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Parents get conflicting advice about mixing infant formula

(Reuters Health) – National and international pediatric and health organizations should develop a uniform set of guidelines around infant formulas, says a group of pediatric experts.

Several existing recommendations from top groups contradict one another, especially when it comes to the temperature of water used to mix formula and when to mix it, note the authors of a commentary in the journal Pediatrics.

“A majority of infants will have formula at some point during their first year of life, but conversations regarding formula mixing are not always standard before (or even after) formula is introduced,” said lead author Dr. Tracey Wilkinson of the Indiana University School of Medicine in Indianapolis.

Recommendations differ primarily around whether caregivers should add formula powder to boiling water or water that has been boiled and then cooled, or should never boil the water at all.

“Parents have a lot of options when it comes to where to get information these days, and they often search for answers on their own for questions they have about new babies,” Wilkinson told Reuters Health in a phone interview. “It was astounding to us that there were so many different directions on how to mix formula out there and that major medical sources were conflicting with their advice.”

For instance, the World Health Organization (WHO) recommends boiling water for no more than 30 minutes, adding powdered formula and immediately cooling it to feeding temperature. The U.S. Centers for Disease Control and Prevention (CDC) recommends heating water to 158 degrees Fahrenheit (70°C), adding formula powder and cooling it, especially for infants under 3 months old, premature infants or those with a compromised immune system.

The U.S. Food and Drug Administration recommends boiling water for one minute and letting it cool, or following the manufacturer’s label. The American Academy of Pediatrics recommends boiling water for one minute, letting it cool to room temperature for no more than 30 minutes and adding powder after that.

Overall, formula cans recommend boiling water for one minute, letting it cool to room temperature around 75 degrees Fahrenheit (about 24°C) and adding powder.

“Each of these organizations has a different focus, and what we need to do is bring together professionals in different areas to develop guidelines that can achieve each of their goals, such as safety, disease, infant growth and development,” said Kelly Corkins, a registered dietician with Le Bonheur Children’s Hospital in Memphis, Tennessee, who wasn’t involved in the commentary.

The conflict tends to revolve around Cronobacter sakazakii bacteria (previously called Enterobacter sakazakii), which can contaminate formula powder during manufacturing and after pasteurization has occurred. The bacteria can cause serious invasive infections and premature infant death. The most recent U.S. outbreak spanned four states in 2011.

The WHO and the U.N. Food and Agricultural Organization held meetings about the bacteria in infant formula in 2004 and 2006, concluding that premature infants and those under 2 months old are at highest risk for the infection. At the same time, the resulting WHO recommendations included 12 steps to make infant formula.

“Some of the recommendations seem unrealistic and could even be harmful if boiling water spilled or was given accidentally to a newborn before it cooled,” Wilkinson said.

About 300 children go to the emergency room for hot water burns each day in the U.S., the commentary notes. Asking tired parents to boil water eight or more times per day to prepare formula makes little sense given the amount of risk involved with burns as compared to these bacterial infections, the authors write. The CDC receives reports of about five infections per year.

Moreover, Corkins said, adding formula powder to boiling water tends to clump up and make it tough to mix. Certain vitamins and proteins can denature at high temperatures as well.

“If you’re using city tap water, not well water or softened water, it’s best to simply follow the manufacturer’s instructions,” Corkins said. “Boil for one minute and then cool before adding powder.”

SOURCE: Pediatrics, online May 22, 2019.

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