Less well known amongst the public is the risk coming from possible contamination of formula. This is contamination coming after pasteurisation. You see, powdered infant formula is not sterile.
But despite all companies in the UK relaunching formula labels this year following the crack down on illegal health claims, only one company has put this important fact on the label. I am not about to praise it, however, as the instructions it gives on mixing up the formula are not those called for by the government and health experts to reduce risks of possible contamination.
The risk from contamination came to public prominence with the death of a 5-day-old child in Belgium in 2002 as a result of meningitis linked to contamination of Nestlé formula with Enterobacter Sakazakii. That case is currently in court. I have written about it here previously. Such serious cases are fortunately very rare. It is not known how much the greater incidence of other illnesses such as gastro entiritis is due to bacteria in the formula. In the UK it was estimated in 1995 that the NHS spends £35 million treating the gastro entiritis attributable to formula feeding. See:
The fact that such contamination occurs has been known about for far longer than the 2002 case.
This and other deaths in France, prompted the World Health Organisation to hold expert meetings produce guidelines. The Food Standard Agency has had its version of these on its website for over a year. See:
Key amongst these is to include a step in the preparation of powdered infant formula that will kill any bacteria such as Enterobacter Sakazakii or Salmonella. The guidance to parents is to use water at more than 70 Deg. C.
UNICEF, blasted this week by some sections of the media for allegedly telling mothers they have to breastfeed, produces leaflets in a variety of languages explaining how to do this practically. The leaflets look like the instructions on the side of a formula pack. They are available on the Baby Friendly website:
Step 1 states: "Boil some fresh tap water and let it cool for a few minutes. (It should still be more than 70 Deg. C so don't leave it for more than half an hour)....
The WHO guidelines explain why this is important: "preparation of Powdered Infant Formula with water at a temperature of no less than 70 °C dramatically reduces the risk."
I was staggered therefore to see the new labels that Hipp has just launched onto the market. Hipp had to change its labels after the Food Standards Agency reminded it that its claim "Formulated to be nutritionally close to breastmilk" does not comply with legislation introduced in 1995! Better late than never. See:
Having the chance to update its labels Hipp has added a notice that: "Powdered baby milk formulas are not sterile and reconstituted feeds are at risk of infection [sic]"
But surely it meant to say: "are a risk of infection" not "at risk of infection".
Then, however, its instructions state: "Boil water and leave to stand until temperature reaches 50 - 60 Deg. C (30 - 40 minutes)."
(Click on the image for a larger version).
Hang on! WHO says water no less than 70 Deg. C. The Food Standards Agency (FSA) says in practice this means don't let the water cool for more than 30 minutes.
Why isn't Hipp giving the correct information?
It turns out it is the 'breastfeeding zealots' who are trying to give mothers the information they need to reduce the risks from formula feeding. Why? Because we want the best for ALL mothers and babies. We want mothers to have the information they need, whether they breastfeed or use formula. The companies have demonstrated time and again they are untrustworthy. They idealize their products and are not open about risks.
The reason we and our partners in the Baby Feeding Law Group and Breastfeeding Manifesto coalition are calling for World Health Assembly marketing requirements to be enforced is because they protect ALL mothers and babies.
Certainly they exist to protect breastfeeding, but not only that. This is what article 1 of the International Code of Marketing of Breastmilk Substitutes actually says.
The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
This point seems to have been missed in the heated debate this week as some parts of the media and some mothers see the call for regulation as an attack on formula feeding. It is, in reality, just the opposite. It is part of our efforts to make formula feeding safer. I wrote about this on Tuesday. See:
Now why doesn't Hipp give the correct information? That is a good question to ask it.
What of the other companies? They have also issued new labels.
None of the main ones give the information as clearly and as accurately as UNICEF and the Food Standards Agency.
None other than Hipp let on that powdered formula is not sterile. It is as if they do not respect the intelligence of mothers to understand this means formula should be prepared carefully and that the high temperature step is very important.
It is as if they do not wish to tarnish their 'inspired by breastmilk' and 'as close as possible to breastmilk' claims (which are used on the new labels from Milupa/Aptamil and Wyeth/SMA despite them being told by the FSA claims like this are non-compliant - see them here).
But if mothers are respected and understand the risks and how to reduce them they are empowered. I imagine anyone who is preparing formula would rather know of the risks and how to reduce them than have facts kept hidden and wrong instructions. Indeed, that is what research by the Food Standards Agency found. Initially mothers were concerned to learn that formula is not sterile, but then agreed:
"Overall, as powdered infant formula may pose a potential risk to babies, parents and healthcare professionals agreed that parents should be informed that it is non-sterile, so that they can are able to make an informed decision about its use and preparation."
None of the other labels give the information on temperature. They do not say let it cool for a few minutes as UNICEF does, nor do they say 'don't let it cool for more than half an hour' as in the Food Standard Agency and Department of Health Guidance. They say 'leave to cool for 30 minutes'. Right on the limit.
Again. Why? They need to be asked and they need to explain. More importantly, they need to give the correct information.
Mixing up formula with water at higher temperature is no more complex or dangerous than making a cup of coffee, which is done with water near boiling point. It is important, of course, to check the feed is at the correct temperature before feeding. This was a point I flagged up when we first saw the Food Standard Agency guidance. It was added.
Again, respecting the intelligence of mothers, UNICEF's leaflet says: "Powdered baby milk is not sterile. Feeds should therefore not be made up in advance. If you are going to need to feed your baby while you are out it is safest to take freshly boiled water in a sealed flask and make up the feed when you need it."
Another alternative is to use ready-to-feed formula, which is sterile.
When changing their labels, the companies had an ideal opportunity to bring their guidance into line with that of health experts. Baby Milk Action and our partners say it should be a legal requirement to have the correct information on labels - it is one of our action points in our letter for the consultation on revising the law. If you agree, you can send a message too. See:
No doubt companies will say they have plans in hand or are studying what to do. We will certainly continue pressing for action. Interestingly, but perhaps not surprisingly, the guidance that some of the formula companies have happily added to their labels already is to throw away unused feed.
Indeed, Hipp was happy to add that information 18 months ago and tried to gain publicity for 'leading the way' soon after the FSA guidance for parents first came out. But it was selective in what it implemented then as well. See our press release from 4 January 2006:
Hipp endangers infants with misleading information on formula preparation.
Commenting on Hipp’s advice at that time, Dr Jorgen Schlundt, Director of WHO’s Department of Food Safety, Zoonoses and Foodborne Diseases, said:
“Although any effort to eliminate the practice of keeping left-over, re-constituted formula at dangerous temperatures for later use should be commended, I am surprised that they seem to be dealing with less than half of the problem, and have not dealt with the bacteria that may be present in the powder itself.”
At least on its new labels we have Hipp acknowledging powdered formula is not sterile, even if its temperature advice means bacteria, if present, will not be eliminated.
We have been working for years for better labeling for formula. If we keep up the pressure we can force Hipp and all the companies to give parents the information they need. The review of the law is our ideal opportunity.
I hope mothers who use formula will feel able to join us in demanding correct warnings and instructions on labels.