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Recommended Daily Infant Formula Amounts - increase the number of feeds to reduce the size of the feed

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Recommended Daily Infant Formula Amounts - increase the number of feeds to reduce the size of the feed

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https://static1.squarespace.com/static/59f75004f09ca48694070f3b/t/66a922686cba9b3d7526d721/1722360425292/Infant+milks_+a+simple+guide_July24_final.pdf

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Are glass bottles better than plastic bottles?

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Not sure what the best bottle is for your baby? Learn more about glass versus plastic bottles, and other types of baby bottles.

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Making infant milk safely — First Steps Nutrition Trust

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First Steps Nutrition Trust is a charity which provides clear, evidence-based and independent information and support for good nutrition from pre-conception to five years of age.

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Ever tried negotiating with your toddler? Not easy, right? Babies don't always have the most refined tastes or opinions. But when do they realise others might not be on exactly the same page as them? And how can parents encourage empathy?

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There is a vast selection of bottles and teats available online or in the High Street. Many of them claim to be closer

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Can you use your dish washer to sterilise bottles?

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Can you use your dish washer to sterilise bottles?

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Can you use a dishwasher instead of a steriliser?

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Wondering whether you can sterilise baby bottles in a dishwasher — or use a dishwasher to safely clean bowls, spoons and other baby weaning equipment? AMI microbiologists provide expert advice to Helen Brown of Made for Mums on what you can and can’t do, depending on your baby’s age.

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Questions about infant milk safety Are powdered infant milks sterile? Powdered infant milks are not sterile and they may contain harmful bacteria. However, if milks are made up appropriately for infants, they should be safe. Salmonellaand Cronobacter sakazakii(previously known as Enterobacter sakazakii)are the organisms of greatest concern in infant formula and a range of Cronobacterspecies ...

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There is a vast selection of bottles and teats available online or in the High Street. Many of them claim to be closer

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1M views · 2.5K reactions | How to make a bottle of formula milk | Expert Kristy demonstrates how to make a bottle of formula milk up for your baby. 🍼 | By Sandwell and West Birmingham NHS Trust | Facebook

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Expert Kristy demonstrates how to make a bottle of formula milk up for your baby. 🍼

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NCT Parent Hub - Pregnancy and parenting information exclusively for NCT Antenatal course attendees.

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Paediatric First Aid Paediatric First Aid Information about our courses Learn more Dates of upcoming courses Learn more

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Information about how milks are made, the ingredients used, the infant milk market, infant feeding safety and other general information

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UK Laws                      Regarding Infant Formula       

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UK Laws                      Regarding Infant Formula       

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Infant formula, follow on formula and infant milks marketed as Foods for Special Medical Purposes

EU Delegated acts
Regulations governing the composition and marketing of infant milks changed on the 22nd February 2020 when the retained EU directive Foods for Specific Groups (FSG) (609/2013) which informs UK regulations, came into force.

The directive contains delegated acts. EU delegated regulation 2016/127 relates to infant formula and follow-on formula (except those manufactured from protein hydrolysates, see below). EU delegated regulation 2016/128 relates to infant milks marketed as foods for special medical purposes (FSMPs).

The UK has adopted these regulations, so infant formula, follow on formula and infant milks marketed as foods for special medical purposes (FSMPs) manufactured from the 22nd of February 2020 must comply with the new regulations. The one exception is infant and follow-on formula manufactured from protein hydrolysates which are governed by Directive 2006/141/EC. These products will be covered by Delegated Regulation 2016/127 only from February 22nd 2022.

It should be noted that the regulations pertain only to composition and marketing, and there are no legal directives relating to the temperature at which powdered infant milks should be reconstituted for safety.

These regulations will remain in force until any alternative regulatory arrangements are made.
UK Statutory Instruments
The Statutory Instruments implementing the EU directives can be accessed here:

Infant and follow-on formula manufactured from protein hydrolysates are covered by The Infant and Follow-on Formula (England) Regulations 2007 (and similar laws in Wales, Scotland and Northern Ireland) until February 22nd 2022.

The regulations related to the marketing and labelling of infant milks (except infant formula and follow on formula made from protein hydrosylates) (which are the same across the four nations) are summarised here:

The DHSC provides information about nutrition legislation in the UK here: Nutrition legislation information sheet - GOV.UK (www.gov.uk).

Detailed information about the regulations related to the composition of infant milks can be found at www.infantmilkinfo.org.
Milk drinks for children over one year of age
It should be noted that there are NO regulations for milks marketed for children over 12 months of age (referred to as 'growing up milks' and 'toddler milks' by manufacturers).

In 2013, the Department of Health provided guidance on interpreting the previous 2007 statutory instruments relating to infant formula and follow on formula, in association with the Welsh Government, and Food Standards Agency in Scotland and Northern Ireland. This guidance therefore applied across the UK. The guidance notes explained the regulations in more detail and were aimed at all companies that manufacture, process, distribute, use, sell or import infant formula and follow-on formula, and those local authorities responsible for enforcing the legislation in this area.

The Department of Health and Social Care regulatory team are in the process of producing new guidance notes which explain how the new infant formula and follow on formula regulations outlined above are interpreted by Government. These are important in terms of monitoring, and challenging inappropriate marketing and labelling of these products. As soon as they are available we will link to them here.

The UK laws on the composition and marketing of infant formula, follow on formula and infant milks marketed as foods for special medical purposes aim to ensure that:

The essential composition of infant formula and follow-on formula satisfy the nutritional requirements of infants in good health, as established by generally accepted scientific data

The labelling allows the proper use of such products and promotes and protects breastfeeding

The rules on composition, labelling and advertising are in line with the principles and aims of the International Code of Marketing of Breast-milk Substitutes ('the Code')

Information provided to carers about infant feeding does not counter the promotion of breastfeeding

Other main provisions are that:

No product other than infant formula may be marketed or otherwise represented as suitable for satisfying by itself the nutritional requirements of normal, healthy infants during the first months of life until the introduction of complementary feeding

These products shall not contain any substance in such quantity as to endanger the health of infants and young children

There are limits on the level of any individual pesticide residue that may be present and specific upper limits for very toxic pesticides

There are mandatory and non-mandatory particulars for labelling

Requirements are made for the labelling which apply to presentation and advertising

There are restrictions on nutrition and health claims that can be made in relation to infant formula and infant milks marketed as foods for special medical purposes (but not follow-on formula)

The labelling, presentation and advertising of infant formula follow-on formula and infant milks marketed as foods for special medical purposes should avoid risk of confusion by the consumer between these three product types

There should be restrictions on the advertising of infant formula

Regulatory civil servants in the Department of Health and Social care and The Food Standards Agency, Trading Standards Officers in local authorities, and the Advertising Standards Authority are responsible for handling breaches in UK regulations and relevant codes of practice.

In theory, the Food Standards Agency works closely with local authorities to investigate complaints via local food safety teams or trading standards officers, depending on what is being reported (their scope of work covers trading practices and product labelling, including claims). The 'Home Authority Principle' means that trading standards officers must pass on complaints to officers in the area where the head office of the offending company is based.

In practice, however, no monitoring or enforcement of the UK legislation takes place, and companies are not prosecuted for breaking the law; see the 2020 UNICEF/WHO/IBFAN Code Implementation Status Report.

The Advertising Standards Authority (ASA) deals with complaints relating to broadcast (radio and television) and internet advertising, by referring to their voluntary codes. The ASA is industry funded. It should be noted that the ASA does not accept that violations of the Code and resolutions are breaches of the requirement that advertising be "legal, decent, honest and truthful".

Ofcom (the independent regulator and competition authority for the UK communication industries) also has relevant rules regarding product placement in television programmes, where products that cannot be placed in programmes include "infant formula (baby milk), including follow-on formula". However, such items may be used as props. Companies can be fined for breaking the rules.

Given the absence of monitoring and enforcement of UK legislation, one way you can take action is by reporting any violations you observe. Baby Milk Action monitors baby food (including breastmilk substitutes) company marketing practices in the UK (in relation to both the UK laws and the Code), on behalf of the Baby Feeding Law Group UK. Please click here to share the details of the observed violation.

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Infant formula, follow on formula and infant milks marketed as Foods for Special Medical Purposes EU Delegated acts Regulations governing the composition and marketing of infant milks changed on the 22nd February 2020 when the retained EU directive Foods for Specific Groups (FSG) (609/2013) which informs UK regulations, came into force.

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Study raises concerns over powdered infant formula preparation machines

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A study by Swansea University academics into powdered infant formula preparation safety has revealed that 85% of the 74 infant formula preparation machines tested by parents in UK homes did not appear to produce water that would be hot enough to kill all harmful bacteria in infant formula, and this…

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The NHS recommends exclusively breast-feeding for the first six months of your baby's life to give him or her the best start. Breast milk gives babies all the nutrients they need, and helps protect them from infection and disease.
If you choose to breast feed, you may still want to buy bottles for when you have expressed milk, giving you flexibility over where and who your baby is fed by. Our breast pump reviews and advice will help you choose breast-feeding products to help.

Even if you don't breast feed - you might not be able to or may choose not to - and no matter whether you then feed your baby with expressed breast milk or with formula, choosing the right bottle is important.

Finding the right bottle for their baby is a task many parents find troublesome. That's because different bottles, and different teats, suit different babies. Here we take a look at the various types of bottles and teats available.

Baby bottle types - how to choose

Standard baby bottles

These narrow, cylindrical bottles are a familiar sight. You can buy them plain, or decorated with various designs. They will fit a range of standard teats, and have self-seal lids.

Wide-necked baby bottles

These are shorter and fatter than standard bottles, but take the same amount of milk. They usually take silicone rather than latex teats, and will normally have a self-sealing lid.

Anti-colic bottles

Anti-colic bottles are designed to reduce the amount of air a baby takes in while feeding, which is thought to be a possible cause of colic (uncontrollable crying in a healthy baby, as a result of wind).To reduce the amount of air swallowed, these bottles usually have air vents, tubes or collapsible bags for the milk.

If your baby is unsettled after feeds, it might be worth trying out one of these bottles.

Unusually shaped baby bottles

Some bottles are shaped to be easier for little hands to hold. For example, oval-shaped bottles with a hole in the middle for fingers to grip are widely available.

Heat-sensitive baby bottles

These bottles have an in-built temperature sensor, which changes colour if the milk is too hot.

Self-sterilising baby bottles

Provided that you have a microwave, these bottles (made by baby brand Mam) don't require any additional equipment for sterilising. You pour water into a chamber in the base of the bottle, arrange the bottle components on top and microwave for three minutes.

Baby bottle 'sets' or 'systems'

Some manufacturers produce bottle sets including attachments such as handles and trainer spouts, which you can fit on to the bottles when your baby reaches the appropriate stage.

Disposable baby bottles

These aren't so much disposable bottles as disposable, sterilised bags which fit into a bottle. You put them into the bottle, fill them with milk, and throw them away when your baby has finished.

Glass baby bottles

These aren't widely available, but parents who are concerned about chemicals in plastic bottles and about the environmental disadvantages of using plastics often opt to buy them.

Baby bottle teats

Teats are made from either silicone or latex, and babies tend to prefer one or the other. There's no great difference between them, but latex teats tend to be softer and more flexible although may need to be replaced regularly, while silicone teats have a reputation for being more durable.

Wide-necked bottles normally only take silicone teats, while standard bottles can take either. The usual shape for a teat is either the traditional bell shape or a bulbous shape that's meant to resemble the shape of a nipple. You may need to try both to find which type your baby prefers.

You can read our first look review of the that's designed to fit onto ready-made formula cartons and water bottles.

Teats are either latex or silicone - although there is no great difference between them, silicone teats have a reputation for being more durable, while latex teats are said to feel more like a nipple.

Teats also vary in shape, and can be bell-shaped or naturally shaped to resemble a nipple.

When it comes down to teat shape and feel, there is no evidence to suggest that one is better than the other, so it is really a question of which your baby prefers.

Flow rate

How fast the milk goes into your baby's mouth, known as the 'flow rate', depends on the number and type of holes in the tip of the teat.

The flow rate suitable for your baby is not necessarily related to his or her age. Change the teat to a slower-flow one if your baby is spluttering his or her milk out and choking, or to a faster one if he or she is sucking hard but seems to be getting frustrated.

You can also buy variflow teats which either work through increasing flow as the baby's sucking increases or by you rotating the teat and bottle into different positions.

Cleaning and sterilising baby bottles

Baby bottles and teats should be sterilised every time you use them - babies under a year are particularly vulnerable to nasty bacteria, which sterilising will kill.

Before you use a steriliser, you'll need to clean the bottles and teats by hand, or in the dishwasher.

There are different types of sterilisation methods: using a microwave or electric steriliser to steam bottles is one of the easiest ways, but you can also boil bottles or sterilise them in cold water with specialised tablets.

Find out more about the .

Top tips for buying baby bottles and teats

If you'll be bottle-feeding your baby more or less from birth, you'll need to buy six bottles.

Even if you're breast-feeding or planning to, some people like to have one or two bottles to hand. And you'll need them if you plan to express breast milk.

Teats normally come with the bottle but you can also buy them separately. It pays to have more teats than bottles, as they'll need replacing.

Most bottles will hold 225ml (8fl oz) of milk, although you can get smaller bottles for new babies.

You'll need a bottle brush to clean your bottles properly before sterilising, and a teat brush to get into the tips of the teats.

When buying plastic bottles, check that they do not contain Bisphenol A (BPA) in the plastic. The National Childbirth Trust (NCT) warns that BPA can leach into the milk and if absorbed by the body, can interfere with healthy growth. Since June 2011, it's been illegal to sell baby bottles containing BPA in the EU.

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The NHS recommends exclusively breast-feeding for the first six months of your baby's life to give him or her the best start. Breast milk gives babies all the nutrients they need, and helps protect them from infection and disease.

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Infant feeding items include bottles and the nipples, rings, and caps that go with them. Certain bottles also may include valves or membranes. Some infants may be fed with a syringe, medicine cup, spoon, or supplemental nursing system.

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centers for disease control and prevention

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How to Clean, Sanitize, and Store Infant Feeding Items

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Infant feeding items include bottles and the nipples, rings, and caps that go with them. Certain bottles also may include valves or membranes. Some infants may be fed with a syringe, medicine cup, spoon, or supplemental nursing system.

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Why do I need to sterilise my baby's feeding equipment?

A baby's immune system is not as well developed as an adult's. So they could become very ill if they drank milk that was contaminated with bacteria.

Milk provides an ideal breeding ground for bacteria that could cause food poisoning, but sterilising kills the majority of these bacteria. Sterilising all your baby's feeding equipment helps to protect your baby against these illnesses, in particular diarrhoea and vomiting (First Steps Nutrition Trust, 2021).

That's why, in the UK, the NHS recommends that all equipment used for collecting, storing or feeding expressed breastmilk or formula milk for babies under 12 months is sterilised before use (NHS, 2019a).

How long do I need to sterilise bottles and other feeding equipment for?

The NHS recommends sterilising all feeding equipment each time you use it for at least the first 12 months of your baby's life (NHS, 2019a). Washing items in a dishwasher doesn't have the same effect of killing the bacteria (NHS, 2019a; 2021).

Do I still need to wash feeding equipment before sterilising it?

Yes, it's still important to wash your baby's feeding equipment thoroughly to remove any dried-on milk, because bacteria can grow on any remaining milk. As soon as possible after you've used bottles, teats, breast pumps and any other milk collection, storage or feeding equipment, thoroughly wash them in warm, soapy water. Check they are not damaged, too (NHS, 2021).

If you're using a dishwasher, make sure you place bottles and teats face down, so they don't fill with dirty water. If you're washing by hand, using clean bottle and teat brushes will help you reach every part of the bottle, teat or breast pump. Only use these brushes for cleaning your baby's bottles and teats (NHS, 2019a).

After washing, rinse all equipment in clean, cold, running water before you sterilise it (NHS, 2021).

Which method of baby bottle sterilisation is best?

We can't say for sure which method of sterilisation is more effective than another. So you might want to consider what suits you best to help you decide which method to use.

Cold water sterilising

Cold water sterilisers use chemicals, which are mixed with cold water, to sterilise feeding equipment. They can be bought in tablet or concentrated liquid form, which you add to cold water. They are also available as a ready-to-use sterilising solution.

Items you're sterilising need to be submerged in the cold water solution for at least 30 minutes before you use them (NHS, 2019a; 2021). This method can be used to sterilise a large number of items, making them ready for use as soon as you need them.

How to cold water sterilise baby-feeding equipment

Use a clean, watertight container with a well-fitting lid.

Make up the sterilising solution in accordance with the manufacturer's guidelines.

Try to make sure all items remain fully submerged in the solution and that there are no air bubbles. Items might need to be held in place by a floating cover or plate.

Leave the items in the solution for at least the length of time specified by the manufacturer and follow the guidance on how often to change the solution.

Remove items from the solution immediately before use. Shake off any excess solution or rinse with cooled boiled water from the kettle (not the tap).

Make sure you have clean, dry hands before removing items from the solution.

(NHS, 2019a; 2021; Public Health Scotland, 2021)

Boiling

The majority of bacteria are killed at a temperature of 100°C (boiling point of water) for 10 minutes. You do not need any specialised equipment, so this method is particularly useful if you're only sterilising occasionally.

Boiling might be particularly useful in the very early days. For example, if you need to hand express some colostrum to feed to your baby using a small cup or teaspoon you've sterilised (see our article about expressing and storing your milk for more information).

If you do use this method on a regular basis, some items may be damaged by the heat so might need replacing more regularly (NHS, 2021).

How to sterilise baby-feeding equipment by boiling

Check that the item is safe to boil.

Bring a saucepan of water to the boil.

Submerge the items to be sterilised in the boiling water, making sure they are completely covered and continue to boil for at least 10 minutes. You could set a timer so you don't forget to turn the heat off.

Never leave hot pans and liquids unattended.

Keep the items covered and remove them just before use.

(NHS, 2019a; 2021)

Steam sterilising

This works on the same principle as boiling. Water is added to the sterilising unit and the water boils, creating steam that kills the bacteria.

Several different types of steam sterilisers are on the market. Some steam sterilisers are used in a microwave, while others are stand-alone units that plug into the mains. Some microwave steam sterilisers can also be used as cold-water sterilisers.

It is also possible to buy reusable steriliser bags for use in the microwave, or bottles that can be sterilised alone in the microwave. These might be a more convenient option when you're away from home but have access to a microwave, or if you don't think you'll need to sterilise equipment very often.

How to steam sterilise baby-feeding equipment

Follow the steam steriliser manufacturer's instructions, which normally involves adding a specific amount of water to the unit and running it for a specific period of time. The length of time can vary from one steam steriliser to another.

Ensure the openings of bottles and teats are facing downwards in the steriliser.

Again, check the manufacturer's guidelines for information about how long you can leave items in the steriliser before using them.

(NHS, 2019a; 2021)

UV sterilising

UV light kills the majority of bacteria and viruses (including coronavirus) by destroying their genetic material and cell structure (Reed, 2010; Raeiszadeh and Adeli, 2020). UV sterilising units have UV light bulbs and reflective inner surfaces so the light bounces around and kills any microorganisms it touches.

UV sterilising units can be used to sterilise any baby equipment except latex rubber teats. As with other sterilisers, all items must be washed thoroughly first because even very small particles left on surfaces can deflect UV rays. Some units have a drying cycle so items can be put in straight after washing.

The advantages of UV sterilisation are that bottles can be used straight out of the machine without rinsing or cooling. They are also safer for the user because they don't use hot water, steam or chemicals and they are effective against a wider range of micro-organisms. They're long lasting, too - bulbs can last for over 2000 hours.

On the other hand, UV light doesn't pass through objects so everything must be completely dis-assembled and not touching. This might make UV sterilisers unsuitable for some things, e.g. the narrow tubing of some breast pumps. Also, the sterilisation cycle can take longer with these sterilisers.

What to do after sterilising

You can leave sterilised items in the steriliser or pan until you need them but the majority of manufacturers advise using or re-sterilising after 24 hours. If you do take sterilised items out, you'll need to put the teats and lids on the bottles immediately.

Clean and disinfect the area that you'll be using to prepare the feed or assemble the pump, or use the upturned lid of the steriliser.

Wash and dry your hands before handling sterilised equipment. Better still, use some sterile tongs.

Expressed breastmilk

Breastmilk contains ingredients that limit the growth of unwanted bacteria, but you'll still need to store and handle it carefully to prevent unwanted bacteria contaminating the milk. See our articles Expressing milk using a breast pump and Expressed Milk: Your questions answered.

You'll need to thoroughly wash and sterilise the cup, bottle or spoon and the washable parts of the breast pump just before you use them again (NHS, 2019b).

Formula milk

Powdered infant milks are not sterile, so it's important that they're made up in line with the instructions on the packet (NHS, 2019c). This will get rid of most of the micro-organisms that may be present (First Steps Nutrition Trust, 2021). Ready-made liquid formula milk is sterile until it is opened, but all feeding equipment will still need to be sterilised (NHS, 2021). See our articles Step-by-step guide to preparing a formula feed and What if I need to formula feed my baby away from home?

Any formula milk that's left in the cup or bottle at the end of the feed should be thrown away (NHS, 2019c). And you'll need to thoroughly wash up and sterilise the cup, bottle or spoon just before you use them again (NHS, 2019a).

Sterilising when out and about

Going out for the day or going on holiday can make the practicalities of sterilising, storing expressed breastmilk, or making up formula more challenging. So if you'd like to talk through how to do this when away from home, you can speak to one of our Breastfeeding Counsellors by calling our Infant Feeding support Line (see below).

Sterilising and microplastics

It has been reported that heating plastics frequently to the high temperatures needed for sterilisation by boiling or steaming them, then shaking when making up formula, releases microplastics from the bottles. The effect of these microplastics on humans is currently unknown (Li, 2020).

UNICEF have recommended parents follow current NHS guidelines until further research investigates the effect of these microplastics (IHV, 2020). Some parents prefer to use glass bottles to avoid microplastic contamination.

Where can I go for support?

You can speak to one of our NCT Breastfeeding Counsellors about any aspect of feeding your baby by calling the NCT Infant Feeding Line on 0300 330 070. The lines are open from 8am to midnight every day.

You might also find it useful to talk things through with your midwife or health visitor (NICE, 2015).
This page was last reviewed in February 2022.
Further information

NCT supports all parents, however they feed their baby. If you have questions, concerns or need support, you can speak to a breastfeeding counsellor by calling our NCT Infant Feeding Line on 0300 330 0700. Breastfeeding counsellors have had extensive training, will listen without judging or criticising and will offer relevant information and suggestions. You can also find more useful articles here.

You might find attending one of our NCT New Baby groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

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How to sterilise baby bottles, breast pumps and other feeding equipment | Baby & toddler, Feeding articles & support | NCT

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It can be hard to know what the best sterilising method for your baby's feeding equipment is and how to do it. Here's some information to help.

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From steam and cold water sterilisers to high tech UV devices, we review the best of this year's new baby bottle sanitisers

This article contains affiliate links. The products or services listed have been selected independently by journalists after hands-on testing or sourcing expert opinions. We may earn a commission when you click a link, buy a product or subscribe to a service.

Even if you're planning to exclusively breastfeed, like I was, it's important to be armed with the best steriliser. You're going to require some sort of disinfecting method, especially in the early days. For formula feeders or pump-users, it's even more essential to find the best bottle steriliser to suit your needs. Without a good system in place, cleaning and sorting bottles and accessories will feel like the bane of your existence.

Like many first-time mothers, I had no idea when I was pregnant whether breastfeeding would prove successful or how often I'd want to express or formula feed. As with every baby product, I was utterly baffled by the choice in sterilisers. Nine months on, I almost exclusively breastfeed but regularly pump and often travel, so I've needed different cleaning methods for varying scenarios.

I've tested them all for this article. You can read my reviews further down, followed by a detailed FAQ on how to use them, but if you're in a hurry, here's a quick look at my top five:

Which are the best sterilisers in 2024? At a glance

How to choose the best bottle steriliser

Lara Basini, a midwife and One Born Every Minute star, who runs a popular TikTok channel on all-things pregnancy and birth, explains: "The NHS recommends sterilising bottles and other feeding equipment for the first 12 months of a baby's life, when their immune systems are still fragile.

"Key methods include cold water sterilising (which requires a chemical to disinfect the water), steam sterilisers (electric appliances that generate hot vapour to clean items), microwave sterilisers (containers that also use steam, which you put in the microwave) and, more recently to the market, UV sterilisers (which use ultraviolet light; the only water-free method)."

There are, of course, advantages and disadvantages to all these, and the right solution for you will be highly dependent on how you choose to feed your baby. Scroll down to the bottom of this article for answers to the most frequently asked questions about steriliers, courtesy of Lara.

How I tested the best sterilisers

Over the course of nine months, from when my son was a newborn to now, I tested every method for sterilising our gear, across best-selling products from the leading brands, on bottles, pump parts, pacifiers, teethers and tableware.

So as not to cheat, I banned my fiancé from helping me figure out the appliances; relying on the instruction manuals alone. I took into account how long each one actually took to do its job (including cooldown and drying time, often not mentioned by brands in their flashy ads), the capacity, the number of functions, how easy they were to clean and how economical to buy and run.

If you have a recent addition to your family, by the way, you may want to read my guides to the best prams, baby carriers and baby bouncers, Cat Hufton's guides to the best high chairs, travel cots and running buggies and Nicola Cutcher's guide to the best reusable nappies.

1. MAM Electric Baby Bottle Steriliser & Express Bottle Warmer
£115.20, Boots Best overall, 9/10
We like: several sterilisation methods, plus other features, in one machine

We don't like: lots of bits and bobs to get to grips with

For pure versatility, and if you'll be using it daily, this model takes the cake. It works as an electric steriliser, microwave steriliser, cold water steriliser, food and bottle warmer, breast milk defroster, and has a 'keep warm' setting. It may be all you'll need from day one until after your baby is weaned.

As such, there are a lot of parts to contend with and it's not the easiest to get to grips with at first. But once you've put down the lengthy instructions, it's perfectly user-friendly.

As a steam steriliser, it's a spacious model that does its job in just over 10 minutes (seven minutes to sterilise, four minutes cooling time) and in microwave mode - useful if you're travelling - it takes about the same time, depending on your wattage. It also keeps items bacteria-free for up to 48 hours, twice the usual duration, and stores all your kit out of sight.

Aside from the steriliser functions, I love that this product comes with a MAM anti-colic bottle and pacifier and that it takes the worrisome calculations out of preparing bottles by keeping milk (or food) at the perfect temperature for 45 minutes.

Overall, this is a high-quality, all-singing, all-dancing gizmo that is great for first-time parents who won't yet know which sterilisation method they'll prefer, and will appreciate the extra feeding functions.

The system my own mother used ('and nobody died', she tells me), and still a favourite on maternity wards, the so-called 'Milton method' has been trusted for more than 70 years, and it doesn't get much simpler.

This five-litre plastic container holds a multitude of bottles, pumping equipment and smaller items with no need to fit them on a rack - simply toss your bits and bobs in with cold water and a sterilising tablet (or a glug of the liquid version) and 15 minutes later they'll be ready to use for up to 24 hours.

There's no need to rinse items after removing them from the solution either, but they will obviously be wet - and sensitive noses might pick up on the slight 'swimming pool' aroma this chemical leaves.

Technically all you require for this method is the Milton's tablets or liquid (this stuff is also great at removing tea and coffee stains from cups, as an aside) and a standard bucket, but you'll want to purchase the branded one, as it has a lid and a weighted grid to keep contents submerged.

Also very useful and worth a mention is Milton's Solo Travel Steriliser, essentially a smaller version (1.2l capacity) of the same thing that's great for on-the-go.

I'm aware this makes me tragic, but I found this unit so fun to use that after I'd finished with the bottles, I was looking around the house for more things to sterilise - baby bowls, scissors, toys, you name it. There's just something so space age and satisfying about it.

Somewhat resembling a mini-fridge, and certainly the most aesthetically pleasing steriliser I tried, this model uses UV light to sterilise your kit, killing viruses (including Covid and flu, according to the manufacturer), plus 99.9 per cent of bacteria and mould, without using water or chemicals.

I particularly liked that, with no steam, I never had to worry about bottles coming out hot to the touch. It also has a drying setting and functions as a storage cabinet (its adjustable shelves enable you to customise the layout), blasting its contents every two hours with a five-minute sterilising dose to keep your equipment disinfected and ready at all times.

The Philips UV bulb inside lasts up to 6,000 hours, and - a bonus if you're watching your electricity bills - it's more energy efficient than using steam, microwave or boiling.

This model's only downside is that it's not the fastest. Clear bottles take 10 minutes to sterilise, coloured bottles are done in 35 minutes, and the drying cycle takes half an hour. Personally I never found this to be an issue, though, as you can always skip the drying if you're in a rush.

Of all the methods, this is expert Lara's preference. "I would always go for the microwave option, as I am lazy and it's so easy and quick," she says. Personally, I have come to trust Philips over the years as being about the most reliable brand for homewares, and it's true of its Avent baby range too.

This microwave steriliser is super simple: just add a little water to the base, stack your items, put the unit in the microwave and start the cycle. Contents then stay sterile for 24 hours.

It's also budget-friendly and fast; delivering the goods in just two minutes for high-power microwaves (1200-1850W). In low-power microwaves (500-800W), it takes six minutes. I found the instruction manual to be the most straightforward I read.

Locking clips on the side ensure that you can't knock the lid off when moving it, so no burnt fingers - a nice feature. One thing to bear in mind, however, is to make sure it will fit it inside your microwave. While it is designed for most models (measuring 16.6 × 28 × 28cm), that doesn't include all of them.

I liked the tall, slimline design of this machine, which takes up less counter space than most comparable models, and the accessories tray that sits above (rather than around) the bottle grid. The tray is roomy enough for lots of pacifiers, teethers and other smaller items. The steriliser is also very light, with a nice digital interface, and comes with a handy measuring cup that takes the guesswork out of how much water to use.

It has several functions, including a sterilise-only, dry-only, or combo sterilise and dry cycle and can be used as storage, keeping contents sterile for 24 hours. If you're using Dr Brown's anti-colic bottles, widely considered to be excellent for reflux, then six of them will fit perfectly, though you can use other brands too.

It's very thorough, eliminating 99.9 per cent of bacteria, mould and the yeast that causes thrush, but it's slow compared to other methods (ten minutes to sterilise, another ten minutes cooling time, plus 45 minutes if you want to run the dry cycle). Like all electric steam sterilisers, it's a bit of a faff to clean; requiring monthly descaling, and you'll need to purchase a new filter after 12 months of use.

And a word of warning: you'll void the warranty unless you use distilled water, since tap water will cause a faster build-up of limescale.

This isn't cheap, so for infrequent trips you're better off with the aforementioned Milton's Solo Travel Steriliser. But if you're regularly away or just out and about, Nuby's portable UV unit is a worthy splurge (plus it comes with a Nuby bottle and pacifier, among other extras.)

It's also the most stylish option, housed in its own wipe-clean zip-up handbag with an adjustable shoulder strap. This is a UV steriliser, so no need for water, steam or chemicals. It works in just three minutes, which is very impressive - just throw in your items, zip the bag and press 'start'.

It is powered by a rechargeable battery that will last up to 17 cycles, so you don't have to find a plug socket to use it, making it more portable than any other tech-based method, though of course this would also be its downfall should you forget to charge it before leaving home. It has a relatively small capacity, as to be expected for a travel steriliser, but you can use it to zap anything you wish (even your mobile phone, the brand suggests).

If you're pregnant and unsure how you'll be feeding, or you're only an occasional bottle-user and don't want to find space for a bulky appliance, Medela's microwave steriliser pouches could be a great option. These would also be handy for days spent at a friend or relative's home, since they're so small and straightforward to use (add water, seal, start the microwave).

The kit consists of five BPA-free plastic bags, each one reusable up to 20 times, allowing 100 cycles in total which is plenty if you mostly breastfeed. I love Medela's products (they make the best pump I've tried) and even these bags are intuitively designed.

Large enough for two bottles plus several pump accessories at a time, each one is clearly marked with instructions, as well as 'touchpoints' that mark the cool spot to hold on one end and the hole from which to pour out the hot water on the other; and a tick chart so you can track how many times you've used them. They work in only three minutes and items stay sterile for 24 hours or until you open the bag - making them another transport-friendly option.

Reviewed by Caroline Stacey
Always a favourite with time-poor parents, a microwave steamer is a cost-effective, quick and easy option. At just £26.99 with a four-minute functioning time and no hard-to-learn instructions, Nanobebe's Microwave Steam Steriliser ticks all of those boxes. Simply pour water in the base, push the pegs into their snug holders and hang your items before popping in the microwave to steam and then allowing to cool.

The domed space-age design of this particular steriliser sets it apart from others I've tried and the turquoise blue detailing is a stylish touch, although I did find the very curved edge was slightly more difficult to slot into the right place. On the first couple of uses, I didn't have the lid on correctly and almost ended up with burnt fingertips.

Once I got the hang of it, its perforated bottom layer steams very efficiently and the contents stays sterilised for 24 hours, so it's a great habit to get into to fill it up, chuck it in the microwave at bedtime and know you've got clean bottles, pump parts and accessories ready when you need them.

The shape of the pegs is particularly useful as you can hang larger items on the small side and vice versa. Plus, they're removable, so if you have bigger bits that need sterilising like chunky breast pump parts or weaning accessories, you can remove a few pegs to make room. Once steamed, it's a simple case of tipping out the water ready for next time.

One tip: it's worth double-checking the size of your microwave. Although it's not huge, the Nanobebe's 25cm width and 17cm height might not fit inside compact models.

With midwife and One Born Every Minute star Lara Basini

What's the difference between steam sterilisers, cold water sterilisers, microwave sterilisers and UV sterilisers?

Cold water sterilisation involves adding a special fluid or tablet to water, then fully submerging your items for about 15 minutes, after which you can remove things at any time up to 24 hours and they'll remain sterile. Its upsides are that you don't need heat or electricity, though parents do complain that it leaves a chlorine smell on your equipment.

Electric steam sterilisers use hot steam to clean your items, and are relatively easy and quick to use. Most models offer a fast sterilisation cycle. They can be bulky and take up space on your worktop, however, and can be pricey. You do also need to clean and descale them regularly.

Microwave sterilisers, my personal preference because they're fast and relatively cheap, are more compact than standalone electric models, but in fact also use steam to sterilise items. They're easier to clean, as there's no metal element to descale - you simply heat the container up in the microwave with the bottles inside. You'll need to make sure your model fits inside your microwave, and it's worth having sterilisation tablets on hand in case the oven breaks or you have a power cut.

UV sterilisers are expensive but effective against the widest range of microorganisms, and the equipment comes out not needing to be rinsed, cooled or dried. Because they use ultraviolet light to kill germs, there's no water, steam or chemicals to contend with either, though the cycles tend to take longer than with other methods, and they're not really suitable for thin breast pump tubing as the UV rays won't penetrate them.

When should I use a steriliser?

The NHS recommends sterilisation for the first 12 months of a baby's life. It's important to note that whatever method you choose to use, everything needs to be washed in hot soapy water as soon as possible following feeds, and rinsed in cold running water, prior to sterilisation.

What can I use a steriliser for?

In addition to bottles, pump parts, pacifiers and cutlery, parents can sterilise frequently-used toys as invariably these will go into your baby's mouth.

How do I choose which is the best steriliser for me?

Price tends to be the first deciding factor, particularly if you aren't yet sure how often you'll be using your steriliser. After that, it's worth considering what your priority is: speed, ease, capacity, portability?

Also think about who else might be using it. If you know you'll have siblings of grandparents helping out, the UV option rules out the risk of burns, for example. You might also need more than one method to fall back on: such as cold water tablets if you travel a lot but an electric steriliser for home use.

Lastly, will you be mainly breastfeeding, pumping or formula feeding? If it's the former, you won't need much in the way of equipment so can get away with something cheaper and more straightforward, whereas if you're exclusively pumping or formula feeding, you'll rely heavily on your steriliser and will need something more heavy-duty with a bigger capacity.

How do I descale a steriliser?

You'll only need to do this with an electric steriliser, and instructions will vary according to the manufacturer's guidance, although a good rule of thumb is to descale it every 4 weeks, or every 14 days if you live in a hard water area.

First remove the trays and give it a wipe over. Then add one cup of white vinegar to the base of the steriliser, turn the appliance on and wait for it to boil. Soak and clean the trays in the meantime in warm soapy water.

Once the machine has finished boiling, pour out the liquid and give the base a really thorough rinse. Then dry and reassemble it.

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The best sterilisers in 2024, tried and tested on baby's bottles, pacifiers and other gear

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From steam and cold water sterilisers to high tech UV devices, we review the best of this year's new baby bottle sanitisers

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Concerns Raise Over Powdered Milk Preparation Machines

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Concerns Raise Over Powdered Milk Preparation Machines

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A study by Swansea University academics into powdered infant formula preparation safety has revealed that 85% of the 74 infant formula preparation machines tested by parents in UK homes did not appear to produce water that would be hot enough to kill all harmful bacteria in infant formula, and this could pose a serious risk to infant health.

This was compared to 69 parents in the study who used a kettle to heat the water used to prepare infant formula, where 22% reported water temperatures that were not hot enough to kill all harmful bacteria.

Almost three quarters of infants in the UK are fed infant formula in the first six weeks of life and this rises to 88% by six months of age.

Formula-fed infants have a higher risk of gastrointestinal infections compared to breastfed infants 1 which can be attributed, in part, to bacterial contamination from: the powdered infant formula itself (which cannot be made sterile), the equipment used for feeding, and also preparing infant formula with unclean hands. To help reduce the risk of such infections, the NHS has adopted the World Health Organization (WHO) recommendation that water used to make infant formula should be boiled and cooled, so that it is at a temperature of at least 70 o C to eliminate bacteria.

The study, which explored the safety of infant formula preparation practices compared to NHS guidelines, used community science methods and involved parents of infants aged 12 months or under. Around half of the 143 parents (74 people) used infant formula preparation machines while the remaining 69 parents used kettles to boil the water for infant formula preparation.

Dr Aimee Grant, Senior Lecturer in Public Health, who led the study stated:

"I was concerned to find that of the 74 infant formula preparation machines tested by parents, 85% appeared to fail to reach a temperature of at least 70 o C, which the NHS say is needed to kill all bacteria that can live in powdered infant formula. If any parents are worried, I'd advise them to buy a food thermometer and test the temperature of just the hot water that comes out of their machine (but not to use this tested water in a feed, due to potential contamination); if it's below 70 degrees, do not use the machine to prepare infant formula and contact the machine manufacturer."

Jonie Cooper, a parent who took part in the study, said: "When I first tested my prep machine, using the setting for a 4-ounce bottle of formula, I got a temperature of 52 o C. When I saw this I was shocked because I trusted the machine to follow the NHS guidelines on the temperature of the water, because it was specifically designed for babies. I advise parents using a prep machine to check the temperature of the water."

The study recommends stronger consumer protections on the marketing of infant formula preparation devices to help protect infants from infant formula related bacterial contamination. It is important that formula is prepared as per NHS guidance to avoid risks from contamination which can result in serious illness and even death.

Researchers are calling for infant formula labelling requirements to be updated to align with NHS and WHO guidance by displaying information that powdered infant formula is not sterile, the optimal water temperature and the risks of not using sufficiently hot water while also stating the importance of hand washing and routinely sterilising all feeding equipment.

The study also recommends that these public health messages should be shared in the course of antenatal and postnatal infant feeding support, following UNICEF Baby Friendly Initiative guidance. Finally, the research team advises that bacterial gastrointestinal infections in infants, particularly those resulting in hospitalisation, should be mapped to batches of infant formula and associated preparation equipment to provide information that could inform measures to improve the safety of formula feeding practices for babies in the UK.

Professor Robin May, Chief Scientific Advisor at the FSA said: "The study is funded by UKRI and The Food Standards Agency (FSA) and delivered in collaboration with the Biotechnology and Biological Sciences Research Council (BBSRC) and the Economic and Social Research Council (ESRC).

"The FSA's programme of citizen science work builds on collaboration between UKRI (working through two of its councils, BBSRC and ESRC), the FSA and Food Standards Scotland, to develop a joined-up approach to tackle the challenges of maintaining safe food in the UK.

"The findings of this project emphasise the importance of checking that water used to prepare infant formula is at a temperature of at least 70C, regardless of the method used. In light of these findings, we recommend that consumers check the water dispensed by infant formula preparation machines is at least 70°C and, if that is not the case, they should contact the manufacturer, their local Trading Standards Department or Citizens Advice.

"The FSA is working closely with other partners including the Office for Product Safety and Standards to determine whether any further actions are required."

The study is published in the Maternal & Child Nutrition journal.

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Study raises concerns over powdered infant formula preparation machines

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A study by Swansea University academics into powdered infant formula preparation safety has revealed that 85% of the 74 infant formula preparation machines tested by parents in UK homes did not appear to produce water that would be hot enough to kill all harmful bacteria in infant formula, and this could pose a serious risk to infant health.

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Intuitive Bottle Feeding for Breastfed Babies

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Responsive bottle-feeding by Emma Pickett We know breastfeeding is about the milk inside the container but it's also about a process - of holding the baby in a particular way; of feeding in response to cues; of encouraging certain oral skills; of focusing on the relationship between baby and mother. Is it possible to bottle-feed in such a way so as to copy breastfeeding as closely as possible?

Breastfeeding has something to do with brain development but it's not all about the long-chain polyunsaturated fatty acids. It's about skin-to-skin and connection and bonding.

If we need to bottle-feed, what's the ideal way to do it? If we are mindful about the WAY we bottle-feed, we will make a difference.

What bottle are we using?

Every bottle manufacturer claims their bottle is 'just like nature' or 'just like the breast'. They all seem to pick different features: texture, shape, sucking difficulty. The one that works best for your baby is the one they can feed from slowly and in a relaxed and calm way. It should be one that can be cleaned easily and one you can afford. When we are nervous new parents, we are vulnerable to messages from commercial companies so don't be tempted to keep shopping for different brands. If we're going to encourage good tongue placement and oral skills, ideally we're going to use a bottle where a baby can gape and feed with a wide open mouth rather than just nipple-feed with pursed lips.

Look for bottles which allow that wide gaping mouth on the soft silicon part of the bottle where the bottom lip can flange out like a fish-lip.

This gives a chance for the tongue to come over the gum ridge rather than be pushed back as it often is with artificial nipples. The tongue is holding the bottle in place rather than tight lip muscles.

How does baby sit?

We don't want the baby to be lying back and we certainly don't want to give a baby a bottle when they are flat as this increases the risk of ear infection. The baby should be sitting fairly upright with their body close against yours.

This is an opportunity for closeness. It is not an aim to have a young baby hold their own bottle.

It is not recommended to have a baby remain in a pram or high chair or be turned away from you. Think of it a cuddle which has milk as a side-benefit. This is not just about a transfer of nutrition. How about bottle-feeding skin-to-skin? Sounds a bit odd, doesn't it? It would certainly give Uncle Bob a bit of a shock. But this isn't about Uncle Bob, it's about your relationship with baby. I'm not saying it's something you'll be doing in Costa Coffee on a Wednesday morning but bottle-feeding skin-to-skin is a lovely way to get that closeness when you can.

Swapping sides

Often bottle-feeding parents have baby on the same arm and hold the bottle with their dominant hand. This means that, over many hours, one of baby's eyes looks at the world and the other is effectively blinkered. The newborn brain is doing a huge amount of development in the first year of life. Connections are being made and brain tissue forming. It seems wise to give the eye/ brain relationship equal chances on both sides so try and swap round and have a different eye on the outside.

How do you hold the bottle?

The bottle stays horizontal as much as possible. Some brands make this very hard as the bottle has to be tipped up to allow milk to flow so watch out for these. We want the baby to create negative pressure and need to make an effort to take the milk out.

When a baby is working hard, they are less likely to overfeed. They are also developing muscles they will need later for speech and eating solid food.

This technique of keeping the bottle horizontal is sometimes called 'paced bottle-feeding'. You can find videos on YouTube. We start the feed by placing the bottle above the top lip and we then stimulate a gape. The baby will tip their head back very slightly and open their mouth wide. We don't push the bottle in without an indication from them. Baby is showing they are ready and accepting the bottle. Remember we're encouraging the bottom lip to be flanged out and the tongue to be extended over the gum ridge if we can. We keep the hole newborn size. This isn't about the milk needing to flow out more quickly. We also want to take pauses during the feed so the baby can catch their breath. We should never feel as though they are overwhelmed by the flow which is why the paced feeding is important. They should be able to breathe calmly and their hands and body relax as they feed. A baby who has tight little fists, and is moving in an agitated way, could be asking for the feed to slow down.

Although baby may fall asleep in your arms, ideally we don't want to encourage babies to fall asleep when bottle-feeding.

When first teeth start to arrive after just a few months, we don't want them to be washed in formula milk just as a baby starts to fall asleep and saliva production slows. When a bottle feed finishes, we can burp baby and then cuddling continues. A baby could then fall asleep in your arms if that feels natural. At night, the safest place for baby to sleep is close to you in the same room. Lots of mums have the Moses basket next to the bed and they can feed in a chair or sitting up in bed and return baby to the Moses basket or cot for sleeping. If you want to bed share (which is normally associated with breastfeeding), you can get more information here

How much do we give?

The formula manufacturer will have recommendations on their packaging for amounts according to baby's weight and age. They may also have recommended times for feeding. You don't have to feed your baby according to a specific schedule. Ideally we respond to baby's cues. A baby who is beginning to be hungry will rustle while asleep, perhaps open their mouth or move their head from side to side as if they are looking for something. They may show interest in their hands or something placed near their cheek. They may begin to make little noises.

We want to feed in response to early hunger cues rather than wait for a baby to start crying or wait until the clock says it is the right time.

We don't want to try and cram in as much as we can. If we go slow and allow the baby to take control of flow and pause occasionally, hopefully they'll have a better chance of receiving those fullness signals. Babies suck to calm themselves and their sucking reflex is powerful. They may choose to keep on going beyond the time when it's best for them if the milk comes out too quickly or if we are too bossy. We'll know we're getting it right if weight gain is going well and a baby has 6 or more wet nappies and at least 3 poos a day. A baby who receives formula will need to poo at least once a day as they get older. Some babies exclusively receiving breastmilk may skip several days between poos and be quite happy.

If your baby has taken too much, they will usually bring up the excess.

This isn't necessarily 'reflux' that we worry about but a safety mechanism that prevents over-feeding and excessive weight gain.

Who's giving the bottle?

If we recognise that feeding is a job for primary carers and relationship-building then we need to appreciate it's not a task for visitors and extended family.

Grannies may want to help by giving a bottle but it's actually better if they help with the winding and nappy changing and looking after you when a baby is younger, just as we would recommend during breastfeeding.

A young baby may only be awake for feeds and we want those times to be in your arms, skin-to-skin with mum (or partner), looking at your face, using the techniques that feel familiar. When granny smells different, holds the bottle in a different way and you're not there - it's not ideal at the beginning.

What's in the bottle?

Modern breast pumps make the option of exclusive pumping far more realistic than it was even just a few years ago. You can read more about exclusive pumping here Mums with a low milk supply can still provide several feeds of expressed milk a day for their baby whether or not they choose to breastfeed.

Even just one tablespoon of breastmilk contains a host of immunological benefits.

Some mums also choose to give their babies donor milk. Ideally this is accessed from a milk bank where milk is screened and prepared carefully. Home pasteurisation is also sometimes used where this is not an option and the informal milk banking sites can tell you more. If you are going to feed your baby formula, this is useful guide. Although it is designed for use by healthcare professionals, it contains valuable information about types of formula available in the UK. This guide from UNICEF Baby Friendly is also useful. It's important to note that 'first' formula can be used up until 12 months of age and a family need not change onto follow-on formula (which was created to get round the marketing rules in the UK). After 12 months, full-fat cow's milk can be used. When you practise responsive bottle-feeding, not everyone around you may appreciate what you're doing. Friends and family might be a bit confused as it may not be familiar to them but have confidence that developing closeness and responding to your baby rather than the clock is the way to go. Your family will soon understand, even uncle Bob.

Further Resources:

The NHS guide to bottlefeeding talks about making up formula safely and lots of other aspects of bottlefeeding. http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/guide_to_bottle_feeding.pdf If you are interested in re-starting breastfeeding, it can be done at any point. The Association of Breastfeeding Mothers leaflet on re-starting breastfeeding after a gap is a good place to begin: http://abm.me.uk/restarting-breastfeeding-after-a-gap/ It is possible to supplement the baby while they are still attached to the breast using a supplementary nursing system. You can read more about that here: http://www.expressyourselfmums.co.uk/Expressing-breastmilk/Medela-Supplemental-Nursing-System-#moreinfo

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Responsive Bottle-Feeding Tips for Bonding with Baby | APUK

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Discover nurturing bottle-feeding techniques that mimic breastfeeding for a deep bond with your baby. Learn responsive feeding tips at Attachment Parenting UK.

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Formula prep machines are marketed as a quick and easy way of preparing formula milk with feeds ready at the correct temperature in minutes.
They claim to simplify the process and are an attractive prospect for sleep-starved new parents, especially considering newborn babies need to be fed at least 8-12 times every 24 hours, but are they worth investing in?

Below we explain how prep machines work, their key features and take a look at NHS guidance as well as key concerns about whether they are safe to use. Plus, where to buy them if you want compare prices at key retailers.
- cut through the confusion with our comprehensive look at formula milk, follow-on formula and toddler milk
What is a bottle prep machine?

Prep machines are intended to make formula bottle feeding quicker and easier than the standard kettle method.

Manufacturers claim they can produce formula feed at the correct temperature and consistency within minutes, meaning you don't need to faff around or wait for the formula to get to the right temperature.

Simply choose the amount of formula you want to be produced and the machine dispenses a hot shot of water above 70°C that kills any bacteria in the formula and helps to dissolve the powder. Then cooler water is added to produce a bottle at body temperature that you can feed to your baby straight away.

Some prep machines are designed slightly differently and boil water like a standard kettle, then quickly cool the boiled water to 70 or 40˚C, or keep it heated at a set temperature for making formula later.

As always, you'll need to test the temperature of the formula on your wrist before feeding your baby.

Make sure to follow the manufacturer guidelines in terms of cleaning and maintenance if you own a prep machine. Run the cleaning cycles often, change the filter when needed, and it's advised to regularly flush sterilising fluid or boiling water through the pipes of the machine.

The most popular prep machines include the (£165), (£260) and (£80). We've rounded some of the most popular retailers further down the page and below we go into detail about some of the concerns.

Does the NHS recommend prep machines?

Some NHS Hospital Trusts do not recommend using prep machines. This is because some models do not heat water at a high enough temperature (70°C) to kill harmful bacteria and germs.

Dr. Vicky Sibson, director of First Steps Nutrition Trust explains, 'There are many different baby formula preparation and feeding devices on the market, designed and advertised to make life easier when bottle feeding hungry babies who just can't wait, or who need a feed in the middle of the night. The marketing typically seeks to reassure parents that these gadgets are safe and adhere to NHS guidance.

'Unfortunately a lot of the time such claims are not true, or there is a lack of evidence available in the public domain to be sure. It's important that parents/carers who bottle feed their babies understand the and the risks to their baby's health it seeks to address. We would advise parents to talk to their midwife, health visitor or GP if they want more information so that they can make a fully informed decision about how they make up their baby's bottles knowing the risks of different ways of doing this, especially if they choose to use a device.'
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Concerns around formula bottle prep machines

If the water is not at least 70°C when added to the powder, any bacteria intrinsic to the formula powder will not be killed. Some prep machines require you to decant the powder in to the machine so that it can be mixed with the water internally, and this also creates extra risks of contamination.

In addition, some machines repeatedly boil water and this concentrates elements, which again is not safe and against NHS advice that fresh water should always be used when preparing powdered infant formula.

A study by Swansea University revealed that 85% of the 74 Perfect Prep Machines tested by parents in UK homes did not appear to produce water that would be hot enough, and this could pose a serious risk to infant health.

If you have any concerns about your prep machine you're advised to buy a food thermometer and test the temperature of the hot water that comes out of the machine. Do not use this tested water in a feed due to potential contamination.

If the temperature is below 70°C, do not use the machine to prepare infant formula and contact the machine manufacturer. We recommend following the NHS' step-by-step guide on .

For further information on this, take a look at the and the best way to prepare formula for your baby.

Can you use any type of formula milk with a prep machine?

Prep machines should be compatible with all types of formula milk.

Tommee Tippee says their machine works with any brand of powdered formula milk while Baby Brezza says their machine works with virtually all formula brands.

If you're using a specialist baby formula it is worth checking with the manufacturer to confirm that it is suitable.

Can you use any bottles with a prep machine?

Key brands claim to work with any brand of baby bottle.

Baby Brezza says their machine works with virtually all bottle brands and sizes, while Tommee Tippee says its machine has an adjustable base that's designed to accommodate different bottle shapes and sizes.

Double-check the specification details of the prep machine before purchasing to make sure your bottle is compatible.
: our guide to feeding explains all of the options and what you need to know
How long can you keep a bottle made by a prep machine?

Formula milk should ideally be made when needed to reduce the risk of infection. The NHS advises parents to use formula stored in the fridge within 24 hours.

If it's stored in a cool bag it should be used within four hours and if it's stored at room temperature it should be used within two hours.

There are a number of portable products available to help with preparing formula milk on the go.

The and claim to cool fresh formula feed to the right temperature in two minutes.

Alternatively there are lots of portable bottle warmers to choose from, which will heat up pre-made formula bottles.

Where to buy a prep machine

There are plenty of retailers to choose from, below we round up five of the most popular high street brands and online retailers.

Whether you're shopping online or in-store, make sure you pay attention to the shop's returns policy.
Not sure what you do and don't need? Read our expert advice on buying baby bottles, sterilisers, warmers and other feeding essentials

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Perfect prep and formula bottle prep machines - Which?

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Find out if it's worth investing in a baby bottle prep machine such as the Tommee Tippee Perfect Prep Machine or the Baby Brezza Formula Pro Advanced, plus we explain NHS and medical expert concerns around formula bottle prep machine temperatures

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1. Infant Formula & Guides to Bottle Feeding

2. Common Questions

3. Sterilising Equipment

4. Bottles/Teats & Associated Equipment

5. Alternatives to Bottles, when giving small amounts

6. How to Make Up Infant Formula

7. Baby-Led/Responsive Bottle Feeding

8. Winding

9. Is Bottle Feeding Going well?

10. Unsafe Bottle Feeding Practice

11. Breast Care as a non Breastfeeding Mum

12. General Information

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The '3 Os'

= Over Used - Over Priced & linked to Obesity

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The impact of infant formula marketing - Baby Friendly Initiative

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UNICEF/WHO webinars on              The impact of infant formula marketing 

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UNICEF/WHO webinars on              The impact of infant formula marketing 

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A series of reports by the WHO and UNICEF explore how the $55 billion breastmilk substitute industry uses pervasive, personalised and powerful marketing strategies to target parents

In November 2020, the World Health Assembly (WHA) requested that the World Health Organization (WHO) review current evidence and prepare a report describing how digital marketing strategies are being used for the promotion of breastmilk substitutes.

As a result, the following reports have been published alongside a series of webinars available on this page:

How marketing of formula milk influences our decisions on infant feeding: This report systematically examines women's and health professionals' experiences of formula milk marketing. The largest ever study of its kind, it draws on surveys with over 8,500 pregnant women and mothers of young children (aged 0-18 months) across eight countries, and more than 300 health professionals.

Scope and impact of digital marketing strategies for promoting breastmilk substitutes: The second in the WHO series, this report examines in greater depth the scope, techniques and impact of digital marketing strategies for the promotion of breastmilk substitutes.

Learn more

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The impact of infant formula marketing - Baby Friendly Initiative

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Access a series of reports by the WHO and UNICEF which explore the marketing strategies of the $55 billion breastmilk substitute industry.

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Using a Supplemental Nursing System (SNS)

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Using a Supplemental Nursing System (SNS)

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These can also be used with infant formula if the parents wish their baby to take formula at the breast as this can increase the non nutritive benefits of feeding for the baby.

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An at-breast supplementer, nursing supplementer or ‘supply line’ allows a mother to feed her baby supplemental milk at the breast. It

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Choose reusable nappies

Number one on the list of most new parents' eco concerns is the amount of nappies they will use that will go into landfill (Which?, 2018). Parents throw away an estimated three billion disposable nappies each year in the UK, which is about 2% to 3% of all household waste (WRAP, 2018).

Reusable nappies are an expensive initial outlay but if you keep using them - and especially if you have more than one child - they are a long-term money saver. Most importantly though, reusable nappies are far, far kinder to the planet. If you avoid disposables, you'll use an estimated 2.7kg of raw materials instead of 120kg if you opt for reusable nappies (The Guardian, 2015). See our article about choosing the right nappies for you for more information - Reusable nappies or disposable nappies?

Ditch the car

This is not only about being green, there are strong links between the air pollution vehicles produce and low birthweight in babies whose mothers breath that air (NHS, 2013; Pederson et al, 2013). So why not ditch the car and find yourself low-pollution walking routes using phone apps or maps.

If you have a car, try to get used to taking babies out without it early on. That way you don't become dependent on it.

If you can, walking is obviously great for you both. If you're going further afield, pop them in the sling and hop on the bus or train instead (The Telegraph, 2017; Moral Fibres, 2018). Once babies are alert, they'll love looking around anyway and will probably find it much more exciting than the car seat.

Use homemade baby food

One way to immediately save on packaging and transportation of packaged baby food is to cook it from scratch instead (The Daily Meal, 2017). And if that makes you roll your eyes at the thought of getting in from work and whipping up a feast, then fair enough. A much better idea is to batch cook a load of meals so you always have stuff in the freezer ready to go. Check out the internet for homemade baby food ideas.

Alternatively, just mash up whatever you're eating (unless it's extremely salty or contains honey etc) and give your child that instead (Parents, 2010). Instead of feeding your baby a mashed version of whatever you're eating, you could offer them your food in a form they can choose and pick up by themself (baby-led weaning). Baby-led weaning can involve offering them super simple finger foods, like strips of toast or boiled parsnips and carrots.

Homemade baby food is much healthier than the packaged stuff too. That's because packaged baby food contains more sugar than home cooked food. Your baby will also need to eat twice as much packaged food to get the same protein and energy as homemade food (Garcia et al, 2013).

Buy second-hand

There is so much pressure for your child, nursery or life to look like they're straight from the grid of an Instagram influencer. But you know what? That doesn't mean a lot of it can't come from Freecycle, Ebay, friends or NCT Nearly New Sales.

Buying second hand will save you so much cash at an expensive time. It's also a good way to give your child a few plastic toys if you want to without bringing yet more plastic into the world (Female First, 2012; The Telegraph, 2017; PBS Parents, 2018).

Borrow maternity clothes from friends

Equally, you don't need to buy a pile of clothes that you can only wear for a few months when you're pregnant. It's much greener to increase the life of existing clothes (Female First, 2012).

Why not rummage around for your loosest items in the back of the wardrobe, check out your local charity shops, NCT Nearly New Sales or borrow a friend's maternity wardrobe. If she's not planning on more children, she'll probably be delighted to hand you her maternity clothes and save herself a trip to the charity shop.

Choose natural products

This is a good practice anyway considering how sensitive babies' skin is. Try to go for products that contain no potentially harmful man-made chemicals and are made from natural ingredients. You could check sites like the FDA website.

Grow houseplants

You could even try to clean the air in your house by keeping houseplants. Plants like peace lilies, spider plants and garden mums (yes, they are plants) can improve the air quality of your house. They do this by removing chemicals like formaldehyde from the air (NASA, 1989).

Breastfeed, if possible

As well as all the other benefits of breastfeeding, if you can do it and want to, you could add its green credentials to the list. By breastfeeding, you are reducing the packaging and plastic in bottles, as well as transportation of formula (Parents, 2010; Female First, 2012).

Use green cleaning products for the many spills

When you have kids, you go through a lot of cleaning products - especially when they start eating. Oh the mess... So it's a great idea to either switch to greener cleaning brands or to homemade cleaners. You could make up a batch of homemade cleaner using ingredients like vinegar, lemon juice and baking soda (Parents, 2010).

Turn growing your own veggies into a family hobby

Ditch supermarket packaging and transport costs and dig a little veggie patch, or get yourself on the list for an allotment. Turn growing fruit and vegetables into a family hobby and you're winning all round (Female First, 2012).

Get crafty

Instead of buying them an extra plastic toy to amuse them, make something together using an old egg box or cardboard cereal box. Bonus: making it will entertain them for a while too... (The Telegraph, 2017)
This page was last reviewed in September 2018.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

Female First. (2012) Green parenting: top tips on being a 'green parent'. Available at: https://www.femalefirst.co.uk/parenting/green+parenting-260502.html [Accessed 22nd November 2018].

Garcia AL, Raza S, Parrett A, Wright CM. (2013) Nutritional content of infant commercial weaning foods in the UK. Arch Dis Child. 98(10):793-797. Available at: https://www.theguardian.com/environment/2015/sep/13/eco-guide-to-green-parenting-lucy-siegle [Accessed 22nd November 2018].

Moral fibres. (2018) Green parenting tips to help the environment. Available at: http://moralfibres.co.uk/how-to-be-a-green-parent-and-save-money/ [Accessed 22nd November 2018].

NASA (1989) Interior landscape plants for indoor air pollution abatement. Available at: https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19930073077.pdf [Accessed 22nd November 2018].

NHS. (2013) Air pollution associated with low birthweight. Available at: https://www.nhs.uk/news/pregnancy-and-child/air-pollution-associated-wi... [Accessed 22nd May 2019].

Parents. (2010) The ultimate guide to green parenting. Available at: https://www.parents.com/parenting/better-parenting/green/the-ultimate-guide-to-green-parenting/ [Accessed 22nd November 2018].

PBS Parents. (2018) Ten tips for green parenting. Available at: http://www.pbs.org/parents/special/article-earthday-greenparenting.html [Accessed 22nd November 2018].

Pedersen M, Giorgis-Allemand L, Bernard C, Aguilera I, Andersen AM, Ballester F, et al. (2013) Ambient air pollution and low birthweight: a European cohort study (ESCAPE). Lancet Respir Med. 1(9):695-704. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24429273 [Accessed 22nd May 2019].

The Daily Meal. (2017) Healthy baby food is hurting the environment. Available at: https://www.thedailymeal.com/healthy-eating/healthy-baby-food-hurting-environment [Accessed 22nd November 2018].

The Guardian. (2015) The eco guide to green parenting. Available at: https://www.theguardian.com/environment/2015/sep/13/eco-guide-to-green-parenting-lucy-siegle [Accessed 22nd November 2018].

The Telegraph. (2017) At home with the nation's greenest family. Available at: https://www.telegraph.co.uk/family/parenting/home-nations-greenest-family/ [Accessed 22nd November 2018].

Which? (2018a) How to buy the best reusable nappies. Available at: https://www.which.co.uk/reviews/nappies/article/how-to-buy-the-best-reusable-nappies [Accessed 22nd November 2018].

WRAP (Waste and Resources Action Programme). (2018) Real nappies. Overview. Available at: http://www.wrap.org.uk/content/real-nappies-overview [Accessed 22nd November 2018].

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Number one on the list of most new parents' eco concerns is the amount of nappies they will use that will go into landfill (Which?, 2018). Parents throw away an estimated three billion disposable nappies each year in the UK, which is about 2% to 3% of all household waste (WRAP, 2018).

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The Change in the Cost of Infant Formulas Since Jan 2020

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The Change in the Cost of Infant Formulas Since Jan 2020

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Do you have softened water at home, want to know what to use when making formula?

- If a Reverse Osmosis system, treat the same as tap water to make formula.
- If a water softener that adds sodium/salt system, avoid use to make formula.  However, the main kitchen tap could well be a hard water mains tap and not have salt added.

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First Steps Nutrition Trust: https://infantmilkinfo.org/faq/questions-about-infant-milk-safety/

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Partial Weaning & Combination Feeding • KellyMom.com

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Breastfeeding is not an all-or-nothing process. You can always keep one or more feedings per day and eliminate the rest. Many moms will continue to nurse only at night and/or first thing in the morning for many months after baby has weaned from all other nursings. If you wish to begin feeding your b…

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The formula manufacturers will encourage giving larger amounts as they are wanting to sell more milk!

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A baby's stomach capacity according to age

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A baby's stomach capacity according to age

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Most babies go through several growth spurts (also called frequency days) during the first 12 months.

What is a growth spurt?

During a growth spurt, breastfed babies nurse more often than usual (sometimes as often as every hour) and often act fussier than usual.

Now infants can get
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The increase in baby's milk intake during growth spurts is temporary. In exclusively breastfed babies, milk intake increases quickly during the first few weeks of life, then stays about the same between one and six months. As solids are gradually introduced after six months, baby's milk intake will gradually decrease.

Physical growth is not the only reason that babies may have a temporary need for increased nursing. Babies often exhibit the same type of behavior (increased nursing with or without increased fussiness) when they are working on developmental advances such as rolling over, crawling, walking or talking. Mom's milk is for growing the brain as well as the body!

When do babies have growth spurts?

Common times for growth spurts are during the first few days at home and around 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months and 9 months (more or less). Babies don't read calendars, however, so your baby may do things differently.

Growth spurts don't stop after the first year - most moms notice growth spurts every few months during the toddler years and periodically thereafter on through the teenage years.

How long do growth spurts last?

Growth spurts usually last 2-3 days, but sometimes last a week or so.

What is the best way to handle a growth spurt?

Follow your child's lead. Baby will automatically get more milk by nursing more frequently, and your milk supply will increase due to the increased nursing. It is not necessary (or advised) to supplement your baby with formula or expressed milk during a growth spurt. Supplementing (and/or scheduling feeds) interferes with the natural supply and demand of milk production and will prevent your body from getting the message to make more milk during the growth spurt.

Some nursing moms feel more hungry or thirsty when baby is going through a growth spurt. Listen to your body - you may need to eat or drink more during the time that baby is nursing more often.

See My baby is fussy! Is something wrong? for tips on comforting a fussy baby.

Additional Resources @ KellyMom

Additional Resources at other websites

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Most babies go through several growth spurts (also called frequency days) during the first 12 months. During a growth spurt, breastfed babies nurse more often than usual (sometimes as often as every hour) and often act fussier than usual. The increase in baby's milk intake during growth spurts is temporary.

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This report summarises the best current data we have on the costs of infant formula, follow-on formula and infant milks marketed as foods for special medical purposes marketed over the counter in the UK. The costs of products are given at purchase and have been calculated per 100ml, and per week for a 2-3 month old baby, so that costs can be compared.

For information on the costs of milks marketed for babies over 1 year of age for which there are no compositional regulations (and which are therefore unnecessary products) follow the link under 'type of infant milks' to 'milks marketed for children over 1 year of age' on this website.

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Costs | Infant formula | follow-on formula & milks marketed in UK

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This report summarises the best current data we have on the costs of infant formula, follow-on formula and infant milks marketed as foods for special medical purposes marketed over the counter in the UK. The costs of products are given at purchase and have been calculated per 100ml, and per week for a 2-3 month old baby, so that costs can be compared.

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Karleen Gribble

Corresponding Author

School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia

Correspondence

Karleen Gribble, School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith, New South Wales 2751, Australia.

Email: k.gribble@westernsydney.edu.au
Search for more papers by this author

Marko Kerac

Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK

Leonard Cheshire Disability and Inclusive Development Centre, Department of Epidemiology and Public Health, University College London, London, UK
Search for more papers by this author

First published:

Abstract

A cross‐sectional examination of the accuracy of volume markers on infant feeding bottles available for sale in Australia between December 2013 and February 2014 was carried out. Ninety‐one bottles representing 28 different brands were examined. Eighty‐eight bottles were hard sided. Volumes in these bottles were marked in a combination of milliliters and ounces. Thirty‐six (41%) bottles claimed compliance with the European standard EN14350, five (6%) with non‐existent Australian standards, and forty‐seven (54%) bottles had no standard claim. Nineteen bottles (22%) had at least one measured marking outside the tolerance of EN14350. Bottles claiming compliance with EN14350 were not less likely to have inaccurate markings than those that made no claim. More expensive bottles did not have fewer inaccurate markings. Three bottles were disposable liner systems and had particularly large volume inaccuracies (up to 43% outside the marked volume). Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Over‐concentrated and under‐concentrated infant formula can cause serious illness or malnutrition. Over‐concentrated infant formula may contribute to obesity. Bottles with inaccurate volume markers are unfit for purpose; disposable liner bottles are particularly poor in this regard and should be prohibited from having volume markers on the bottle casing. To avoid individual or public harms, well‐enforced standards are needed. Guidance for parents, carers, and health professionals is needed to ensure that infant formula is accurately reconstituted.

1 INTRODUCTION

Infants have special dietary needs. It is recommended that they be fed nothing but breast milk for the first 6 months of life and continue to be breastfed up until 2 years of age or longer (WHO and UNICEF, 2003). However, substantial proportions of infants in developed nations, and increasingly in developing nations, are exclusively or partially weaned from breast milk in early infancy (McAndrew et al., 2012; Australian Institute for Health and Welfare, 2011; Tang et al., 2014; Lee Mendoza, 2010). When breast milk is not available, infants should be fed an infant formula that conforms to the relevant provisions of the Codex Alimentarius (WHO and UNICEF, 2003; Fomon, 2001). Because infant formula is a substitute for a human tissue and may be the sole source of nutrition for infants for up to 6 months, strict regulation of its composition is necessary (Cohen, Xiong, & Sakamoto, 2010; Shaw, 2008). This is because variations in the nutritional profile of infant formula can have significant and adverse impacts on infant health (Fattal‐Valevski et al., 2005; Centers for Disease Control and Prevention, 1996; Skinner, Thomas, & Osterloh, 2010; Taitz & Byers, 1972; Chambers & Steel, 1975; Keating, Schears, & Dodge, 1991).

Where infant formula is manufactured in powdered form, the provision of the intended nutrition is dependent upon accurate reconstitution. Errors in the measurement of powdered milk for reconstitution of infant formula are common in a variety of contexts (Wise, 1979; Jacob, 1985; Plaster & Bergman, 1995; Jeffs, 1989; Chambers & Steel, 1975; Paxson, Adcock, & Morris, 1977). However, the measurement of an accurate volume of water is just as critical to the proper reconstitution of infant formula. Parents using infant formula are routinely instructed to reconstitute the product in infant feeding bottles using the volume markers on the bottles to measure water (World Health Organization and Food and Agriculture Organization, 2007). Such advice assumes that bottle volume markers are accurate. Inaccurate volume markers may result in improper reconstitution of infant formula to the detriment of infant health.

The only comprehensive standard for infant feeding bottles in the world is EN14350 produced by the European Committee for Standardization (European Committee for Standardization, 2004). In relation to accuracy of measurement, EN14350 requires the validation of three volume markings. Where these volume markers are less than 100 ml, they must be accurate to within 5 ml of the nominated value. Volume markers of 100 ml or more must be accurate to within 5% of the nominated value. Although EN14350 is only enforceable within the European Community, conformity with this standard is used as a quality claim for infant feeding bottles sold elsewhere. This study aimed to determine whether volume markings displayed on infant feeding bottles for sale in Australia are accurate using the tolerance in the provisions of EN14350 as a benchmark.

Key messages

Volume marker on infant feeding bottles can be inaccurate even where compliance the European Standard EN14350 is claimed.

Disposable liner bottle systems are particularly inaccurate and volume markings on them should be prohibited to prevent them being used to measure water.

The health of formula fed infants is likely to adversely impacted by inaccurate volume markers on infant feeding bottles leading to infant formula reconstitution errors.

2 MATERIALS AND METHODS

2.1 Study design and setting

A cross‐sectional examination of infant feeding bottles available for sale in Australia between December 2013 and February 2014 is used in this study.

2.2 Inclusion and exclusions criteria

Purposive sampling: one sample of each and every bottle found available for sale. Bottles were primarily purchased in New South Wales by the first author; however, requests for bottle searchers were also made via social media sites supporting mothers who bottle feed their babies and the Australian Breastfeeding Association in order to obtain bottles from throughout Australia. All brands, volumes, and shapes of infant feeding bottles were eligible for inclusion. The search for bottles ceased when saturation was reached and no additional bottle types could be found.

2.3 Variables

Deionized water was used to fill each bottle to its graduated markings so that the base of the meniscus was level with the midpoint of markings at 50, 60, 90, 100, 120, and 150 ml. These are the volumes specified in manufacturers' instructions for reconstituting infant formula for infants 2 months of age or less (those most vulnerable in the event of reconstitution error) in Australia. The mass of the water to 0.1 g was measured at each of these graduations at 25°C, by placing each bottle empty on an FX‐400 balance (A&D Company Ltd, Japan) and using the "tare" function to account for the mass of the empty bottle and reading the weight of water filled to the relevant volume markers. The balance had been calibrated a week prior to data collection, and each measurement was taken by two investigators and was recorded. Duplicate measurements were made for disposable liner bottles (bottle systems that had a rigid outer casing with a disposable liner for holding liquid). Notes were made about the ease of measurement and anomalies in markings.

2.4 Data and statistical methods

Data were recorded in Excel 2013 (Microsoft, USA) to facilitate calculation of differences between visually observed volume and volume by mass, which were then expressed as percent difference between the two measurements. These data were used to identify bottles that failed to achieve the relevant European Standard (EN14350). Failure to achieve the requirements of the standard was recorded as a categorical variable (inaccuracy), where 1 indicated that the bottle contained at least one volume mark that did not fall within the tolerance specified in EN14350. Data for results tables and the figure were produced in Stata Intercooled v.13.1 (StataCorp LP, USA). Chi‐square tests (with Yates Continuity Correction) were conducted using IBM SPSS Statistics Package 24 (IBM, USA) to determine whether bottles that displayed one or more inaccurate volume marker (as defined by EN14350) were more likely to cost more than US$5 (price), bear the European Standard mark, or display embossed (in lieu of or as well as printed) volume markers.

3 RESULTS

Ninety‐one different infant feeding bottles were purchased, representing 28 brands (mode three bottles per brand). These came from 19 different outlets including department stores, discount stores, chemists, supermarkets, hospital supply stores, online stores, and convenience stores. Ninety‐one of these bottles were hard sided, and three were disposable liner bottles. Table 1 summarizes the key characteristics of the 88 hard‐sided bottles explored in the main analysis.

Variable

N

%

Brands ( n = 27)

Mode 3 per brand (min 1, max 10)

Price (US$)*

Median $4.83 (interquartile range: 2.23-8.90), min $0.89, max $26.71

ml and US fl. oz. †

2

2

ml and UK fl. oz. †

3

3

* Purchased in Australian dollars between December 2013 and February 2014. US dollar price calculated at midpoint exchange rate, January 15, 2014. US$1 = AUS$1.123

† UK (Imperial) fluid oz. = 28 ml; US fluid oz. = 30 ml.

The commonest total volume of hard‐sided bottles was 250 ml (25 bottles, 28% of sample); 47 (53%) were <250 ml; and 16 (18%) were >250 ml in volume. Median price was US$4.83 per bottle, although there was a wide range ($0.89-$26.71). Markings on some bottles were hard to read or ambiguous; for example, one had a marking that was not horizontal but angled. Observers noted that measuring water was easier in narrow bottles than in wide bottles. Most bottles displayed markings in both milliliters and ounces, although often (54 bottles, 61% of sample) the type of ounce was not specified.

As shown in Figure 1, volume markings are both underestimated and overestimated actual volumes. Thirty‐seven markings on 19 bottles (22%) (range 1-5) were found to be so inaccurate that they were outside the requirements of EN14350. Twenty‐one of these markings overestimated the volume, and 16 underestimated the volume. Furthermore, 39 bottles (44%) had at least one missing marking (range 1-3) for volumes specified in manufacturers' instructions for reconstitution of infant formula available in Australia for infants 2 months of age and younger (range 1-6). In total, 50 bottles (57%) had either inaccurate or missing markings. A summary of the frequency of inaccurate and missing markings is presented in Table 2.

Volume

Inaccurate*

Missing

N

%

N

%

* Inaccurate is defined as being outside the tolerance levels provided by standard EN14350 of plus or minus 5 ml for volumes under 100 ml and plus or minus 5% for volumes over 100 ml.

Bottles with inaccurate markings were produced or distributed by companies based in Australia, China, New Zealand, the UK, and the USA and manufactured in Bulgaria, China, Germany, New Zealand, Thailand, and the UK. Bottles with missing markings were produced or distributed by companies based in Australia, China, Malaysia, New Zealand, Singapore, the UK, and the USA and manufactured in Australia, Austria, China, Hungary, Germany, Thailand, the UK, and the USA.

The disposable liner bottles were made by two manufacturers. Total volumes of the liners were 300, 120 ml, and an unspecified maximum >150 ml. Volume markers printed on the rigid casings of these products underestimated water volume to the extent that they were outside the requirements of EN14350 in all but one case. Wide variations were observed when repeat measurements were taken; expansion of the plastic liners with the addition of water was observed to influence volume. Thus, second measurements in the same plastic liner resulted in smaller discrepancies (not reported). Markings were both printed on the bottle casing and embossed on the liners; however, measurements could only be made using the markings on bottle casings as the observers were unable to read those printed on the plastic liners once they were filled with water. Table 3 shows volume discrepancies for the three disposable bottle systems in the sample.

Disposable bottle

Actual volume at

50 ml (% off stated volume)

60 ml (% off)

90 ml (% off)

100 ml (% off)

120 ml (% off)

150 ml (% off)

Brand A

31.4 (−37)

38.8 (−21)

51.3 (43)

70.1 (−30)

86.8 (−28)

138.5 (−8)

Brand B - 300 ml

56.6 (13)

-

-

120.9 (21)

-

184.0 (23)

Brand B - 120 ml

45.3 (9)

-

-

93.7 (6)

-

"-" indicates no mark at this volume.

Forty bottles (45%) had embossed markings, some of which were difficult to read; 45 (51%) had printed markings. Three bottles (3%) had both printed and embossed markings, but these markings were not aligned with one another. Bottles with only embossed markings were no more likely to be inaccurate than bottles with only printed markings ( p = .78).

The manufacturers of 36 (41%) bottles claimed that their product met EN14350. Five (6%) bottles claimed adherence to "Australian Approved Safety Standards" despite the absence of any Australian standard for infant feeding bottles. Ten of the 36 bottles (28%) that claimed compliance with EN14350 and nine of the 52 bottles (17%) that made no such claim had markings that were outside the tolerance requirements of EN14350. Bottles that claimed to comply with EN14350 were no less likely to be inaccurate than those that did not make a compliance claim ( p = .23).

Nine of 53 bottles priced >$5 (17%) were found to be inaccurate, and 12 of 38 bottles priced <$5 (32%) were inaccurate. No statistically significant association between price category and inaccuracy was detected ( p = .13).

4 DISCUSSION

This study reveals that volume markings on infant feeding bottles are commonly inaccurate and may make it difficult for infant formula to be properly reconstituted. An appreciable proportion of volume markings on the bottles purchased were outside tolerances required by standard EN13450. Factors that consumers might consider to indicate quality, such as claims of compliance with EN13450 or higher price, were not associated with greater accuracy.

The "bottle marker" problem adds to an already long list of factors responsible for error in infant formula reconstitution, including variation in composition of powdered milk (Paxson et al., 1977); errors in measurement of powdered infant formula due to addition of too few or too many scoops of powder (Lilburne, Oates, Thompson, & Tong, 1988); under‐filling, packing, or using heaped scoops of infant formula (Lilburne et al., 1988); and adding water or powdered infant formula in the incorrect order (Daly, MacDonald, & Booth, 1998). Errors in infant formula reconstitution may neutralize one another. However, it has been found that the parents, caregivers, and health professionals tend to add more powdered infant formula than is instructed, resulting in over‐concentration (Lilburne et al., 1988; Chambers & Steel, 1975; Jacob, 1985; McJunkin, Bithoney, & McCormick, 1987; Jeffs, 1989; Daly et al., 1998). The risk of over‐concentration is likely to be compounded in cases where bottles over‐represent volumes.

Over‐concentrated infant formula has implications for infant health. The most extreme of these is hypernatremia, a life‐threatening form of dehydration (Taitz & Byers, 1972; Chambers & Steel, 1975; Lilburne et al., 1988). Risks are greatest in very small/premature infants whose renal function has least capacity to deal with over‐concentration and in young infants with diarrhea (Khuffash & Majeed, 1984; Rhodin et al., 2009).

Less dramatic, but more significant for public health, over‐concentrated infant formula may contribute to excessive weight gain in infancy. Lucas, Lockton, and Davies ( 1992) found that infants fed a powdered infant formula gained more weight and were more likely to be overweight at 6 months of age than infants fed the same volume of a comparable ready‐to‐use liquid infant formula. Over‐concentration of powdered infant formula resulted in consumption of an additional 209 kJ/day (Lucas et al., 1992). Other research indicates that infants can self‐regulate energy intake, suggesting that growth may not be affected by errors in formula concentration (Fomon, Filmer, Thomas, Anderson, & Nelson, 1975; Adair, 1984). However, carer‐driven feeding may override compensatory mechanisms (Bartok & Ventura, 2009).

Over‐concentrated infant formula can also exacerbate constipation in formula‐fed infants (Vandenplas et al., 2013; Nevo, Rubin, Tamir, Levine, & Shaoul, 2007) and increase the severity of gastroesophageal reflux disease (Vandenplas et al., 2013; Salvia et al., 2001; Carroll, Garrison, & Christakis, 2002).

Under‐concentrated infant formula also has health implications. Sustained suboptimal nutrient intake could result in poor growth and development (David & David, 1984).

4.1 Regulatory framework

Greater attention to the regulation of the manufacture of infant feeding bottles is necessary to ensure that volume markers are accurate and adequate. Comprehensive standards should require testing of all volume markers as bottles can have a mixture of accurate and inaccurate volume markers. In addition, standards should require that markings are present for the volumes of water specified for infant formula reconstitution on the packaging of infant formula products sold in corresponding markets. Missing markings are potentially just as problematic as inaccurate ones as caregivers may seek to estimate water volume using the available markers. Consideration might be given to standardizing the volumes of water required for reconstitution of infant formula products.

This study suggests that volume markers on disposable liner bottles are grossly inaccurate and that this problem is inherent to the design of these bottles. Thus, disposable liner bottles should be prohibited from displaying volume markers so that they cannot be used for measuring water. Although the study included only bottles for sale within Australia, inaccurate bottles originated in a large number of countries. This suggests that the problem of inaccurate volume markers is unlikely to be limited to Australia and that international standards should be developed.

This study also identified that active external monitoring and enforcement of compliance with standards of manufacture is required. A number of bottles claiming compliance with EN14350 had volume markers that were outside the tolerance of the standard. As it currently stands, manufacturers are responsible for monitoring compliance with EN14350, and there is no provision for testing frequency within the standard.

4.2 Advising on choice of infant feeding bottle

Caregivers should be encouraged to choose infant feeding bottles that display clear volume markings commensurate with the instructions printed on the infant formula product that they are using and to test the volume markers of purchased bottles using a scale accurate to 1 g. Such scales are generally available in pharmacies (where many parents purchase infant formula and bottles) and hospitals. In the process of measuring water in bottles for the study, it was noted that measurement of water was easier in tall, thin bottles rather than squat and wide ones. It is known that the narrower the container within which liquid is measured, the more accurate the measurement. Hence, measuring cylinders and pipettes are the instruments of choice in laboratories, and for applications where accurate measurement of liquid volumes is crucial (Ansel, 2012). Caregivers should therefore be advised that narrow bottles will make accurate measurement of water easier.

Those using powdered infant formula require instruction in the accurate measurement of water. Providing parents with education can reduce adverse consequences associated with dilution errors (Sunderland & Emery, 1979). However, despite requirements for individualized instruction for parents using infant formula in schemes such as the Baby Friendly Hospital Initiative, there is evidence that many parents do not receive such education (Tarrant, Sheridan‐Pereira, McCarthy, Younger, & Kearney, 2012; Wirihana & Barnard, 2012). Given the vulnerability of formula‐fed infants to a variety of avoidable risks, including those associated with reconstitution errors but also poor hygiene, cleaning, and overfeeding, this is alarming. Education and support of parents and caregivers who are using infant formula by health providers should be considered essential.

4.3 Limitations

There are a number of limitations to this research. One of each bottle type was sampled. It may be that different production batches, or even different bottles within the same batch, have greater or fewer accurate markings and that accuracy would vary over time. It is also possible that that bottles for sale in countries other than Australia may be less or more accurate. Indeed, an investigation by the New Zealand Ministry of Consumer Affairs found that even when only a single volume marking was measured on bottles purchased in New Zealand, 42% of bottles measured were inaccurately marked (Ministry of Health, 2013).

The consequences of the inaccuracies that we observed in "real life" settings, at individual, or population levels have not been studied. Further research is necessary to ascertain how common the problems identified are and to determine how inaccurate volume markers impact infant formula reconstitution in practice.

5 CONCLUSIONS

Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Markers were identified that overestimate actual volume predisposing to over‐concentrated infant formula and potential problems like hypernatremia, obesity, and constipation. Other markers underestimate actual volumes and thus over‐dilute the end product, predisposing to undernutrition. Infant feeding bottles with inaccurate volume markers should be considered unfit for purpose: disposable bottle systems are particularly poor in this regard. To avoid either individual or public harms, well‐enforced standards are needed, as is better guidance to both carers and health professionals to accurately measure water volume when reconstituting powdered infant formula.

ACKNOWLEDGMENT

The authors would like to thank Ge Gribble for research assistance.

SOURCE OF FUNDING

This study was self‐funded with no external source of funds.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

KG conceived and designed the study, purchased infant feeding bottles, collected data, and wrote and revised the manuscript. NB conceived and designed the study, collected data, and wrote and revised the manuscript. MK conducted the statistical analysis and critically revised the manuscript. MC assisted in study design, collected data, and critically revised the manuscript. All authors contributed to and approve the final manuscript.

Abstract

A cross‐sectional examination of the accuracy of volume markers on infant feeding bottles available for sale in Australia between December 2013 and February 2014 was carried out. Ninety‐one bottles representing 28 different brands were examined. Eighty‐eight bottles were hard sided. Volumes in these bottles were marked in a combination of milliliters and ounces. Thirty‐six (41%) bottles claimed compliance with the European standard EN14350, five (6%) with non‐existent Australian standards, and forty‐seven (54%) bottles had no standard claim. Nineteen bottles (22%) had at least one measured marking outside the tolerance of EN14350. Bottles claiming compliance with EN14350 were not less likely to have inaccurate markings than those that made no claim. More expensive bottles did not have fewer inaccurate markings. Three bottles were disposable liner systems and had particularly large volume inaccuracies (up to 43% outside the marked volume). Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Over‐concentrated and under‐concentrated infant formula can cause serious illness or malnutrition. Over‐concentrated infant formula may contribute to obesity. Bottles with inaccurate volume markers are unfit for purpose; disposable liner bottles are particularly poor in this regard and should be prohibited from having volume markers on the bottle casing. To avoid individual or public harms, well‐enforced standards are needed. Guidance for parents, carers, and health professionals is needed to ensure that infant formula is accurately reconstituted.

1 INTRODUCTION

Infants have special dietary needs. It is recommended that they be fed nothing but breast milk for the first 6 months of life and continue to be breastfed up until 2 years of age or longer (WHO and UNICEF, 2003). However, substantial proportions of infants in developed nations, and increasingly in developing nations, are exclusively or partially weaned from breast milk in early infancy (McAndrew et al., 2012; Australian Institute for Health and Welfare, 2011; Tang et al., 2014; Lee Mendoza, 2010). When breast milk is not available, infants should be fed an infant formula that conforms to the relevant provisions of the Codex Alimentarius (WHO and UNICEF, 2003; Fomon, 2001). Because infant formula is a substitute for a human tissue and may be the sole source of nutrition for infants for up to 6 months, strict regulation of its composition is necessary (Cohen, Xiong, & Sakamoto, 2010; Shaw, 2008). This is because variations in the nutritional profile of infant formula can have significant and adverse impacts on infant health (Fattal‐Valevski et al., 2005; Centers for Disease Control and Prevention, 1996; Skinner, Thomas, & Osterloh, 2010; Taitz & Byers, 1972; Chambers & Steel, 1975; Keating, Schears, & Dodge, 1991).

Where infant formula is manufactured in powdered form, the provision of the intended nutrition is dependent upon accurate reconstitution. Errors in the measurement of powdered milk for reconstitution of infant formula are common in a variety of contexts (Wise, 1979; Jacob, 1985; Plaster & Bergman, 1995; Jeffs, 1989; Chambers & Steel, 1975; Paxson, Adcock, & Morris, 1977). However, the measurement of an accurate volume of water is just as critical to the proper reconstitution of infant formula. Parents using infant formula are routinely instructed to reconstitute the product in infant feeding bottles using the volume markers on the bottles to measure water (World Health Organization and Food and Agriculture Organization, 2007). Such advice assumes that bottle volume markers are accurate. Inaccurate volume markers may result in improper reconstitution of infant formula to the detriment of infant health.

The only comprehensive standard for infant feeding bottles in the world is EN14350 produced by the European Committee for Standardization (European Committee for Standardization, 2004). In relation to accuracy of measurement, EN14350 requires the validation of three volume markings. Where these volume markers are less than 100 ml, they must be accurate to within 5 ml of the nominated value. Volume markers of 100 ml or more must be accurate to within 5% of the nominated value. Although EN14350 is only enforceable within the European Community, conformity with this standard is used as a quality claim for infant feeding bottles sold elsewhere. This study aimed to determine whether volume markings displayed on infant feeding bottles for sale in Australia are accurate using the tolerance in the provisions of EN14350 as a benchmark.

Key messages

Volume marker on infant feeding bottles can be inaccurate even where compliance the European Standard EN14350 is claimed.

Disposable liner bottle systems are particularly inaccurate and volume markings on them should be prohibited to prevent them being used to measure water.

The health of formula fed infants is likely to adversely impacted by inaccurate volume markers on infant feeding bottles leading to infant formula reconstitution errors.

2 MATERIALS AND METHODS

2.1 Study design and setting

A cross‐sectional examination of infant feeding bottles available for sale in Australia between December 2013 and February 2014 is used in this study.

2.2 Inclusion and exclusions criteria

Purposive sampling: one sample of each and every bottle found available for sale. Bottles were primarily purchased in New South Wales by the first author; however, requests for bottle searchers were also made via social media sites supporting mothers who bottle feed their babies and the Australian Breastfeeding Association in order to obtain bottles from throughout Australia. All brands, volumes, and shapes of infant feeding bottles were eligible for inclusion. The search for bottles ceased when saturation was reached and no additional bottle types could be found.

2.3 Variables

Deionized water was used to fill each bottle to its graduated markings so that the base of the meniscus was level with the midpoint of markings at 50, 60, 90, 100, 120, and 150 ml. These are the volumes specified in manufacturers' instructions for reconstituting infant formula for infants 2 months of age or less (those most vulnerable in the event of reconstitution error) in Australia. The mass of the water to 0.1 g was measured at each of these graduations at 25°C, by placing each bottle empty on an FX‐400 balance (A&D Company Ltd, Japan) and using the "tare" function to account for the mass of the empty bottle and reading the weight of water filled to the relevant volume markers. The balance had been calibrated a week prior to data collection, and each measurement was taken by two investigators and was recorded. Duplicate measurements were made for disposable liner bottles (bottle systems that had a rigid outer casing with a disposable liner for holding liquid). Notes were made about the ease of measurement and anomalies in markings.

2.4 Data and statistical methods

Data were recorded in Excel 2013 (Microsoft, USA) to facilitate calculation of differences between visually observed volume and volume by mass, which were then expressed as percent difference between the two measurements. These data were used to identify bottles that failed to achieve the relevant European Standard (EN14350). Failure to achieve the requirements of the standard was recorded as a categorical variable (inaccuracy), where 1 indicated that the bottle contained at least one volume mark that did not fall within the tolerance specified in EN14350. Data for results tables and the figure were produced in Stata Intercooled v.13.1 (StataCorp LP, USA). Chi‐square tests (with Yates Continuity Correction) were conducted using IBM SPSS Statistics Package 24 (IBM, USA) to determine whether bottles that displayed one or more inaccurate volume marker (as defined by EN14350) were more likely to cost more than US$5 (price), bear the European Standard mark, or display embossed (in lieu of or as well as printed) volume markers.

3 RESULTS

Ninety‐one different infant feeding bottles were purchased, representing 28 brands (mode three bottles per brand). These came from 19 different outlets including department stores, discount stores, chemists, supermarkets, hospital supply stores, online stores, and convenience stores. Ninety‐one of these bottles were hard sided, and three were disposable liner bottles. Table 1 summarizes the key characteristics of the 88 hard‐sided bottles explored in the main analysis.

Variable

N

%

Brands ( n = 27)

Mode 3 per brand (min 1, max 10)

Price (US$)*

Median $4.83 (interquartile range: 2.23-8.90), min $0.89, max $26.71

ml and US fl. oz. †

2

2

ml and UK fl. oz. †

3

3

* Purchased in Australian dollars between December 2013 and February 2014. US dollar price calculated at midpoint exchange rate, January 15, 2014. US$1 = AUS$1.123

† UK (Imperial) fluid oz. = 28 ml; US fluid oz. = 30 ml.

The commonest total volume of hard‐sided bottles was 250 ml (25 bottles, 28% of sample); 47 (53%) were <250 ml; and 16 (18%) were >250 ml in volume. Median price was US$4.83 per bottle, although there was a wide range ($0.89-$26.71). Markings on some bottles were hard to read or ambiguous; for example, one had a marking that was not horizontal but angled. Observers noted that measuring water was easier in narrow bottles than in wide bottles. Most bottles displayed markings in both milliliters and ounces, although often (54 bottles, 61% of sample) the type of ounce was not specified.

As shown in Figure 1, volume markings are both underestimated and overestimated actual volumes. Thirty‐seven markings on 19 bottles (22%) (range 1-5) were found to be so inaccurate that they were outside the requirements of EN14350. Twenty‐one of these markings overestimated the volume, and 16 underestimated the volume. Furthermore, 39 bottles (44%) had at least one missing marking (range 1-3) for volumes specified in manufacturers' instructions for reconstitution of infant formula available in Australia for infants 2 months of age and younger (range 1-6). In total, 50 bottles (57%) had either inaccurate or missing markings. A summary of the frequency of inaccurate and missing markings is presented in Table 2.

Volume

Inaccurate*

Missing

N

%

N

%

* Inaccurate is defined as being outside the tolerance levels provided by standard EN14350 of plus or minus 5 ml for volumes under 100 ml and plus or minus 5% for volumes over 100 ml.

Bottles with inaccurate markings were produced or distributed by companies based in Australia, China, New Zealand, the UK, and the USA and manufactured in Bulgaria, China, Germany, New Zealand, Thailand, and the UK. Bottles with missing markings were produced or distributed by companies based in Australia, China, Malaysia, New Zealand, Singapore, the UK, and the USA and manufactured in Australia, Austria, China, Hungary, Germany, Thailand, the UK, and the USA.

The disposable liner bottles were made by two manufacturers. Total volumes of the liners were 300, 120 ml, and an unspecified maximum >150 ml. Volume markers printed on the rigid casings of these products underestimated water volume to the extent that they were outside the requirements of EN14350 in all but one case. Wide variations were observed when repeat measurements were taken; expansion of the plastic liners with the addition of water was observed to influence volume. Thus, second measurements in the same plastic liner resulted in smaller discrepancies (not reported). Markings were both printed on the bottle casing and embossed on the liners; however, measurements could only be made using the markings on bottle casings as the observers were unable to read those printed on the plastic liners once they were filled with water. Table 3 shows volume discrepancies for the three disposable bottle systems in the sample.

Disposable bottle

Actual volume at

50 ml (% off stated volume)

60 ml (% off)

90 ml (% off)

100 ml (% off)

120 ml (% off)

150 ml (% off)

Brand A

31.4 (−37)

38.8 (−21)

51.3 (43)

70.1 (−30)

86.8 (−28)

138.5 (−8)

Brand B - 300 ml

56.6 (13)

-

-

120.9 (21)

-

184.0 (23)

Brand B - 120 ml

45.3 (9)

-

-

93.7 (6)

-

"-" indicates no mark at this volume.

Forty bottles (45%) had embossed markings, some of which were difficult to read; 45 (51%) had printed markings. Three bottles (3%) had both printed and embossed markings, but these markings were not aligned with one another. Bottles with only embossed markings were no more likely to be inaccurate than bottles with only printed markings ( p = .78).

The manufacturers of 36 (41%) bottles claimed that their product met EN14350. Five (6%) bottles claimed adherence to "Australian Approved Safety Standards" despite the absence of any Australian standard for infant feeding bottles. Ten of the 36 bottles (28%) that claimed compliance with EN14350 and nine of the 52 bottles (17%) that made no such claim had markings that were outside the tolerance requirements of EN14350. Bottles that claimed to comply with EN14350 were no less likely to be inaccurate than those that did not make a compliance claim ( p = .23).

Nine of 53 bottles priced >$5 (17%) were found to be inaccurate, and 12 of 38 bottles priced <$5 (32%) were inaccurate. No statistically significant association between price category and inaccuracy was detected ( p = .13).

4 DISCUSSION

This study reveals that volume markings on infant feeding bottles are commonly inaccurate and may make it difficult for infant formula to be properly reconstituted. An appreciable proportion of volume markings on the bottles purchased were outside tolerances required by standard EN13450. Factors that consumers might consider to indicate quality, such as claims of compliance with EN13450 or higher price, were not associated with greater accuracy.

The "bottle marker" problem adds to an already long list of factors responsible for error in infant formula reconstitution, including variation in composition of powdered milk (Paxson et al., 1977); errors in measurement of powdered infant formula due to addition of too few or too many scoops of powder (Lilburne, Oates, Thompson, & Tong, 1988); under‐filling, packing, or using heaped scoops of infant formula (Lilburne et al., 1988); and adding water or powdered infant formula in the incorrect order (Daly, MacDonald, & Booth, 1998). Errors in infant formula reconstitution may neutralize one another. However, it has been found that the parents, caregivers, and health professionals tend to add more powdered infant formula than is instructed, resulting in over‐concentration (Lilburne et al., 1988; Chambers & Steel, 1975; Jacob, 1985; McJunkin, Bithoney, & McCormick, 1987; Jeffs, 1989; Daly et al., 1998). The risk of over‐concentration is likely to be compounded in cases where bottles over‐represent volumes.

Over‐concentrated infant formula has implications for infant health. The most extreme of these is hypernatremia, a life‐threatening form of dehydration (Taitz & Byers, 1972; Chambers & Steel, 1975; Lilburne et al., 1988). Risks are greatest in very small/premature infants whose renal function has least capacity to deal with over‐concentration and in young infants with diarrhea (Khuffash & Majeed, 1984; Rhodin et al., 2009).

Less dramatic, but more significant for public health, over‐concentrated infant formula may contribute to excessive weight gain in infancy. Lucas, Lockton, and Davies ( 1992) found that infants fed a powdered infant formula gained more weight and were more likely to be overweight at 6 months of age than infants fed the same volume of a comparable ready‐to‐use liquid infant formula. Over‐concentration of powdered infant formula resulted in consumption of an additional 209 kJ/day (Lucas et al., 1992). Other research indicates that infants can self‐regulate energy intake, suggesting that growth may not be affected by errors in formula concentration (Fomon, Filmer, Thomas, Anderson, & Nelson, 1975; Adair, 1984). However, carer‐driven feeding may override compensatory mechanisms (Bartok & Ventura, 2009).

Over‐concentrated infant formula can also exacerbate constipation in formula‐fed infants (Vandenplas et al., 2013; Nevo, Rubin, Tamir, Levine, & Shaoul, 2007) and increase the severity of gastroesophageal reflux disease (Vandenplas et al., 2013; Salvia et al., 2001; Carroll, Garrison, & Christakis, 2002).

Under‐concentrated infant formula also has health implications. Sustained suboptimal nutrient intake could result in poor growth and development (David & David, 1984).

4.1 Regulatory framework

Greater attention to the regulation of the manufacture of infant feeding bottles is necessary to ensure that volume markers are accurate and adequate. Comprehensive standards should require testing of all volume markers as bottles can have a mixture of accurate and inaccurate volume markers. In addition, standards should require that markings are present for the volumes of water specified for infant formula reconstitution on the packaging of infant formula products sold in corresponding markets. Missing markings are potentially just as problematic as inaccurate ones as caregivers may seek to estimate water volume using the available markers. Consideration might be given to standardizing the volumes of water required for reconstitution of infant formula products.

This study suggests that volume markers on disposable liner bottles are grossly inaccurate and that this problem is inherent to the design of these bottles. Thus, disposable liner bottles should be prohibited from displaying volume markers so that they cannot be used for measuring water. Although the study included only bottles for sale within Australia, inaccurate bottles originated in a large number of countries. This suggests that the problem of inaccurate volume markers is unlikely to be limited to Australia and that international standards should be developed.

This study also identified that active external monitoring and enforcement of compliance with standards of manufacture is required. A number of bottles claiming compliance with EN14350 had volume markers that were outside the tolerance of the standard. As it currently stands, manufacturers are responsible for monitoring compliance with EN14350, and there is no provision for testing frequency within the standard.

4.2 Advising on choice of infant feeding bottle

Caregivers should be encouraged to choose infant feeding bottles that display clear volume markings commensurate with the instructions printed on the infant formula product that they are using and to test the volume markers of purchased bottles using a scale accurate to 1 g. Such scales are generally available in pharmacies (where many parents purchase infant formula and bottles) and hospitals. In the process of measuring water in bottles for the study, it was noted that measurement of water was easier in tall, thin bottles rather than squat and wide ones. It is known that the narrower the container within which liquid is measured, the more accurate the measurement. Hence, measuring cylinders and pipettes are the instruments of choice in laboratories, and for applications where accurate measurement of liquid volumes is crucial (Ansel, 2012). Caregivers should therefore be advised that narrow bottles will make accurate measurement of water easier.

Those using powdered infant formula require instruction in the accurate measurement of water. Providing parents with education can reduce adverse consequences associated with dilution errors (Sunderland & Emery, 1979). However, despite requirements for individualized instruction for parents using infant formula in schemes such as the Baby Friendly Hospital Initiative, there is evidence that many parents do not receive such education (Tarrant, Sheridan‐Pereira, McCarthy, Younger, & Kearney, 2012; Wirihana & Barnard, 2012). Given the vulnerability of formula‐fed infants to a variety of avoidable risks, including those associated with reconstitution errors but also poor hygiene, cleaning, and overfeeding, this is alarming. Education and support of parents and caregivers who are using infant formula by health providers should be considered essential.

4.3 Limitations

There are a number of limitations to this research. One of each bottle type was sampled. It may be that different production batches, or even different bottles within the same batch, have greater or fewer accurate markings and that accuracy would vary over time. It is also possible that that bottles for sale in countries other than Australia may be less or more accurate. Indeed, an investigation by the New Zealand Ministry of Consumer Affairs found that even when only a single volume marking was measured on bottles purchased in New Zealand, 42% of bottles measured were inaccurately marked (Ministry of Health, 2013).

The consequences of the inaccuracies that we observed in "real life" settings, at individual, or population levels have not been studied. Further research is necessary to ascertain how common the problems identified are and to determine how inaccurate volume markers impact infant formula reconstitution in practice.

5 CONCLUSIONS

Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Markers were identified that overestimate actual volume predisposing to over‐concentrated infant formula and potential problems like hypernatremia, obesity, and constipation. Other markers underestimate actual volumes and thus over‐dilute the end product, predisposing to undernutrition. Infant feeding bottles with inaccurate volume markers should be considered unfit for purpose: disposable bottle systems are particularly poor in this regard. To avoid either individual or public harms, well‐enforced standards are needed, as is better guidance to both carers and health professionals to accurately measure water volume when reconstituting powdered infant formula.

ACKNOWLEDGMENT

The authors would like to thank Ge Gribble for research assistance.

SOURCE OF FUNDING

This study was self‐funded with no external source of funds.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

KG conceived and designed the study, purchased infant feeding bottles, collected data, and wrote and revised the manuscript. NB conceived and designed the study, collected data, and wrote and revised the manuscript. MK conducted the statistical analysis and critically revised the manuscript. MC assisted in study design, collected data, and critically revised the manuscript. All authors contributed to and approve the final manuscript.

# data[].attributes.attachment_link.title
Volume marker inaccuracies: A cross‐sectional survey of infant feeding bottles

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Karleen Gribble Corresponding Author School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia Correspondence Karleen Gribble, School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith, New South Wales 2751, Australia.

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6 Don't force your baby to finish the bottle. It's so hard when you know how much work went into making that milk, but one of the great things about breastfeeding is that babies learn to eat when they're hungry and stop when they're done. We have to trust them to do the same thing with the bottle, if their feeding is paced.

My favorite sweet spot for bottle feeds is that baby should take about 5 minutes to eat once ounce/30 mL. So for example, a 3 oz bottle should take a baby about 15 minutes to eat.

If they gulp the feeding down faster than 5 minutes per ounce you want to pace the feed more frequently OR go down one nipple speed.

And more importantly- if it is taking baby much MORE than 5 minutes per ounce, they need less pacing and possibly also need a faster flow nipple.

WARNING! If you are using the Avent Natural Response bottles- which I do NOT recommend for lots of reasons- their nipples have almost no flow. Levels 1-3 of the Avent Natural bottle with the Natural Response nipple have been independently lab tested and all have a flow rate of less than 1 mL/minute, which would mean it would take a baby 30 minutes to eat ONE OUNCE.

This is dangerously slow, especially for newborns who will get exhausted and fall asleep long before they eat a full feeding.

If you have the Avent Naturals bottles and are experiencing problems, as so many other parents are, please contact the company and make your concerns known.

You can learn more and hear other parents' experiences with these bottles here (Instagram post) or here (Facebook post).

# data[].attributes.attachment_link.title
how to give a bottle to a breastfed baby

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Introducing bottles to breastfed babies doesn't have to be complicated or stressful. Here are the simple steps, with examples of good and bad bottle latches.

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You may not be breastfeeding but this information on bottles/teats may interest you

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You may not be breastfeeding but this information on bottles/teats may interest you

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Bottles for Breastfed Babies (Introducing a Bottle, Part 1) | Rachel O'Brien, IBCLC

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Let's say you're breastfeeding and you really want to use bottles sometimes, too. How on earth are you supposed to pick a bottle to even start with if every company has similar claims and the boogeyman of "nipple confusion" is lurking around every corner?

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Weaning | Fussy Eating | The Children's Nutritionist

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Can paced feeding help bonding between parent and baby?

The paced bottle technique can help to strengthen the bond between parent and baby by helping parents to tune into their babies' cues, make eye contact and hold their baby close during feeding (3).

It has been noted that bottle fed babies could miss out on some elements of bonding such as closeness when feeding or skin to skin contact, particularly when babies are propped up with a bottle and parents are distracted. This feeding method aims to bring these important bonding techniques into bottle feeding (4).

Can anyone feeding my baby do paced feeding?

Anyone can use these methods and actually being consistent in how you feed using a bottle is helpful, so yes, other people who feed your baby can be shown the pace feeding method.

Having said that, in the early days it may help for the parents to give the majority of the feeds so the principles of the baby paced method become established between baby and parent so the benefits of bonding can be experienced (3).

If I'm interested in paced feeding, what else should I consider?

Paced feeding follows the ethos of the 'division of responsibility of feeding', a model of feeding created by Ellyn Satter, a Dietitian and Family Therapist. This is where parents decide the 'what', 'when', 'where' of feeding but their child chooses how much to eat and how quickly(6). This philosophy is designed to be used right from infant and right through childhood. You can read more about it here.

In the division of responsibility, what are my responsibilities as a parent in terms of feeding?

You are responsible for (6):

What your child has to eat - formula or breast milk.

How they are fed - bottle, breast or both.

The environment your little one feeds in.

Helping them to be calm before and during a feed.

Being aware of your little one's feeding and fullness cues.

Being aware of your baby's sleep and awake patterns.

Knowing their usual feed amounts, timings and frequency.

Your little one is responsible for:

How does the division of responsibility apply to different aged babies?

Newborn to 2 months (6);

Pay attention to their feeding cues and feed them when they want to eat, when they are alert and calm.

Sit still during feeding and make sure the environment is peaceful, without distractions.

Let your little one eat the way they want to. We all like to eat differently! Some babies feed quickly, others slowly and some like to start and stop.

Stop feeding when they show you signs that they have finished.

Continue to feed on demand and go by what your baby is showing they need.

Continue to let them eat in the way they prefer.

Bring them to the table when you eat so they can start to learn about food.

6 months plus (6);

Allow your baby to get the nourishment they need from their milk feeds.

You will be introducing solids around this time and this method of feeding can also apply to introducing solids.

You don't need to change how you feed for the first month or so of weaning, it's only when your baby starts to eat 3 meals a day at 7 months or so that it can be helpful to introduce a more structured milk and food routine.

But how will my baby know how much to eat?

The ethos of the division of responsibility believes that your little one will know what they need to grow in the right way for them (6). There is some science behind this too. Babies are born with an ability to self regulate their food (milk) intake depending upon what their bodies need.

Over time, we as parents have encouraged them to ignore their internal cues by offering the bottle or breast again when they have stopped feeding, to get them to take just a little more. We do it when they start eating by asking them to take 'just one more bite'. This encouragement actually tells our children to ignore their hunger and fullness cues and is thought to contribute towards childhood obesity.

Is it challenging to follow the 'division of responsibility' method?

Simply put......yes, it can be. This type of method encourages us not to focus on how much we believe our child should be consuming and to step away from taking control and wanting to make sure our babies are as 'well fed' as possible.

This can be challenging when one of our main roles as parents is to feed our children. However feeding is much more than just what your baby eats. Your parenting style around feeding contributes towards how you nurture and grow a healthy child.

Is paced feeding suitable for all babies?

Yes, unless your baby has a medical condition and needs to be artificially fed. You can get more advice on this from a Registered Paediatric Dietitian or Health Visitor.

Is paced feeding the right method for me to follow?

Only you can decide this, but the research on it's effects is very promising.

Paced feeding requires you to be very in tune with your little one's feeding and fullness cues and to be able to provide the right calm environment to follow the techniques.

There are lots of reasons why this may be challenging in some situations, but it is worth the effort to try and give your baby the very best start in life.

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Why you should practice pace feeding when bottle-feeding your baby - Weaning | Fussy Eating | The Children's Nutritionist

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Paced feeding is a new bottle feeding technique that allows your baby to be in control of how much and how quickly they feed. The technique strengthens the attachment between you and your baby.

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Breast-feeding is a natural and convenient way to feed your newborn baby, but it may not be right for you, or possible. If you decide not to breast-feed, there are several things that you can do to be more comfortable.

During pregnancy, your body makes many hormones to help prepare to deliver a baby. A hormone called prolactin helps your breasts to produce milk.

Within several days after your baby is born, your breasts will stop making milk if you do not breast feed or express your milk. However, you may have other symptoms during this time, such as:

Your breasts may feel firm and tender. This is a normal process called breast engorgement. It usually goes away in a couple of days.

Your breasts may leak drops of milk for several weeks after you give birth.

Here are some ways to help relieve discomfort while your breasts stop making milk:

Wear a well-fitting, supportive bra. Sleep in the bra.

Put an ice pack, gel pack, or package of frozen vegetables wrapped in a cloth on your breasts for 15 to 20 minutes every 1 to 2 hours while you are awake.

Use a towel or stretch bandage to bind your breasts. The hospital staff or a lactation consultant can help you learn the correct way to do this.

Do not pump your breast milk, massage your breasts, or rub your nipples. If your breasts are stimulated or emptied, they will keep making milk and your breasts will stay painful.

Nonprescription pain medicine may help. Talk to your healthcare provider before you use any medicine to be sure that the medicine is OK for you to use.

Some breast-feeding experts recommend using cool cabbage leaves to treat painful breast engorgement. Many women who have tried cabbage leaves claim the treatment brings relief from discomfort. Why this works is not known. Here is how you can use cabbage leaves for engorgement:

Put washed and dried, crisp, cold, green cabbage leaves on your engorged breasts. You can wear the leaves inside your bra or use them as compresses covered by a cool towel. You can cut holes in the leaves to keep your nipples dry.

Leave the cabbage leaves in place for about 20 to 30 minutes or until they have wilted. You may need to apply leaves several times a day for several days while you are trying to dry up your milk.

In the past, certain medicines were used to stop milk production. These medicines are no longer given to women who choose not to breast-feed.

Developed by RelayHealth.
Published by RelayHealth.
Copyright ©2014 McKesson Corporation and/or one of its subsidiaries. All rights reserved.

References

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Breast-feeding is a natural and convenient way to feed your newborn baby, but it may not be right for you, or possible. If you decide not to breast-feed, there are several things that you can do to be more comfortable. During pregnancy, your body makes many hormones to help prepare to deliver a baby.

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Natural disasters can make bottle feeding difficult. Learn tips for how to be prepared for bottle feeding through an emergency.

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Are you getting frustrated with the endless stream of unwanted advice you get from other people about how to raise your child? You may love your friends and family, but how do you get them to stop dispensing all this unwanted advice?

The important place to start is to understand that just as your baby is an important part of your life, he is also important to others. People who care about your baby are bonded to you and your child in a special way that invites their counsel. Knowing this may give you a reason to handle the interference gently, in a way that leaves everyone's feelings intact.

Regardless of the advice, however, it is your baby, and in the end, you will raise your child the way that you think best. So it's rarely worth creating a war over a well-meaning person's comments. You can respond to unwanted advice in a variety of ways:

Listen first

It's natural to be defensive if you feel that someone is judging you; but chances are you are not being criticized; rather, the other person is sharing what they feel to be valuable insight. Try to listen - you may just learn something valuable.

Disregard

If you know that there is no convincing the other person to change her mind, simply smile, nod, and make a non-committal response, such as, "Interesting!" Then go about your own business...your way.

Agree

You might find one part of the advice that you agree with. If you can, provide wholehearted agreement on that topic.

Pick your battles

If your mother-in-law insists that Baby wear a hat on your walk to the park, go ahead and pop one on his head. This won't have any long-term effects except that of placating her. However, don't capitulate on issues that are important to you or the health or well-being of your child.

Steer clear of the topic

If your brother is pressuring you to let your baby cry to sleep, but you would never do that, then don't complain to him about your baby getting you up five times the night before. If he brings up the topic, then distraction is definitely in order, such as, " Would you like a cup of coffee? "

Educate the other person

If your "teacher" is imparting information that you know to be outdated or wrong, share what you've learned on the topic. You may be able to open the other person's mind. Refer to a study, book, or report that you have read.

Quote a doctor

Many people accept a point of view if a professional has validated it. If your own pediatrician agrees with your position, say, " My doctor said to wait until she's at least six months before starting solids. " If your own doctor doesn't back your view on that issue, then refer to another doctor - perhaps the author of a baby care book.

Be vague

You can avoid confrontation with an elusive response. For example, if your sister asks if you've started potty training yet (but you are many months away from even starting the process), you can answer with, " We're moving in that direction. "

Ask for advice!

Your friendly counselor is possibly an expert on a few issues that you can agree on. Search out these points and invite guidance. She'll be happy that she is helping you, and you'll be happy you have a way to avoid a showdown about topics that you don't agree on.

Memorize a standard response

Here's a comment that can be said in response to almost any piece of advice: " This may not be the right way for you, but it's the right way for me. "

Be honest

Try being honest about your feelings. Pick a time free of distractions and choose your words carefully, such as, " I know how much you love Harry, and I'm glad you spend so much time with him. I know you think you're helping me when you give me advice about this, but I'm comfortable with my own approach, and I'd really appreciate if you'd understand that. "

Find a mediator

If the situation is putting a strain on your relationship with the advice-giver, you may want to ask another person to step in for you.

Search out like-minded friends

Join a support group or on-line club with people who share your parenting philosophies. Talking with others who are raising their babies in a way that is similar to your own can give you the strength to face people who don't understand your viewpoints.
Ideas from The No-Cry Discipline Solution Follow Elizabeth Pantley: Pinterest | Facebook | Instagram

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Handling Unwanted Advice - Elizabeth Pantley - The No-Cry Solution

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Are you getting frustrated with the endless stream of unwanted advice you get from other people about how to raise your child? You may love your friends and family, but how do you get them to stop dispensing all this unwanted advice?

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18 March 2019

On Channel 4 Dispatches on Monday 18 March, new mum Kate Quilton asked if formula milk is being priced fairly, and whether claims made for it are unbiased and scientifically accurate.

The programme showed the impact that the cost of formula milk is having on family budgets. In a time where the cost of living has increased, but the wages in people's pockets have not kept pace, some families are having to make difficult choices in order to feed their children. Dispatches also demonstrated how we need to make sure babies and parents are protected from commercial interests and misleading marketing practices.

The programme explored how powerful multi-national companies have been pushing the boundaries of existing legislation to promote their products. It highlighted the importance of strengthening legislation to better protect families from harmful commerical interests and instead promote evidence based information about infant feeding. This fits in with our Call to Action campaign, which urges UK governments to fully implement the International Code of Marketing of Breasmtilk Substitutes (the Code) into UK law. It also explored potential conflicts of interest within health services.

The programme ended with a quote from programme director Sue Ashmore, " We need to make sure babies and parents are protected from commercial interests and misleading marketing practices. Di spatches has highlighted how powerful multi-national companies have been pushing the boundaries of existing legislation to promote their products. We urgently need better legislation to protect babies."

The episode follows last year's Dispatches: Breastfeeding Uncovered, in which Kate Quilton looked into breastfeeding in the UK and considered why the UK has one of the lowest breastfeeding rates in the world.

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Channel 4 Dispatches: The Great Formula Milk Scandal - Baby Friendly Initiative

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18 March 2019 The programme showed the impact that the cost of formula milk is having on family budgets. In a time where the cost of living has increased, but the wages in people's pockets have not kept pace, some families are having to make difficult choices in order to feed their children.

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Bottle feeding - How to make up a bottle

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https://attachmentparenting.co.uk/project/responsive-bottle-feeding/

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Bottle feeding resources - Baby Friendly Initiative

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These resources cover a range of issues around bottle feeding, including making up feeds and responsive bottle feeding.

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The Institute for Breastfeeding and Lactation Education (IABLE)

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CQ #132 - February 19, 2019

by Anne Eglash MD, IBCLC, FABM

Bottle nipple flow rates are not always as described by the manufacturer.

Advances in Neonatal Care 19(1) 32-41

What is the difference in flow rates of different baby bottle nipples, and why does it matter?

I am frequently asked by parents, particularly breastfeeding mothers, 'What is the best nipple for feeding my baby a bottle?' For infants with oral feeding challenges, such as prematurity, cleft palate, or heart disease, speech therapists often decide what nipples to use, and they work with the infant and family to make sure that the bottle and nipple are appropriate. But what about term healthy infants who are breastfeeding, who may need to bottle feed in the future?

I often consider the shape of nipples and flow rate. My personal preference is to suggest a nipple that is cylindrical. I suspect that a flat or bulbous shaped nipple may keep the tongue back when feeding, while during breastfeeding, the tongue needs to protrude to grasp and maintain contact with the breast.

The article for this week's clinical question of the week addresses flow rate of different nipples. The authors explain that flow rate matters because swallowing interrupts breathing. If flow rate is too fast, respirations are more frequently interrupted. Healthy term infants can modify how strongly or quickly they are sucking to control the flow rate to some extent, whereas infants with prematurity or other challenges such as heart disease or lung disease have more difficulty moderating the flow rate with a given nipple, and are at higher risk for respiratory distress, choking and aspiration.

This study tested the rate of milk flow from bottle nipples commonly used in the hospital or after discharge, for a total of 375 nipples. They compared the flow rate of nipples in a few different ways: 1) comparison between the exact same type of nipple, and 2) comparison between nipples marketed in the same category, such as extra slow flow nipples.

They hooked up the bottles of milk to a Medela pump using the proper shield sizes at a controlled angle, applying the same pressure each time, and measured the flow rate.

What do you think are accurate statements, according to the authors of this study, regarding the milk flow rate of different nipples? Choose 1 or more:

1. The nipple with the fastest flow rate is the Medela Calma nipple.

2. All of the nipples marketed as 'slow flow' had very similar flow rates.

3. Products labeled as 'premature' nipples were slower flow than the 'slow flow' nipples.

4. The packaging for nipples tends to be accurate in its description for rate of milk flow.

5. In general, each nipple of a particular type (i.e. all Gerber First Essential Nipples) have nearly the exact same flow rate.

See the Answer

Advances in Neonatal Care 19(1) 32-41

Britt Frisk Pados, PhD, RN, NNP-BC; Jinhee Park, PhD, RN; Pamela Dodrill, PhD, CCC-SLP

Background:

Milk flow rate may play an important role in an infant's ability to safely and efficiently coordinate sucking, swallowing, and breathing during feeding.

Purpose:

To test milk flow rates from bottle nipples used in the hospital and after discharge.

Methods:

Bottle nipples used in hospitals (10 unique types) and available nationwide at major retailers (15 unique types) were identified. For each of the 25 nipple types, 15 nipples of that type were tested by measuring the amount of infant formula extracted in 1 minute by a breast pump. Mean milk flow rate (mL/min) and coefficient of variation (CV) were calculated for each nipple type. Comparisons between nipple types were made within brand and within category (e.g., Slow, Standard). A cluster analysis was conducted to identify nipples of comparable flow.

Results:

A total of 375 individual nipples were tested. Milk flow rates varied widely, from 0.86 to 37.61 mL/min. There was also a wide range of CVs, from 0.03 to 0.35. Packing information did not accurately reflect the flow rates of bottle nipples. The cluster analysis revealed 5 clusters of nipples, with flow rates from Extra Slow to Very Fast.

Implications for Practice:

These data can be used to guide decisions regarding nipples to use for feeding infants with medical complexity in the hospital and after discharge.

Implications for Research:

Research on infant feeding should consider the flow rate and variability of nipples used, as these factors may impact findings.

This study has important implications for practice:

1. Don't trust the label on the package! For example, the flow rates of bottles that are in the same category as 'slow flow' will differ significantly.

2. Preemie nipples are not slower than slow flow nipples.

3. The slowest flow nipple, among those studied, is the Phillips Avent Natural First Flow. The fastest by a huge margin is the Medela Calma.

4. When comparing the exact same nipple brands/type, the nipple with the most variability in flow, is the Phillips Avent Natural First Flow, but the majority of the nipples had a high degree of variability.

5. Obtain this article and use this information to guide families on appropriate nipple brands to match infant needs.

6. Don't over-tighten the nipple collar onto the bottle. This can lead to negative pressure and nipple collapse, affecting milk flow.

7. Adding a high volume of milk in the bottle will cause the milk to flow at a higher rate due to hydrostatic pressure. So, if feeding a frail preemie, don't put much more in the bottle than the infant is going to take. Pacing the feeding, by keeping the bottle horizontal, helps to decrease the hydrostatic pressure.

8. And, holey moley, some of the nipples studied didn't even have a hole!

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Bottle Nipple Flow Rates - The Institute for Breastfeeding and Lactation Education (IABLE)

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CQ #132 - February 19, 2019 by Anne Eglash MD, IBCLC, FABM Bottle nipple flow rates are not always as described by the manufacturer. Advances in Neonatal Care 19(1) 32-41 What is the difference in flow rates of different baby bottle nipples, and why does it matter?

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Dispatches Channel 4 TV programme

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It is important that infant milks are made up safely. Powdered infant formula is not sterile and needs to be made up at a temperature which will kill any potential bacteria present. All equipment needs to be sterilised, and it is important to know how to make up and store milk safely.

The bacterial contamination of powdered infant formula

This report summarises evidence about the known risks associated with potential bacterial contamination of powdered infant formula (PIF). We believe that maintaining the minimum 70 ⁰ C water temperature for making up PIF is essential but also recommend a review of water cooling times and alternative preparation methods. In addition, we recommend an urgent independent review by the Food Standards Agency of risks and/or benefits of the use of probiotics in infant milk products bearing in mind the known risks associated with potential pathogen presence in PIF.

Information and our concerns about formula preparation machines (including the Tommee Tippee Perfect Prep machine) can be found on pages 37-40 of this report.

Latest evidence on formula preparation devices

In October 2023 a paper was published which confirms that, despite their marketing claims, formula preparation devices often do not deliver water hot enough (i.e. at least 70˚C) to kill any bacteria that may be in the powdered infant formula.

The FSA are advising parents/carers to check that the temperature of the water used to prepare infant formula is at least 70˚C "regardless of the method used", and that if that is not the case for those using an infant formula preparation machine, that they should contact the manufacturer and their local Trading Standards Department or Citizens Advice.

The UK's product safety regulator, the Office for Product Safety and Standards has purchased examples of the infant formula preparation machines to assess compliance and have said that, if necessary, UK consumers will be informed of any actions they might need to take.

The safest way to prepare infant formula is using a kettle, following NHS guidance

If you use a formula preparation machine, we suggest: Check the temperature of the water dispensed using a food thermometer. Always do this separately to making a bottle as the thermometer can contaminate the water. If the temperature if below 70 degrees: - Use a kettle instead to make up bottles following NHS guidance - Report to your manufacturer. Scan QR code for NHS advice: https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/bottle-feeding/making-up-baby-formula

Guide to bottle feeding:
How to prepare infant formula and sterilise bottles

Guide to Bottle Feeding by UNICEF Baby Friendly, Better Health Start for Life and the NHS provides information on safe preparation and storage of infant milks.

It is important that infant milks are made up safely. Powdered infant formula is not sterile and needs to be made up a temperature which will kill any potential bacteria present. All equipment needs to be sterilised, and it is important to know how to make up and store milk safely.

Making up bottles of infant formula from hot taps and baby kettles

More kitchens are now fitted with hot water taps dispensing boiling water directly. This statement provides some information to support families making up formula this way to do so safely.

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Making infant milk safely - First Steps Nutrition Trust

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It is important that infant milks are made up safely. Powdered infant formula is not sterile and needs to be made up at a temperature which will kill any potential bacteria present. All equipment needs to be sterilised, and it is important to know how to make up and store milk safely.

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BABY’s BEHAVIOURS Vs IM NOT GETTING ENOUGH TO EAT

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BABY’s BEHAVIOURS Vs IM NOT GETTING ENOUGH TO EAT

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Dear Mommy,

Thank you so much for breastfeeding me! You probably already know that your milk is designed especially for me, and is better than anything else you could feed me.

I know that right now, you feel like your friends who aren't breastfeeding their babies seem to have an easier time of things. Those other babies sleep soundly and longer between feedings, they drink so much, and they don't fuss to eat all the time like I do! I can tell you're getting a little bit frustrated, and I hear all the advice you're getting ... my grandma says you weren't breastfed and you turned out just fine, my daddy says he feels like he can't do anything to soothe me, and that lady with the cold hands that you call "doctor" gave you a can of something that she says will help me grow faster. You're tired and frustrated because taking care of me just seems too hard, but please mommy, before you give up this yummy breastfeeding thing, let me explain some of my behavior to you. It might help you feel better.

First, if you and I were separated after I was born, for any reason (maybe it was hospital protocol that I be left under a warmer, maybe you were recovering from surgery), I've got some catching up to do, because I probably lost more weight than my friends who got to stay close to their mommies. It's OK ... I'm really good at letting you know when I need some more calories, but it's important that you let me breastfeed lots and lots, even if my grandma says "he just ate!!" In my first few days, the nurses at the hospital might tell you I'm hungry and your body can't make enough milk for me ... but mommy, that colostrum from your breasts is some awesome stuff! It's packed with protein, which binds to any bilirubin in my body (elevated bilirubin causes jaundice in more than half of newborns) so I can poop it on out. It's also a great laxative, which makes it easy for me to get all that black, tarry meconium out of me and we can move on to the seedy, yellow-brown poops that are much easier to clean off my sweet tushie. Now, the colostrum is really thick and sticky, and I'm so small and still figuring out how to move my tongue, and we're both still trying to get comfortable together, so it might take me 20 minutes or longer to suck out just ONE TEASPOON (5-7 mL) of that liquid gold.

But it's OK, mommy! You know, there is really nowhere I'd rather be than in your arms, hearing your sweet voice and smelling you - even though you haven't had a shower since before I was born, you're just delicious to me. And something else you should know about me ... even though I have a really cute "Buddha belly" that looks all chubby, the capacity of my stomach on the day I'm born is just 5-7 milliliters - that's the size of a small marble! You're the smartest woman in my whole world, so I know you see the connection here! The amount of colostrum in your breast is exactly the capacity of my tummy! My stomach walls on my first day of life are very rigid and won't stretch; this is why, if anyone tries to feed me with a bottle, I'm going to spit most of it back up again, even though I eagerly suck at it. See, mommy, I only have two ways to send and receive information from my brand-new world - I can cry, and I can suck. I can't see much, and all these sounds are so much louder than when I was inside you, and I can use my hands to help me orient myself on your breast, but crying and sucking are pretty much how I make sense of everything.

I know it seems really confusing, mommy, that I would want to suck and suck and suck even though my tummy is full. When I suck, lots of great things happen for both of us. I keep my own digestion moving by triggering the involuntary digestive muscles in peristalsis - moving the contents of my stomach along because I'm still moving my mouth and tongue, which are the beginning of my digestive tract. When you let me do all this suckling at your breast, I can very easily regulate how I suck, depending on why I'm sucking at any given moment. You can probably feel when I'm suckling nutritively and swallowing lots of milk, and when I'm kind of relaxed about it, feeding sort of like I'm savoring a bowl of ice cream ... you know how sometimes, you scrape just a tiny bit onto your spoon, because you want it to last a long time? To me, you're better than ice cream! But on a bottle, it's impossible for me to suck and not get whatever's in there, and that's confusing to me, so I might keep sucking because that's what my instinct is telling me to do, or I might realize my tummy hurts (because even on day 10, my stomach capacity is only a ping pong ball) and I'll cry and cry because all I really know is crying and sucking!

A word about these instincts I feel ... I really can't help it, mommy, that I want to suckle so much. It's just how I came out, and there doesn't seem to be much that I can do about it. Please believe me, I'm not trying to trick you! In a few weeks, this need lets up a tiny bit, but for now, suckling is my M.O. But, do you want to know something really cool? I'm not the only one who benefits! When I suckle at your breast in these early days, your body actually activates prolactin receptors! Isn't that amazing? In my first two weeks, the higher I make your prolactin levels go (my suckling triggers a prolactin surge in your body), the more of these receptors get activated in your breasts, and the higher your potential milk production will be for as long as you choose to breastfeed me. That's one reason your lactation consultant tells you to wait on introducing that bottle or that binky- this prolactin receptor thing only happens for the first 10-14 days. After that, the prolatcin surges when I breastfeed are much smaller, so the more receptors there are to gobble up what prolactin is there, the more easily you'll make all the milk I need.

Besides prolactin, there's oxytocin, another hormone I activate when I am at your breast. Oxytocin is part of what makes you so addicted to me! It's "the love hormone" and it helps you feel relaxed and content when we're breastfeeding. Go ahead, mommy, exhale and relax! It's OK! Oxytocin release is triggered by nipple stimulation, not necessarily milk removal (though when things are going well, my stimulation of your nipples usually means I'm removing milk!). Now, I know this might sound a little awkward coming from your baby, but I need you to know something about oxytocin. There are only three events in your life that trigger oxytocin release: nipple stimulation (like when I'm breastfeeding), labor (the oxytocin released during childbirth stimulates uterine contractions, which is why nipple stimulation might be suggested when labor stalls, and also explains why sometimes, after you breastfeed me, you feel an increased expulsion of lochia and maybe some cramping), and ... orgasm!! Isn't neat that the same hormone plays a part in making me, birthing me, and feeding me, and it's a hormone that makes you feel GOOD to do all three?

Mommy, I know you are trying your very best for me and you've been worried about whether your body can satisfy my appetite. I know you're used to being able to measure everything, and your breasts don't have markers on them to tell you how much milk I got. Maybe you used a breast pump, and that confirmed your worries that there isn't much milk there - but mommy, please understand that a good pump can mimic me, but your body wasn't designed to have all these wonderful hormone surges for a cold piece of plastic with a noisy vacuum motor. You know that feeling you get when you hold my warmth and weight, smell how delicious I am, and nom nom nom on my fat cheeks? That feeling helps you make milk! That feeling is part of the whole system that was designed to make you need to be close to me, just as much as I need to be close to you. And mommy, I know you're very busy, and important, and there's so much you used to do before I came, and I know right now, it feels like you'll never do those things again, and our house is getting messy, and maybe that scares you. But please know, every moment you spend holding me, every time you gaze lovingly at me, and every hour you spend breastfeeding me in these early days is so important to me, because you're all I know. I love daddy and grandma and all of our friends, but I'm designed to be happiest and least stressed when I'm with you. Can you wear me in a sling or soft carrier after I'm milk-drunk? I really like listening to your heart beating while I sleep, and you are warm and soft and smell so good. That space between your breasts is perfectly sized for my head, and there's nothing I like better than the feel of your skin against mine. Well, maybe there is something I like better ... I love it when you sleep next to me after we've been breastfeeding. Oh, mommy, when you nurse me while lying down, you relax and your milk flows so nicely, and I feel like you're so happy to be with me, and I'm very special to you because you don't have to run off and do something else as soon as I've let your breast go.

And mommy, I have a promise to make to you. I can't say for sure when it will happen, but there will come a day when I need you a little bit less intensely. My feedings will get more organized, my weight gain will stabilize, and sometimes, I'll even like when my daddy or grandma or other loving person holds me. But today, I need you. You'll always be my number one, even after we're done breastfeeding, but I will learn, like you did, to defer my needs and to trust others to meet them once you and I get a good thing going. Thank you so much for all you've done for me so far. Until you start giving me an allowance, I hope my good health, sweet smiles, coos, and giggles will sustain you!

Love,

Baby

Many thanks to the hundreds of readers that shared so many beautiful photos of their newborn babies. There is just a small sampling here but you all have incredible photographs of your beautiful babies. Thank you for being willing to share and to all the photographers of these precious images! Diana Cassar-Uhl, IBCLC and La Leche League Leader, has written articles for the La Leche League publications Leaven and Breastfeeding Today, and is the author of the La Leche League tear-off sheet Vitamin D, Your Baby, and You. She is a frequent presenter at breastfeeding education events. Excited about her work toward a Master of Public Health, Diana hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition. Diana, mother to three breastfed children, has served as a clarinetist on active Army duty in the West Point Band since 1995. Diana enjoys running, writing, skiing, and cross-stitching when she finds herself with spare time. She also writes at Normal, like breathing.

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Dear Mommy, Thank you so much for breastfeeding me! You probably already know that your milk is designed especially for me, and is better than anything else you could feed me. I know that right now, you feel like your friends who aren't breastfeeding their babies seem to have an easier time of things.

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Newborn Cues narrated - What is Your Baby Trying to Tell You?

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Like your Birth Plan but to think about feeding your baby

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A Video on Alternative Feeding Methods for Newborns

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Here's a video on Cup Feeding and other Alternative Methods to help in case you are not able to breastfeed. Supplements are not recommended for your newborn.

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Information about giving your baby milk without using a bottle.

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Yes, babies can drink from a cup! It may seem a bit awkward but they just need a little practice.

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This can be used for a newborn to avoid introducing a bottle.

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Support groups

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PLEASE CHECK the numbers on your bottles

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PLEASE CHECK the numbers on your bottles

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Particularly if your using powdered infant formula.

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A new Australian study has been published investigating the accuracy of the volume marks on baby bottles used in making up formula. It is important that formula is made up to the correct concentration because formula that is too weak doesn't provide enough nutrition and formula that is too strong can lead to dehydration, constipation and excessive weight gain. One possible source of inaccuracy is the measurement of the water volume. The researchers tested the accuracy of one example of each baby bottle brand, volume and shape available in Australia.

The only quality standard for baby bottles is the European standard EN14350, which states that volume measurements should be within 5 ml or 5% of the stated volume. Of 91 bottles tested, 37 markings on 19 bottles were so inaccurate that they were outside the European standard. Some of those bottles falsely claimed they met the standard, though they did not.

Inaccurate measurements were a mix of overestimation and underestimation. Some bottles did not have volumes marked that could be needed for making up formula. Altogether, 50 bottles or 57% of the bottles tested, had inaccurate or missing volume measurements. Disposable liner bottles were particularly inaccurate, with one liner's 100ml mark actually measuring only 70ml. Bottle price had no bearing on the accuracy of the volume markings - more expensive did not guarantee more accurate.

Associate Professor Karleen Gribble of Western Sydney University is concerned that consistent over- or under- concentration of formula could lead to poor infant health. "To avoid either individual or public harms, well-enforced standards are needed, as is better guidance to both carers and health professionals to accurately measure water volume when reconstituting powdered infant formula."

These findings lead to more questions: Are the errors practically significant in terms of infant health? And what alternative measurement system could parents use to be sure they make up formula accurately?

The question of the practical significance of these measurement errors is hard to answer. The error mentioned above in the disposable bottle liner is very large and the study authors would like to prohibit volume markers on this style of bottle.

Sustained over-dilution of formula, which would occur if formula was often made up in a bottle with stated volumes smaller than the real volume, could lead to undernutrition, poor growth and development.

Over-concentrated formula (which happens if too much powdered formula is added to the water, or the stated water volume on the bottle is higher than the real volume) has been shown to lead to excess weight gain in infants and can also exacerbate constipation and gastric reflux.

Parents can't compensate for errors in the bottle measurements because they don't know in which direction their bottles' markings might differ from the true volume or how large the error might be. Since even those bottles claiming to meet the European standard were not reliable, parents are ill-served by the current situation.

So, what can parents and carers of formula-fed infants do? The researchers used laboratory scales to weigh the volume, accurate to 0.1g, but those scales are not readily available to parents. What alternative measurement system could parents use? Accurate measuring cylinders are used in scientific laboratories and can be bought online without great expense. Also, ready-to-use formula is another way around the problem, though it is very expensive and is currently only available online to Australians.

To read the media release prepared by Western Sydney University, please follow this link.

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New study indicates discrepancies in baby bottle measurements

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A new Australian study has been published investigating the accuracy of the volume marks on baby bottles used in making up formula. It is important that formula is made up to the correct concentration because formula that is too weak doesn't provide enough nutrition and formula that is too strong can lead to dehydration, constipation and excessive weight gain.

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It sounds like a dream for formula feeders everywhere; previously torn between risking making bottles in advance or trying to prep them as per the guidelines at 2am - now the perfect prep machine promises to help.

At first glance it looks like the baby equivalent of a Tassimo.

I get the appeal.

Making up formula properly (as any honest mum will tell you) is a complete pain in the arse. It's not easy or convenient to wash, sterilise and prepare each and every bottle to a 14 step plan; particularly when you consider newborns can feed 12 times per day if fed responsively/on demand.

The perfect prep promises to deliver a ready made bottle in under 2 minutes, at just the touch of a button.

Too good to be true?
If you're expecting something like a coffee machine, whereby you press a button and get a ready to go bottle of formula, you're probably going to be quite disappointed.

You still have to measure and add the powder, add to the machine which first adds a "hot shot" to kill any bacteria in the powder. You then shake the bottle before cold water is dispensed, resulting (when all works well) in a body temperature bottle.

You also can't make up bottles any smaller than 4 ounces, which is a vast amount for a newborn or young baby and may result in lots of waste or encouraging overfeeding. This is in my opinion a big downside to the product, as surely it's mums of newborns who wake and feed lots who would potentially benefit most from such a gadget?

So how hot is the hot shot?
Establishing this isn't as easy as you might think, a Google threw up different results and so two mums with perfect prep machines kindly dispensed a shot and measured the temperature.

One reported a reading of 99 degrees and the other 92. Of course this doesn't mean much as it's hardly controlled, one might have a less accurate thermometer or suchlike - but suffice to say these two are well above the recommended 70 degrees.
Does this matter?
As many will know there has been changes in formula preparation guidelines over the past 10 years or so. We've gone from people using any temperature cooled boiled water, storing bottles for long periods etc to quite a strict protocol.

This has come about not because the UK Government wants to make life difficult for formula users, but because the more we have learnt about the bacteria linked with conditions like gastroenteritis and what their main vessels of transfer are, we can make things safer. For example we now know 50 degrees is a lovely temperature for bacteria to breed, whereas 70 kills things like E-Coli.

Initially the formula companies were (in my opinion and for quite obvious reasons) quite resistant to these changes. Making the product more difficult and time consuming to prepare is not a manufacturers dream. Even now tins say things like "3 Level scoops; Cooled, freshly boiled water", with no measure of an appropriate temperature (taken from SMA first milk for sale @ Ocado).

The infant nutrition council (the association for the infant formula industry in Australia and New Zealand) quite quickly expressed concerns about people using water too hot stating:

"Nutrients most destructible by heat are the vitamins; thiamin, folate,pantothenic acid and vitamin C. For example, thiamin is destroyed at 100°C."

I had the link for this saved, but interestingly whilst other references to it remain online, I can't locate it any more anywhere on the internet: http://infantnutritioncouncil.com/wp-content/uploads/2009/03/preparation-of-infant-formula-and-safety-around-70-degrees.pdf

Their general guidance as to safe preparation of formula has also been removed.

There was no reference for this statement at the time and nobody seems very sure whether it's actually true.
Several members of a parenting forum therefore contacted formula companies directly to ask. These posts still currently stand including comments like:

"Originally Posted by mamas_melon I actually emailed sma about this and this is what they said:
Thank you for your enquiry.
We would expect boiling water to adversely affect the nutritional value of Vitamin C, followed by Vitamin B1 and B6. We would not expect any of the other nutrients to be adversely affected, but we don't have any data to support this position."

Others have been told it's because of the probiotics or to avoid scalding the powder.

I found this "Letter to the Editor" in the Journal of Pediatric Gastroenterology & Nutrition 2010

"On the other hand, the use of hot water implies acceptance of some untoward consequences, such as the formation of curds and the loss of some nutrients, mainly vitamins" (14)

In conclusion, before definitive changes in the recommendations on home handling of powdered milk are made, additional studies may be needed to clarify the cost/benefit ratio of the 2 possible options: water heated to 50°C or to ≥70°C.

According to the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition, water heated to ≥70°C is not required and may be potentially harmful to the nutritional quality of formulas.

Unfortunately I was also unable to track down the paper for reference 14: "Buchanan R. 2003. Resistance-Thermal and Other. Presentation to the US FDA Advisory Committee, 18-19 March 2003. http://www.fds.gov/ohrms/dockets/ac/03/slides/3939sl_Buchanan_file/frame.htm." A midwife I asked said some parents she has worked with, have commented some breastmilk substitutes become really lumpy if the water is too hot. A quick scan through Amazon reviews suggests others have had experienced similar:

"Great invention but the bottles end up too full of air and lumpy."

Other reviewers suggest people check the temperature as they felt the resulting formula was much too cold.

Overall the good reviews do outweigh the bad - a lot of the negative reviews are about reliability and technical problems experienced with the machine, rather than dissatisfaction when it was working well.

So I wondered: is there a cheaper alternative to faster, safer formula?
If you want instant boiling/near boiling water instead of waiting for a kettle? I can't see any reason you couldn't use something like the Breville hot cup currently selling for £25 if you can wait for it to return to stock (you will see under other sellers on the right there is Amazon at the cheaper rate).

If you want a product that can serve more than one purpose, and doesn't need wiping/washing like something that touches milk would, we have this one below.

It has one mode to take the temperature of people or animals, and a second for liquids or other objects. I've compared this with a mercury thermometer and was surprised at how accurate it was. It comes in a drawstring bag for travel too.

Have you got a perfect prep? Has it revolutionised formula making for you? Let me know in the comments below :)

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Is the Perfect Prep Formula Machine Really Perfect? & Cheaper Cheat Alternative...

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It sounds like a dream for formula feeders everywhere; previously torn between risking making bottles in advance or trying to prep them as per the guidelines at 2am - now the perfect prep machine promises to help. At first glance it looks like the baby equivalent of a Tassimo.