Safe preparation of infant formula

[tabouleh]

Hello childminders/nannies/au pairs!

I am trying to raise awareness of the guidelines on safe preparation of infant formula, the reasons for these guidelines and the various methods of making formula.

I often post on the BF/FF board but I thought I would pop over here as I'm wanting to spread the word but I am also interested as to whether Ofstead or childminding associations etc issue guidance on this topic.

My interest came due to BFing not working out and me being shocked to learn that formula powder is not sterile and that the World Health Organisation guidelines (adopted in the UK) are not widely followed or understood.

Formula powder should be made up with water which is 70 degrees C. (In practice this means 1 litre of water boiled in the kettle and left for 30 mins).

Hotter than this and it can destroy nutrients and vitamins and cooler that this and it may not kill the harmful bacteria.

Bottles should then be cooled and used within 2 hours.

As this can be difficult to do in practice people seem to ignore the advice and make up bottles with cool water.

However the guidelines explain that it is far safer to make bottles with 70 deg water, cool them and store them in a fridge.

Although the documentented cases of infection are low they are very serious and in some cases fatal. It is also thought that many other cases of D&V are caused by incorrect formula preparation/sterilisation etc.

FSA/DOH guidance for health care professionals.

WHO guidelines

Best leaflet I have ever seen - Irish Guidance Note 22.

I would be interested in your thoughts and experiences.

The FSA/DOH Guidance does not appear to have a Date on it... would have expected to see a date on it, given that the guidance has changed over the years. Think that guidance is the Feb 2006 revised guidance.

There use to be a poster available... is that still around?

These days babies are often fed on-demand, rather than to a schedule. This creates a problem as when the baby wants a bottle, you need to boil the kettle, then wait 20 to 30 minutes before using that water. Babies won't wait half an hour... so bottle end up being made with water that is too hot.
What is the solution to that?

I've known parents to use hot water, put in bottles and cool. Then add powder to that cooled water... and serve cold. Those babies are thriving, they haven't died or got ill. So while there are risks associated with doing things that way... how big a risk is it? Are there any statistics available?

Perhaps baby formula manufacturers should be made to produce sterile formula... that is in small individual serve packets, rather than big tubs. Then you would not need boiling water to kill the bacteria in the formula.

"What is the solution to that?" -

A thermos flask of water - per the NHS leaflet.

Experiments as to how much boiling water added to how much cooled boiled water = 70 degrees?

Making in advance with 70 degree water, cooling rapidly and refridgerating has less risks than making up with cool water. (The WHO experiments showed this).

It is a small risk but one with huge consequences. The risk is higher for younger babies.

Apparently it is techincally impossible to make a powder sterile - I read somewhere?

Therefore even it it was in smaller packets it still would not be guarateed sterile.

There is some info on cases in the Irish Guidance leaflet I posted. They are believed to be under reported thought.

I have water at 70 degrees - half a bottle full (eg 3oz) with full powder then cooled with the other half of the water

So mixed at 70 degrees then cooled & drunk immediately - no storing at all

I've known parents to make it that way KatyMac (though the water temp is not checked - expect you check it first). Works quite well, though can be hard to get all the formula to dissolve.

tabouleh - nannies tend to have to do as they are told by their employer. While nannies can tell parents about the Guidelines, if the parent wants a bottle prepared a certain way then the nanny may not have a choice but to do it as instructed.

I have always followed current guidelines during 20 years of nannying, thats an important part of my job. Its quite straightforward to keep water at 70 degrees in a thermos flask.

Im still breastfeeding with my own (now 16 month old) son so it hasnt been an issue & my current charge is on cow`s milk during thed day & BM at night so not an issue at the moment.

Thanks for highlighting this tabouleh

thanks for the info./awareness. Are breasts sterile?

Fuck. I sometimes made my children's formula up with hotter water than that.

No but I don't need/intend to breast feed anyone else's child - I do need/intend to bottle feed them therefore I follow the guidelines

There are so many ways to skin a cat that it's hard to monitor/educate everyone on a single Best Practice in formula preparation. I have used pre-prepared bottles from the fridge, KayMac's way, using a thermos, using a bottle warmer... none of the babies got ill. One set of parents prepped the bottles and had them out on the side of the Aga all day keeping them warm FFS and their kids survived (I suggest maybe this was not a good idea) but parents will generally do whatever makes their lives easier. As long as everything is clean and sterile the first few weeks I have yet to see any harm come to any babies. I have visited mothers who live in squalid council flats and their babies are fat and healthy. My own personal ethos (as opposed to my professional ethos which I follow all guidelines for safe/best/healthy practice) is use common sense. No one takes deliberate risks by using dirty bottles etc and most parents/nannies/etc manage to not make their children ill even if they don't follow these guidelines. The formula powder might not be sterile but neither are boobs, and neither are the babies fingers and toes. If the bottle is sterile and the environment is clean then really I can't see the harm in making up a bottle like KatyMac does. I follow all the guidelines in my job but tbh I will probably be a little more relaxed when I am a mother as at 3 am who the heck wants to faff around checking them temp of water etc?

the point about powder formula is that it cannot be guaranteed sterile and using 70C water decreases the amount of potentially toxic bacteria avaialble

Anyway, it's a moot point for my practice as I ask parents to provide ready made cartons if not expressing

iiiiiiii - This is not a BF-v-FF debate but yes, breastmilk is completely sterile. And it comes straight from source.

Bacteria multiplies very quickly in milk so the teensiest amount on a bottle (or in formula not stored properly can be a big problem). BM goes straight from the inside the breast into the baby`s mouth.

Im quite lazy when Im not in pro-nanny mode so it suited me down to the ground

I used to make 2 or 3 feeds up with hotter than 70 degree water and cool and store in fridge
If I made according to directions then the mixture of comfort milk and gaviscon didnt dissolve proparly
Now I tend to either make bottles as needed or put water in bottle and add powder an hour or so later and use straight away - he's almost 8 months and on normal milk and seems fine

wrinklyraisin

"The formula powder might not be sterile but neither are boobs, and neither are the babies fingers and toes."

I would really really like people to understand the difference between the bacteria which has been found in formula powder and bacteria which are on "boobs/fingers/toes".

Firstly - milk is the perfect breeding ground for bacteria - a liquid/food at a good temperature for growing. Bacteria in a food stuff multiplies like crazy and is then ingested by drinking that milk.

Bacteria on "boobs/fingers/toes" is smaller in quantity and does not tend to be this particularly awful E. sakazakii.

Tests were done on a bottle of forumla milk and a bottle of espressed milk stored inthe fridge for the same amount of time. The bacteria in the formula had multiplied greatly, th bacteria in the formula had actually decreased.

Expressed breastmilk does not even need to be kept in a fridge for up to 8 hours. When I fed ds ebm I just carried it around all day, formula was made up according to the guidelines for this reason.

Why would Ofsted or a Childminding Association issue guidance on this kind of thing... when there is guidance available from HPA/food.gov.uk

Ofsted are not going to regulate how someone prepares a bottle. I feel they would more likely say that childcarers should take notice of guidance issued by other authorities - such as HPA.

Good post tabouleh, you`ve pretty much covered my response.

Sadly, I`ve often seen(non-serious)tummy upsets in FF babies. Less so where current guidelines have been followed & in BF babies.

Bacteria on the nipple has no chance to muliply in BM. Bacteria on fingers/toes has no chance to multiply in formula. That`s the point.

nannynick - I am interested in whether Ofsted does tell childcarers to follow the guidance and whether it checks up on this - eg I know they ask to see evidence of fire drills/medicines administering policies etc.

I get your point nannynick.

However I agree that safe preparation of formula should be recognised by Ofsted. Its a HEEEOOOOGE part of any nanny/CM/nusery-nurses job after all.

Sadly I know too many nannies who would not consider checking latest guidelines

I did just read a nursery inspection report from 2004 (so pre EYFS) that said:
"However, accident records are not used to identify hazards and minimise risks and the procedure for bottlefeeding is not consistent with requirements."
GoogleCache Ofsted Report 258949

So in 2004, an inspector did pick up that the bottlefeeding procedure being used by the nursery was not consistent with requirements - though no mention of what those requirements were... from National Standards (Childminder) 2003, "A.5 Babies are normally held whilst bottle feeding.
A.6 There is adequate provision for the sterilisation of feeding bottles and utensils and the preparation of baby food." (Haven't got the nursery 2003 on file... though expect it would be similar.)

EYFS says some things:

"Providers should be aware of their responsibilities under food hygiene legislation including registration with the relevant Local Authority Environmental Health Department."
"There should be suitable facilities for the hygienic preparation of babies? feeds if necessary. Suitable sterilisation equipment is used for the sterilisation of babies? feeding equipment and dummies."

So an inspector could look at the preparation of babies' feeds, but I can not locate any specific guidance issued by Ofsted on the matter.

Good practice would be to follow the guidelines and I expect most childcarers (if they know about the guidance) would be following it as best they can.

Nannies can be in an awkward position as their employer may tell them to do things in a different way. So the nanny can tell the parent it's not following latest guidance, the parents can still say they want it done the way they do it. Some nannies are fairly forceful and will ignore the parents instructions - but that could be grounds for losing their job.