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,
Only an opinion: There are several research papers from several contexts that document bacterial contamination of bottled water. These include many well-known brands.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025974/

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1365-2672.1997.00353.x

https://www.researchgate.net/publication/290455821_Microbial_assessment_of_bottled_drinking_water_of_Kathmandu_valley

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6222228/

An emerging problem is also that of micro plastic contamination that seems to be prevalent in a majority of bottled water types.

https://www.theguardian.com/environment/2018/mar/15/microplastics-found-in-more-than-90-of-bottled-water-study-says

Boiling/ filtration is difficult, but where possible (IMO) it should probably be recommended equivalently for bottled and other water sources. If the situation makes boiling and filtration impossible and water must be used 'as-is', then I would rather go with bottled than natural water sources. If the climate is hot and sunny, natural UV decontamination may be an option.

That said, water would normally be heated for making formula in any case. I've never made formula without hot water so not sure how soluble it is at low temperature.

Other (expensive) potential options for decontamination are:

UV light wands
http://www.berkeleywellness.com/self-care/over-counter-products/article/sanitizing-wands-do-they-really-kill-germs

the life straw / filter bottles.
https://www.lifestraw.com/products/lifestraw

Regards,
Paul

Dear Mija,

You may have heard that heating water is NOT routinely recommended in France when preparing infant formula.

See the document (both in English and French):

https://www.anses.fr/fr/system/files/MIC-Ra-BIB.pdf

see p 37 and 91

Note that this recommendation is applicable only in situations where tap water is safe, which is the case in most places in France where its quality is highly controlled permanently.

Dear all, reading all the articles and recommendations from the various experts I want to share with you the findings:
From WHO (thanks Alex!): How to reduce the risk
For infants at greatest risk, sterile liquid infant formula should be used where available. If powdered infant formula is used, correct preparation and storage reduces the risk of illness. Powdered infant formula should be prepared with water that is no cooler than 70ºC (in order to kill E. sakazakii) and prepared feeds should be consumed immediately or stored in a refrigerator (to prevent growth of E. sakazakii).
WHO states: Powdered infant formula should be prepared with water that is no cooler than 70ºC.

From some peer reveiwed journals that were shared I read that there is no guarantee that bottled water is clean and completely safe (at least not for 0-6 months).

This all combined- my take away is that if you use bottled water, ideally boil it before (and/or at least heat to above 70 degrees Celsius when you are absolutely sure your bottled water is safe) and add infant formula powder before it cools down to 70 degrees Celsius.
I refer here only to a disaster setting in middle/high income countries where one deals with a non-breastfed infant.

Other thoughts?

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

Mija,

Victoria raises an important point. You should check the mineral content of water. All over the EU, the water should comply with strict quality criteria including a Na level < 200 mg/L.

See: https://www.en-net.org/question/3550.aspx#lastpost

This is important to avoid the risk of hypernatremic dehydration.

Some countries, including France, have specific rules for mineral water used for preparation of infant formula. See:

https://www.anses.fr/fr/system/files/EAUX2001sa0257.pdf

These specifications include additional lower limits for quite a few minerals, including SO4, Mg, Ca etc…. But as mentioned in my previous post, the standard recommendation is to use standard unboiled tap water just complying with the EU regulations above.

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

Both Victoria and Ali mention a sodium content of water for preparing infant formula of less than 20mg/L. This is the level below which mineral water can be marketed in the EU as “Suitable for a low-sodium diet”. This is very low, corresponding to about 1 mmole/L, and would make many sources of water unsuitable for infant feeding in many tropical countries.

The renal solute load of a typical infant formula is about 135 mOsm/L (1). As mentioned by Ali, the solute load (more exactly, the potential renal solute load PRSL) is the problem limiting the sodium (and overall mineral) content of water. Limiting the amount derived from sodium in water to less than 1 mmole to make an infant formula with a total of 135 mOsm/L PRSL seems unnecessarily strict to me and may lead to the use of bottle water in many places where it is presumably not needed.

I never heard of a problem of excess Na in healthy European children fed formulas made from tap water containing a maximum of 200 mg Na /L., which is equivalent to 9 mmole/L of Na. Arguably, it is possible that the Na level in water is usually much lower than that.

1. Fomon SJ, Ziegler EE. Renal solute load and potential renal solute load in infancy. J Pediatr. 1999;134:11–4.

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

Dear colleagues
I want to sincerely thank you all for your very useful comments. It led to an animated discussion on bottled water, for sure. I have highly appreciated your valuable inputs.

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.