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

[IdaClair]

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.

I know that, and you don't know that, but if you ring the helplines they give you the impression the powder is sterile. Gives me the RAGE.

I know that, and you know* that, but...

Note to self: don't MN whilst talking to toddler.

Oh for God's sake. This is a bit hysterical. A child of this age is going to be eating eggs and other foods which might inadvertently contain contaminants and, yes, mouthing all manner of inappropriate things. If they are on the floor at playgroup they may be mouthing items that are contaminated by other baby's illnesses. What does "not kitchen germs" mean? Surely all these nasties are also kitchen germs if they are food-related?

It's this sort of hysteria that has women in their droves developing obsessive compulsive symptoms in pregnancy and the postnatal period. Imminent death, despite what many would have you believe, is not around the corner. As the sunscreen song once put it, "the real worries in your life are apt to be those that never crossed your worried mind, the kind that blindside you at 4pm on some idle Tuesday". If this was a newborn, I might think there was some sense to it but at 8 months old I think that just generally picking a set of guidelines and following it is unlikely to result in much harm.

working - given that the bugs we are talking about include salmonella and E. coli, I think it is fair to say nobody in their right mind would skip cooking any ingredient that might contain them.

Above 70 degrees means cooking. It isn't hysterical to cook something that might give you E. coli otherwise.

well, quite, follow the guidelines of the WHO and DoH, not the manufacturers!

I use hipp and I ignored their advice re 50deg and followed who and NHS guidelines and used water at 70deg.

Yes but the important fact here is actually that the current guidance is 70 degrees from the NHS, not the discussion about bloody contaminated formula and all the things it can contain.

The risk is really very, very low and this is but unfortunately these sorts of things terrify the life out of women and for vulnerable women can easily trigger obsessions and compulsions about these figures.

"No one in their right mind" should really get into a car if we're honest with ourselves about relative risks, but we do it without thinking.

The NCT and RCM both said it was highly important to stress just how low the risk of contaminated formula is. Sterilising bottles and maintaining hand hygiene is far more important in real terms and given that a huge amount of people stop sterilising bottles at six months and there hasn't been any epidemics of baby death as a result, I think it's fair to say that the risk is going to be very, very small indeed. That's not to say it isn't a risk but it's up to individuals to make their own decisions about risks that are as tiny as this one.

I am all for people following reputable vs commercial advice but scaremongering is unnecessary.

It's not hysteria, it's basic food safety.

Tellinf people to cook chicken properly might trigger anxiety too, but the authorities quite rightly do it. I can't understand why convenience trumps infant welfare so easily.

Yes because my point was about convenience .

There's just something about the way this information is presented. Even the NHS info is very clear the risk is very low.

It is not a risk I've personally taken but this thread reads as though there was a clear immediate danger. It is a risk. Most probably a risk that is lower than taking a baby on a motorway.

Yes, it is true that taking a baby in a car is risky. But the benefit (transport) is substantial and the risk can be minimised by using a suitable car seat, driving prudently, etc.

Using formula is risky. The benefit of doing so (feeding baby) is substantial and the risk can be minimised by using properly hot water and sterilised bottles.

I realise that "using a car seat" is more obviously risk-minimising than "using very hot water" but surely responsible parents do both automatically, because they're absolutely the best idea.

I know of several people who.consider me irresponsible for not using a rear facing car seat for my three year old. I am not disputing the need for clear guidance or even the importance of water being at whatever temperature, just the general hoohah about how much more dangerous formula is than 'regular' kitchen e coli or salmonella. I know someone who lost her sight from a bizarre contamination of contact lenses but it doesn't make contact lenses inherently risky. Everything has risk. I breastfed my ds2 exclusively until at 20 weeks he was described as wasted and on the verge of dehydration. Turned out it was tongue tie. That doesn't make breastfeeding risky any more than rare contamination of formula. Road traffic accidents, on the other hand, are a leading cause of child death globally.

Does this mean I think OP shouldn't follow NHS guidance? No. It just means I think arguing formula is a special case and eating stuff off the floor or reheating day old food is essentially potentially as risky. Death and serious illness are highly improbable.

"The NCT and RCM both said it was highly important to stress just how low the risk of contaminated formula is. "

Where do they say this?

The risk of formula being contaminated is high - but infections from it are rare when preparation is careful and hygienic.

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

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.

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.

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.

Risk = consequence x probability.

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

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.

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.

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.

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.

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.

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.

I'm assuming Betterbet's praise is sarcastic, BTW :)