Boiled or not? Bottled water for preparation of infant formula

Thanks for this question. Please find a link to the FAO/WHO recommendation on safe preparation of Powder Infant Formula. The main recommendation is to bring the water at around 70oC and its not about the water safety but its about the potential presence of microorganism (bacteria) in the powder even when purchased new from the supermarket.
https://www.who.int/foodsafety/publications/powdered-infant-formula/en/

Thanks and again a very important discussion to continue

Surely in a situation where there is an emergency, then water for preparing emergency formula-feeding would definitely need to be boiled....??? But how much effort is being put into promoting breastfeeding before the emergency situation occurs, and especially exclusive breastfeeding from birth for all newborns born into emergencies, eg Yemen, Saudi Arabia, pregnant women refugees landing in Europe? An examination of stats shows that breastfeeding rates are often low outside of emergency situations - what can be done to prepare for emergencies, prevention being better than cure??

hi Mija!

I presume you've seen this? :

https://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf

We've been doing some work on this in my (UK focused) organisation (www.firststepsnutrition.org).

I understood that the reason to boil and use tap water that has been allowed to cool to no less than 70 degrees, is to to kill any harmful bacteria that may be present in powdered infant formula. And because bottled water is not sterile, it also does need to be boiled.

But, there is also a concern that some bottled water may contain too high concentration of sodium or sulphate.. so it's not ideal to use it, at least routinely.. this article is relevant and endorses 'emergency' use .. though in the UK ..

https://www.ncbi.nlm.nih.gov/pubmed/20345057

Hope that helps/ would be very interesting to know the sources of information that say bottle water does not need to be boiled and what the rationale is.

Vicky

hi Mija

If you were being really meticulous, you may want to consider the mineral content of the bottled water. NHS guidance (obviously not the emergency context you're focused on, but still interesting I think) for or use of bottled water to make up powdered infant formula in the UK (where necessary, as it's not the recommended first choice..), is that the sodium (Na) level is less than 20mg/l (I think, I have also read 200mg/l but that seems very high) and the sulphate (SO or SO4) level is no higher than 250mg/l.

Also consider that the point on boiling the water and then preparing after no more than 30mins is it will cool rather fast. I would not recommend aiming for prep at 70 degrees (also somewhat impractical unless you have a thermometer??) but stick to the message that you boil the water and then not let it cool for more than 30 mins before making up the PIF. The volume you boil is important in relation to cooling speed - NHS recommendation is 1l. I think the logic is smaller volumes cool faster.

Hope that's helpful

Vicky

Just to add my thoughts on the mineral content of bottled water. This is something that I looked into a long time ago when I read about not using bottled water with high sodium levels in the IFE guidelines. I tried to speak to a few experts about the risk and find out the basis on which the guidelines were made. I found it quite hard to get any definitive answers. But from a practical point of view I would recommend that
- where possible people shouldn't buy / logistics shouldn't procure bottled water with sodium content higher than 20 mmol (I can't remember the exact number) or at least they shouldn't buy mineral water (some mothers I spoke to thought higher mineral content the better).
- the mineral content increases every time the water is boiled. So I recommended to only boil amount of water that is needed and then not to reboil any water left over to make more formula. Essentially, boil fresh water for each formula feed.
- I would also emphasise that the children most at risk from a high solute load were those who were premature and sick, so the guidelines were particularly important for them.

Hi All,
Some of you may be interested in this paper discussing the use of bottled water for reconstituting infant formula. Osborn K, Lyons M: Is bottled water really unsafe for making up infant formula? Community Practitioner 2010, 83(3):31-34.
Karleen

Health Canada's guidance is to follow FAO/WHO guidance and prepare powdered infant formula with water that has been boiled and then cooled to 70C. They state this is because of concern with possible contamination of powdered infant formula during manufacturing from harmful bacteria such as Cronobacter or Salmonella. https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/infant-feeding/recommendations-preparation-handling-powdered-infant-formula-infant-feeding.html

We haven't had any recent reports of Chronobacter or Salmonella contamination in Canada, but I note there was an outbreak of salmonella within the last year, with over 3 dozen cases in infants in France, Belgium, Italy and Greece, and a widespread recall by French formula maker Lactalis that impacted products in many countries around the world.

In ordinary household circumstances, Health Canada does acknowledge that cooled, previously boiled water can be used if the formula is consumed immediately and if any leftovers are discarded.

Of course, an emergency situation is not a normal household circumstance.

Our direct experience in the field in Canada during the mass evacuation of 88,000 people including 3,000 infants under the age of 24 months after the Fort McMurray/House River wildfire was that the main evacuation centre (serving 19,000+ people) experienced a gastro outbreak. During this time families were given tins of powdered formula which were opened and then used over the next several hours/days to prepare bottles without facilities that would allow for Health Canada's preparation guidelines to be followed. Save the Children workers touring the facility also reported a significant volume of opened powdered infant formula on the site during this outbreak.

The risk of contamination of open tins of powdered formula is a real risk in an emergency setting in Canada, and ensuring that emergency centres have facilities set up to allow WHO guidelines to be followed when infant formula is being prepared will reduce risk of illness for these infants.

hi Andre
That is extremely helpful as I wasn't too sure what the right safe level was, or the rationale behind these different values. Thanks so much
Vicky

I have not post a reply but took the opportunity to read through the replies since in my African setting formula is not used much because of the cost and the strict guidelines that promote breastfeeding.