IBFAN emphasises that breastfeeding is the norm: it is the gold standard and protects the health of vulnerable infants. Artificial feeding using breastmilk substitutes and feeding bottles and teats (nipples) is a deviation from this norm. It can involve serious health risks and extra precautions should be taken when preparing, storing and handling feeds and selecting feeding utensils.To address this problem, the UN’s World Health Organization and Food and Agriculture Organization have issued Guidelines on safe preparation storage and handling of powdered formula: http://www.who.int/foodsafety/publications/powdered-infant-formula/en/
Are the bacteria in powdered formulas friendly or unfriendly?
Unfounded claims for beneficial bacteria
Baby food companiesmanufacture and marketpowdered milk formulas and cereal products for infants and young children. These companiesmake unfounded claims on product labels, stating that their product contains special ingredients which are alleged to improve growth, make digestion easier or protect against infections. Such additives include probiotics, the so-called ‘friendly bacteria’ which are claimed to improve infant health and make the formula ‘even closer to breastmilk’. The heavy promotion of products claiming such benefits for these added probiotics gives some companies a competitive edge over others.
Yet these claims are unsubstantiated by scientific evidence, meaning that parents, care-givers and health professionals are misled (1).
Failure to warn about harmful bacteria
At the same time, the baby food companies fail to state on product labels that powdered infant formulas and cereals may also contain harmful bacteria – the definitely ‘unfriendly bacteria’. Thesecompanies do not inform parents and health professionals that powdered formulas are not sterile and can also contain pathogenic bacteria, such as Salmonella species or Cronobacter/Enterobactersakazakii. These bacteria can be introduced during the manufacturing process and may cause severe invasive infections which can be fatal or cause life-long disability.
All those responsible for the care and healthy development of infants and young children must be warned of this risk.
World Health Organization guidance informs – and warns
For this reason, in 2007 the World Health Organization, WHO, producedGuidelines for the safe preparation, storage and handling of powdered infant formula. These Guidelines state in the very first sentence “Powdered infant formula (PIF) has been associated with serious illness and death in infants due to infections with Enterobactersakazakii. During production, powdered infant formula can become contaminated with harmful bacteria such as Enterobactersakazakii and Salmonella enterica. This is because, using current manufacturing technology, it is not feasible to produce sterile PIF.” In these Guidelines, WHO insists that “Users of PIF are made aware that powdered infant formula is not a sterile product and maybe contaminated with pathogens that can cause serious illness. Correct preparation and handling reduces the risk of illness.” (2).
This risk of contamination can thus have serious consequences for the survival and health of infants and young children.
Steps to reduce a risk that cannot be eliminated
There is no such thing as safe formula feeding, as evidenced by the repeated withdrawals and recalls of potentially contaminated infant and follow-on formulas, as well as baby cereals. Theseofficial withdrawals are regularly documented since 2002 by the International Code Documentation Centre in their Product Recall lists:https://www.ibfan-icdc.org/wp-content/uploads/Product-Recall-List-2014-2019.pdf and https://www.ibfan.org/fact-contaminants-reports-recall/
The WHO Safety Advice “How to Prepare Formula for Bottle-feeding at Home” explains the careful preparation that is needed to reduce risks:
“This leaflet contains new information to help you prepare bottle feeds from powdered infant formula as safely as possible.”http://www.who.int/foodsafety/document_centre/PIF_Bottle_en.pdf
The decontamination step
Instructions for careful preparation include the decontamination step, also called the lethal or ‘kill’ step. This step is recommended by the WHO Guidelines to inactivate any harmful bacteria which might be present, even in unopened tins of powdered formula.
This is a sensible but stringent precaution for all users of PIF. Species of pathogenic bacteria such as Salmonella and Cronobacter/Enterobacterthrive and multiply in the warm milk when the powdered formula is made up with lukewarm water. However, such bacteria are heat resistant and so the water needs to be very hot to kill them and thus prevent rapid multiplication. Reconstitution with water first boiled and then cooled to no less than 70°C is the lethal step required for inactivation. Prepared formula should be fed to the baby promptly and then any leftovers must be discarded and not re-used.
Several governments have issued guidance and policies to implement the WHO Guidelines, including the decontamination step. However, there is evidence that the companies are actively opposing the WHO Guidelines so as to protect their market for formulas with ‘added probiotics’. This is because the added probiotics, on which all the company claims are based, are heat-sensitive bacteria: they are killed off by reconstitution with water first boiled and then cooled to no less than 70°C. Therefore the claims made by the companies that their formulas are ‘modelled on breastmilk’ or ‘patterned after breastmilk’ are invalidated. It is only the living fluid, breastmilk, which provides the baby with live anti-infective agents and helps boost the development of its still immature immunesystem.
The new WHO Safety Advice therefore confirms “Breast is best:
“The World Health Organization (WHO) recommends that infants are exclusively breastfed for the first six months of life. Babies who are exclusively breastfed will get the best start for growth, development and health.”
Action needed to protect infant and young child health
The survey of examples being prepared by the International Baby Food Action Network, IBFAN, shows that manufacturers are still failing to warn of risks: labels on powdered formulas, whether milk-based or rice-based, and on baby cereal packages give incomplete and confusing instructions.
IBFAN aims to avoid undue alarm among parents, health professionals and care-givers, but insists on the need to alert them to the risks by providing accurate and objective information.
IBFAN groups therefore work to reduce the risks of invasive infections caused by bacterial contamination of powdered formula. What is urgently required is global action by government agencies to counter the inaction by formula manufacturers to implement the WHO Guidelines.
IBFAN groups worldwide continue to monitor product labels and advocate for mandatory measures by governments. (3)
The earlier article ‘Time for Governments and Industry to Take Action’ provides more detailed information and includes notes and references to the scientific articles and Expert Meetings jointly organized by the United Nations Food and Agriculture Organization (FAO) and the World Health Organization (WHO). The text was prepared after the deaths and life-long disabilities of infants in the USA and France caused by Enterobacter/Cronobacter and Salmonella infections: https://www.ibfan.org/cronobacter-sakazakii-infections-time-for-governments-and-industry-to-take-action/
For further information on the history of Cronobacter/Enterobacter, see the article by Farmer: ‘My 40-year history with Cronobacter/Enterobacter sakazakii – lessons learned, myths debunked, and recommendations.’
(1)The scientific evidence that these probiotic bacteria confer health benefits was seriously questioned in 2011 by the ESPGHAN Committee on Nutrition: ESPGHAN. The Opinion of the ESPGHANsummarised the lack of evidence to justify most of these claims.
(2) This provides the link to the WHO Guidelines in the six United Nations languages: https://www.who.int/foodsafety/publications/powdered-infant-formula/en
(3) The United States Centers for Disease Control and Prevention updates its advice on Cronobacter infection in infants and the latest version is at: https://www.cdc.gov/Features/Cronobacter/
and at : https://www.cdc.gov/cronobacter/
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