Friday, July 27, 2007

Advice on infant feeding during the UK floods

Thousands of people have been affected by flooding in the UK. In one county 340,000 people have lost their water supply. More rain is expected this weekend, which may lead to further problems.

The Food Standards Agency has posted advice on its website for carers who are feeding infants with infant formula:

This states:

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If your drinking water supply is either interrupted or contaminated by the flooding and you need to prepare formula feed for a baby, it is important to be careful with the water you use. Here are some tips on preparing formula safely.

  • Ideally use water from a bowser (a water tank provided by water companies), or bottled water, brought to a ‘rolling’ boil and left covered to cool for no more than half an hour, then follow the manufacturer’s instructions on making up the feed. The use of unboiled bowser water should be avoided.
  • Use cooled boiled water or bottled water for cooling the feed once it has been made up.
  • Ready-to-feed liquid formula could be used instead.
  • If there is no electricity or gas to allow boiling and you don’t have ready-to-feed liquid formula available, bottled water (table, spring or mineral water) can be used without boiling to prepare baby feeds, but the prepared feed should then be used immediately.
  • Some bottled water labelled as 'natural mineral water' may have high levels of sodium. When buying bottles of natural mineral water, look at the label and check that the figure for sodium or 'Na' is not higher than 200mg a litre. If it is, then try to use another water. If no other water is available, then use this water for as short a time as possible.
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In past emergency situations affecting other countries, we have had to warn people not to send donations of formula as this is not wanted by people on the ground and can do more harm than good. For those that do need formula it is better if this is purchased locally so labels are in the correct language and distributed appropriately and with necessary instructions to minimise risks.

Whether overseas or in the UK, it is important for field workers who will be advising carers familiarise themselves with the materials produced by the Emergency Nutrition Network. These can be accessed at:

We have received an article from Sarah Saunby, a Baby Milk Action Area Contact in Sheffield. Sarah is also a Registered Breastfeeding Supporter with the Breastfeeding Network, which provides support to mothers.

I am included the article below. If you would like to reproduce this in any form, please contact me for permission.

---Article by Sarah Saunby

Infant Feeding in Emergencies – is it relevant in the UK?

Late last night I eagerly watched the news to see the scenes of devastation, due to flooding, in my home town of Sheffield. Sheffield is well known for being built on 7 hills, which naturally means we have a lot of valleys and rivers. These valleys and rivers took the brunt of a months’ rainfall falling in 24 hours. Local rivers were unable to cope with the volume of water, bursting their banks and subsequently flooding many roads, buildings and houses, causing severe disruption.

As I watched, my thoughts went out to all those affected by the flooding. I felt lucky to be living at the top of a hill and that the worst I had to cope with was a few clothes to dry, when the children returned home from school. My sister’s basement had flooded and both her and my parent’s home were left without electricity. Things were also not so good for those, left stranded at work. Rescue RAF helicopters were called in to the area to help winch over 100 people, including a woman and her baby, to safety.

So what’s this got to do with breastfeeding?

Well SKY news and BBC news 24 reported late yesterday that 35,000 homes were left without power and some 250 homes had been evacuated. Sheffield Hallam Arena was providing emergency accomodation, as were local nightclubs, leisure centres, schools and various other places. I then began to wonder how many babies would have been amongst those evacuated or left in a home without power. How are those babies being fed, I wonder?

When we think about Infant Feeding in Emergencies (IFE), it’s generally associated with some crisis in developing countries; a tornado, earthquake, tsunami or displacement due to conflict or fighting. The UK shouldn’t really need to give much consideration to the WHO and IBFAN publications on IFE, which give guidance (Ref. 1, 2) because things like this just don’t happen in the UK.

So when I heard the following day that in South Yorkshire alone 14,000 people remained evacuated from their homes and that 86,000 homes had disrupted power supplies with 32,000 homes being completely without power I wondered what systems, if any, do we have in place to protect vulnerable babies in these situtations in the UK? When it does become a reality it must be worth highlighting that In emergencies, children under five are more likely to become ill and die from malnutrition and disease than anyone else. In general, the younger they are, the more vulnerable they are. Inappropriate feeding increases their risks (Ref: 3).

Irrespective of any emergency, artificially fed infants already constitute a risk group (Ref: 4) and should receive special attention from the health and social welfare system, so situations like this really emphasise the importance of breastfeeding. Without wishing to add to any mother’s distress I think it is valid to ask how parents of formula feeding infants, are coping with this situation? Babies continue to need feeding. In these emergency shelters and when there is no power supply - how easy is it to maintain safety guidelines set out by the Food Standards Agency, Department of Health and infant formula manufacturers for preparing infant formula? Such as mixing powdered formula with water at 70 degrees centigrade (the temperature necessary to kill harmful pathogens) (Ref: 5, 6) and cleaning and sterilising bottles and teats. A recent report in The Guardian newspaper highlighted the acute risks that formula feeding presents to infants where there aren't the resources to safely support it (Ref: 7). Whilst anecdotally it is discussed that we don’t have the same problems as in developing countries, the current situation across South Yorkshire and other areas of the country show that occasionally we do (Ref: 8).

In a BBC Radio Sheffield interview, one man described how he was woken in the middle of the night by emergency crews who told him he and his family had 5 minutes to get ready and leave their home. This must have been an incredibly frightening experience, especially for those families with young babies and children. For a breastfeeding mother, so long as the mother and baby are kept together, the baby’s food needs are pretty much catered for, plus the baby will have additional protection from the new environment she / he is faced with, via mum’s antibodies. Breastmilk is known to contain anti-infective properties which provide protection against illnesses and reduce the severity of those that occur (Ref: 9). In a room full of strangers and unfamiliar bugs / germs, this will be very reassuring. But for those mothers artificially feeding, how must they have felt to have to leave their homes so suddenly without any necessary equipment or means to feed their infant? Their babies will not have any additional protection by any antibodies made by mum and are already at risk due to the pathogens already present in up to 14% of tins of infant formula (Ref: 10, 11, 12, 13).

If local authorities and other agencies are donating supplies of food; which includes infant formula milk are they following the UK Law (Ref: 14) WHO and UNICEF code and resolutions and IBFAN guidelines (Ref: 15) in ensuring breastfeeding is protected and not undermined by emergency relief efforts and distribution of breastmilk substitutes? Are those aid workers / staff aware that such guidelines even exist? Any appeals being made on behalf of victims should be for money rather than donations. Many health workers and parents are not aware that infant formula is not even a sterile product to start with (Ref: 16).

Is this covered as part of the ‘major incident’ preparations? Is the importance of keeping a mother and her infant together understood and training given in assisting mothers with relactation, if necessary? Breastfeeding is the safest method of feeding infants. Those women who are feeding both breastmilk and infant formula should be encouraged to breastfeed exclusively and be informed and educated about how supply and demand process of milk production works, if they have concerned about their breastmilk supply.

In situations where the infant is around 6 months and the mother is thinking of weaning, then consideration should be given as to whether it would be safer to continue exclusively breastfeeding, for a while, particularly if the necessary means to wean safely are not available.

Do health workers and other aid agencies have knowledge to inform breastfeeding mothers that stress has no effect on the milk-making hormone (prolactin), but it can have a temporary effect on the hormone which makes the milk flow out of the breast (oxytocin)? The temporary stoppage of this reflex is a useful biological mechanism to stop milk being ejected from the breast at difficult moments. The oxytocin reflex is sensitive: it can stop temporarily, but it resumes quickly. So lots of skin-to-skin contact and continued suckling is important. The skin-to-skin also can help the baby feel secure and limit the damage of the emotional traumas of stressful situations (Ref: 17). The breastfeeding hormones help many women feel calmer in stressful situations. Women should be given additional information about where they can get help with breastfeeding (regardless of current method of feeding).

For those babies being formula fed, is advice given to parents, that it could be safer to cup feed? (Ref: 18). Cups are safer than bottles as they can be cleaned easier. Bottles and teats have intricate parts and need to be thoroughly clean, an important consideration when little or no mains water is available and the kitchen is not big enough for safe handling and preparation to cope with many different babies’ equipment. Kitchen areas may have already been contaminated with debris from the river and also from burst sewage systems. For babies and young children, who’s immune systems are still maturing and may not be fully developed until around 6 years this becomes a real concern (Ref: 19). Health workers should be aware that, at an already difficult time of cleaning up their homes and having to look after small babies and children, people may not have time or necessary resources to be so thorough.

Mothers using powdered formula should be informed that the ready to feed cartons of infant formula may pose less of a risk than powdered feed, during this time, particularly where the clean water supply has been affected. Bottled waters (mineral, spring and table) may be unsuitable to mix with powdered feeds (Ref: 20). This is because the solute levels (sodium, nitrate, sulphate and fluoride) may not be suitable levels for the infant’s system to cope with. In circumstances where people are left without mains, drinking water supply or any bowser water bottled water may be the only option. The advice given by the Food Standards Agency and Health Protection Agency is that in circumstances where the power supply is affected then bottled water can be used unboiled. Prepared feeds should be used immediately (Ref: 21, 22). Whilst boiling water may kill off some bacteria and parasites it does not remove chemical contaminants (Ref: 23). Repeated boiling may actually lead to further concentrating of certain chemicals as the water is boiled off.

If it is felt that the that Infant Feeding in Emergencies guidelines are not that relevant in this country then it’s really time to think again. My feeling is that this highlights just how important it is in the UK as well as the rest of the world and I would urge the Government and other agencies to ensure systems are in place to protect this vulnerable group at such a difficult time.

One real concern is for those people in disadvantaged groups and who are already experiencing inequalities in health. They are likely to be the most affected in these circumstances as they are more likely to have health problems, have lower incomes (ready-to-feed cartons of formula are usually more expensive than powdered formula), less likely to be able to afford house insurance (to replace any damaged items such as sterilisers, bottles and teats), and may be less likely to have their own transport to collect water from depots.

Sarah Saunby
Sheffield Area Contact, Baby Milk Action & BfN Registered Breastfeeding Supporter.


IBFAN Infant feeding in emergencies, 2000

WHO Infant feeding in emergencies; a guide for mothers, 1997

Infant Feeding in Emergencies, Module 1;for emergency relief staff WHO, UNICEF, LINKAGES, IBFAN, ENN, 2001

WHO/ UNICEF Global Strategy on Infant and Young Child Feeding, 2003

Food Standards Agency Revised guidance on powdered infant formula, 2006

Food Standards Agency / Department of Health Guidelines for Health Professionals on safe preparation, storage and handling of powdered infant formula

The Guardian Formula milk is even more deadly in disaster zones, by Marie McGrath, Wednesday May 30th, 2007

BBC News Floods force thousands from homes Tuesday, 26 June 2007


Health Professionals Letter on Enterobacter sakazakii Infections Associated With Use of Powdered (Dry) Infant Formulas in Neonatal Intensive Care Units, U. S. Food and Drug Administration, April 11 2002 Ref: Muytjens HL, Roelofs-Willemse H, Jaspar GHJ.

Iversen, C., & Forsythe, SJ. 2004 Isolation of Enterobacter sakazakii and other Enterobacteriaceae from powdered infant formula milk and related products. Food Microbiology as cited in New Scientist 5 June 2004.

Quality of powdered substitutes for breast milk with regard to members of the family Enterobacteriacae. J Clin Microbiol 1988;26:743-746.

Iversen, C., & Forsythe, SJ. 2004 Isolation of Enterobacter sakazakii and other Enterobacteriaceae from powdered infant formula milk and related products. Food Microbiology as cited in New Scientist 5 June 2004.

The Infant Formula and Follow-on Formula Regulations 1995; Statutory Instrument 1995 No. 77

The WHO / UNICEF International Code of Marketing of Breastmilk Substitutes and Subsequent WHA Resolutions

COI and FSA Powdered Infant Formula Qualitative Research Final Report Coi Ref: 272546 (Define ref: 1547) April 2006

WHO Infant feeding in emergencies; a guide for mothers, 1997

WHO Infant feeding in emergencies; a guide for mothers, 1997

Katherine Dettwyler, PhD A Natural Age of Weaning

Baby Milk Action Briefing Paper, Bottled water and infant feeding, June 1998

Health Protection Agency, Health Advice Following Flooding

Food Standards Agency, Food Safety advice for people affected by flooding, Tuesday 24th July 2007

Centres for Disease Control and Prevention, Keep Food and Water Safe after a Natural Disaster or Power Outage


Anonymous said...

Thanks for this article. The floods show just how fragile our infrastructure is. If we don't stop climate change soon, extreme weather events plus sea level rise will mean more floods in more parts of the UK - oh yes and the rest of the world too! These are the years when we have to get everybody breastfeeding, soon.

Anonymous said...

La Leche League helped many breastfeeding mothers during the flooding in New Orleans. They have a wealth of useful information here:

Unknown said...

The Emergency Nutrition Network has been working with infants in emergencies for some time. We have written to the Foods Standard Agency saying that the allowed sodium levels in water to make up formula is far too high. We have asked for clarification about how these levels are allowed for infants but as yet have received no reply. We recommend that bottled water with a sodium concentration of less than 20mg and preferably less than 10mg is used. As the solute load increases the more you boil the water we also recommend that the bottled water should be boiled but only the amount that is needed at that time/ or that can then be kept clean.

Anonymous said...

"Mothers using powdered formula should be informed that the ready to feed cartons of infant formula may pose less of a risk than powdered feed"

Shocking that this isnt standard practice!