Karleen D Gribble* and Nina J Berry
Corresponding author: Karleen D Gribble firstname.lastname@example.org
International Breastfeeding Journal 2011, 6:16 doi:10.1186/1746-4358-6-16
(2012-01-29 02:58) University of Western Sydney
After the publication of our paper ��Emergency preparedness for those who care for
infants in developed country contexts�� the authors received questions, helpful comments
and suggestions for possible modification of emergency kits for babies. We would
like to respond.
Several health professionals and mothers questioned whether there was a place for
a chemical sterilisation process in emergencies. Chemical sterilisation could be used
in an emergency situation however, there would be little benefit to doing so. Thorough
washing using hot water of feeding and preparation implements is required before sterilisation.
Furthermore the water used for chemical sterilisation needs to be renewed every 24
hours. Thus, avoiding sterilisation by boiling by using chemical sterilisation would
only save a small amount of water and fuel.
Some have questioned the volume of water required for hand washing, suggesting that
much less water is required. The authors allowed 500 mL for each hand washing. This
figure was chosen after discussion with Water, Sanitation and Hygiene (WASH) specialists
in the humanitarian sector. It should be recognised that in an emergency situation,
contamination of surfaces with waste is common and hands can become very soiled. Five
hundred millilitres to thoroughly clean dirty hands is a conservative estimate based
on field experience. However, the authors recognise that there is no research to indicate
how much water is needed to thoroughly clean hands and that such research would be
Reducing the volume of water required to be stored in the ready-to-use infant formula
kit is possible if disposable knifes can be used to open the containers of ready-to-use
infant formula. This would reduce the amount of water required to be stored to 56L.
Disposable knifes might be either high quality plastic knives that are intended to
be disposable or metal knifes that are intended to be reusable but are disposed of
after a single use. Care needs to be taken to ensure that the knives are sharp enough
and strong enough to open the containers.
The authors have been made aware that in some locations it is possible to purchase
ready-to-use infant formula in disposable bottles and with disposable teats. This
option may be more cost effective and take less space to store than purchasing ready-to-use
infant formula and bottles and teats separately. However, use of this product still
requires the opening of the bottle before assemblage with the teat. Therefore water
to clean hands and a preparation area are still required. This option does not materially
change the requirements for the ready-to-use infant formula kit.
Some mothers expressed confusion about the amount of ready-to-use infant formula that
needs to be stored, stating that they believed that the volume suggested was excessive.
It should be understood that the amount of ready-to-use formula stored needs to be
based both on the anticipated volume of milk that the infant would be expected to
consume and the number of feeds per day that the infant is expected to need. This
is because once a package of formula is opened it must be fed immediately to the infant
and any leftover formula discarded; left over infant formula cannot be saved to be
fed to the infant later. Thus, if an infant requires frequent small feeds (most likely
in a very young infant), the amount of formula that needs to be stored may be much
greater than the volume that the infant will actually consume because of the number
of feeds required each day.
One mother suggested to the authors that it would be possible to reconstitute powdered
infant formula with stored water in disposable bottles, negating the need for heating
water for cleaning and sterilisation. This would require storage of the same number
of bottles and teats as for the ready-to-use infant formula kit but also make it more
feasible to use powdered infant formula in an emergency situation. This option has
some risks. In particular, reconstitution of powdered infant formula with cool water
does not deactivate any bacteria present in the infant formula. Whilst intrinsic contamination
of powdered infant formula is common , infection causing illness as a result,
is rare. However, it should be noted that medical resources required to treat infections
may not be readily available during emergencies.
It should also be noted that the risk of infection differs depending on characteristics
of the infant with newborns, premature or low birth weight infants and infants otherwise
immunocompromised over represented amongst those infected . Mothers with healthy
older infants may decide that the risk posed by intrinsic contamination of powdered
infant formula is acceptable and that they are willing to reconstitute infant formula
with water at ambient temperature.
The other factor to consider is the quality of water for reconstitution. Ordinary
bottled water is not sterile and can contain levels of microbes greater than that
in tap water . Tap water itself can be contaminated with disease causing organisms
[4-6]. Long-term storage of water can allow bacterial proliferation . Guidelines
for the safe storage of water for emergency use are available and include practices
such as rinsing storage containers with bleach prior to use, limiting storage to six
months and chlorination of water [8, 9]. In some locations it is possible to purchase
sterile water for reconstitution of infant formula.
Given that the option of reconstituting powdered infant formula in disposable bottles
involves practices that are more likely to result in the infant formula containing
higher levels of bacterial contamination than is usually the case, it is even more
important that the formula be fed immediately to the infant and the unused portion
If considering using powdered infant formula with disposable bottles in an emergency
kit, caregivers should ensure that the volumetric measurements on the feeding bottle
are accurate. Clinical experience has shown that volumetric measurements on feeding
bottles can be inaccurate and if the bottle is used to measure water for reconstitution,
errors resulting in over or under-dilution of the infant formula can occur
Thus, while reconstitution of powdered infant formula in disposable bottles is certainly
feasible, the risks associated with it require careful consideration. It is unlikely
that this option would be recommended by health authorities because of these risks.
If individual caregivers decide that this option is one that they wish to use, ensuring
that they understand how to minimise the risks is important. The risks of this option
are decreased if the infant is older, has no history of low birth weight, prematurity
or immunocompromise, if sterile water is used for reconstituting the powdered infant
formula and if the formula is fed immediately to the infant.
Some concerns were raised about the cost of the emergency kits for formula fed infants.
The figures provided were based on the cost of purchasing the products at one of Australia��s
major supermarkets. The cost is likely to vary widely depending upon location and
the ability of the individual to source the cheapest possible products. It should
be recognised however, that in the event of an approaching emergency (such as a cyclone
or hurricane) that caregivers will have limited options for sourcing the items in
the kits and costs may be much greater than those provided in the paper.
The authors would welcome further comment and questions from health professionals
Karleen D Gribble
Nina J Berry
1. Forsythe SJ: Enterobacter sakazakii and other bacteria in powdered infant milk
formula. Maternal and Child Nutrition 2005, 1:44-50.
2. WHO, FAO: Enterobacter sakazakii and other microorganisms in powdered infant formula.
Geneva: WHO; 2004.
3. Lalumandier JA, Ayers LW: Fluoride and bacterial content of bottled water vs tap
water. Archives of Family Medicine 2000, 9:246-250.
4. Almeida A, Moreira MJ, Soares S, Delgado ML, Figueiredo J, Silva E, Castro A, Cosa
JM: Presence of Cryptosporidium spp. and Giardia duodenalis in drinking water samples
in the north of Portugal. Korean Journal of Parasitology 2010, 48:43-48.
5. Rudi K, Tannaes T, Vatn M: Temporal and spatial diversity of the tap water microbiota
in a Norwegian hospital. Applied and Environmental Microbiology 2009, 75:7855-7857.
6. Xi C, Zhang Y, Marrs CF, Ye W, Simon C, Foxman B, Nriagu J: Prevalence of antibiotic
resistance in drinking water treatment and distribution systems. Applied and Environmental
Microbiology 2009, 75:5714-5718.
7. Morais PV, Da Costa MS: Alterations in the major heterotrophic bacterial populations
from a still bottled mineral water. Journal of Applied Bacteriology 1990, 69:750-757.
8. Food and Water Concerns [http://www.bt.cdc.gov/disasters/earthquakes/food.asp]
9. Water [http://www.fema.gov/plan/prepare/water.shtm]
The authors declare that they have no competing interests.
BioMed Central Ltd unless otherwise stated. Part of Springer Science+Business Media.