere in the world are relevant to the risk in the UK IYSWIM.

Have a look at the intro to Irish Guidance Note 22 here - it is very well set out.

There are lots and lots of WHO meetings on this issue.

www.enterobactersakazakiiblog.com/ is useful.

This presentation is good.

Some info from baby milk action

Research commissioned by FSA

To me - there is a recommended method of making formula - the key is to use water which is at least 70 degrees C - I think it is the presentation above which sets this out clearly.

Why would people not want to follow this?

Main reason - hassle - plus many people don't do it.

However, really the main thing that I try to highlight is the guidelines/experiments show that there is a much safer way than make fresh with cool water - and that is make in advance with 70 degree water and cool.

I am that HCPs don't promote that advice from their leaflets.

I don't see the issue with making fresh on demand or cartons for prems/newborns and then moving on to making a few bottles in advance (provided the guidelines are followed).

It is a low risk agreed - but it is a risk which most mothers don't even know about.

So when you talk about the evidence - you will find evidence that formula is not sterile - evidence that the bacteria in the powder has caused deaths/serious illness and evidence that water at 70 degrees kills those bacteria.

Does that answer the OP?

NHS/FSA guidelines for those who haven't seen them.

That Food Standards Agency research report was prepared in December 2009.

1. EXECUTIVE SUMMARY

Powdered infant formula (PIF) is a generic term used to cover a range of breast milk fortifiers and substitutes. These are not manufactured as sterile products, but are intended to conform to appropriate microbiological specifications.

For PIF in international trade these were recently revised by Codex Alimentarius Commission (CAC 2008). Previous FAO/WHO 2004 and 2006 expert meetings on the microbiological risk assessment of powdered infant formulas have recommended the reconstitution of PIF with water no less than 70°C, and used within 2 hours.

The use of high reconstitution temperature is considered to reduce the viable count of Cronobacter spp. and Salmonella serovars and a short storage period would limit the growth of any survivors, and therefore this practice would reduce the risk of neonatal infection through the ingestion of contaminated infant formula. However it is apparent that various preparation practices are used by caregivers.

This report considers the risk associated with bacterial survival and subsequent multiplication following reconstitution at 70°C guideline. Reconstitution using water which had been boiled and left for 30 minutes resulted in temperatures ranging from 46 to 74°C depending on the volume of water boiled. This results in different degrees of lethality to bacteria, but boiling 1000ml of water gave temperatures on average >70°C after 30 minutes.

1. In general, bacteria had similar growth rates in whey-based (or first milks) infant formulas compared with casein-based (or second milks) infant formula. However, in whey-based infant formulas they were more heat tolerant and had shorter lag-periods. These resulted in differences in predicted outcomes following reconstitution at various temperatures using the JEMRA E. sakazakii risk model; point 5 below.

1. There was variation in thermotolerance between Cronobacter strains, with no single Cronobacter species more thermotolerant than the others. All Cronobacter were less thermotolerant than the well described, highly thermotolerant strains of Salmonella enterica serovar Senftenberg. Of the remaining organisms, the most thermotolerant

5organism was a strain of Enterobacter hormaechiae, which was nearly twice as thermotolerant as Salm. Senftenberg at 55ºC.

1. The upper growth temperature varied within the Enterobacteriaceae, with Cr. sakazakii, Cr. malonaticus, Cr. dublinensis, Ent. cloacae, and Esch. coli being able to grow at 44°C.

1. Bacterial growth and death rates in whey- and casein-based infant formulas for Cronobacter spp., Salmonella serovars, other Enterobacteriaceae, and Acinetobacter spp. (Category A and B organisms; FAO/WHO 2004 & 2006) were used with the JEMRA E. sakazakii risk model for 7 scenarios with reconstitution temperatures between 10 and 70°C.

For all scenarios, reconstitution at 70°C predicted decreases in bacterial numbers ranging from 1 log for Salm. Senftenberg and Salm. Enteritidis, to >104 log decrease for Cr. sakazakii and was dependent on the formula base.

The model also predicted overall decreases in bacterial numbers for all scenarios when the reconstitution temperature was 60°C, although this was less than a 0.5 log decrease for some strains. In contrast, at 50°C some strains had predicted increases depending upon the scenario and the formula base. For all strains growth was predicted for 2 scenarios of mixing in a 1 or 25 L container, 1 h preparation time at room temperature (20°C), refrigeration (4°C) for 6 h, rewarm to 37°C, and feed within 30 min (37°C).

Funny - thanks for starting the thread and asking the question - I know the other thread got a bit heated.

Thanks Tabouleh. I accept the guidelines and the risk which has been assessed. I am particularly interested in the context in which that risk operates. From what I have seen and read, there is a risk, but it is tiny.

It is important that mother are informed of the risk, but also important that they understand the context.

FF is a massively contentious issue and I feel that mothers should be aware of the risk they are taking in context with the actual harm that a poorly prepared bottle of milk presents.

This thread was not designed to be contentious, and thanks to those who treated it as such. Merely a more level headed examination of a highly emotive issue.