Infant feeding bottles, infant feeding & consumer protection
A few thoughts about the infant feeding bottles with inaccurate markings issue – yes, it’s an ‘old’ story in New Zealand but one that’s bugged me for a while.  Let’s unpack this and look at some other associated issues at the same time.
Starting with the history – after health workers expressing concern that measurements on some infant feeding bottles were inaccurate, this issue became ‘live’ in New Zealand in 2013, with informational, warning notifications to health workers about the issue, accompanied by media releases. This information outlined the dangers of too dilute or too concentrated feeds and suggested that parents take their bottles to a pharmacy for a measurement check, with the added note that pharmacists could charge for this service.
Now firstly, issues are NOT just confined to the measurements on the bottles and the powder scoops to water ratios, even though this is important. Consumer Affairs point out that some bottles overestimate the fluid volume by up to 40 percent and that may have serious health consequences for infants. Even though media messages at the time suggested ‘all’ ‘we’ needed to do was make sure the measurements were correct and all risk would be reduced, this is quite clearly not the case. Although the formula industry would like the world to believe that a parent making up a feed correctly is the only issue, the research evidence about infant & young child health would quite significantly beg to differ.
Secondly – health workers such as midwives and nurses in maternity facilities are there to support ALL parents with ALL aspects of infant feeding – the protection, promotion and support of breastfeeding AND ensuring parents using infant formula/bottle-feeding have access to non-judgemental support and information about how to prepare bottle feeds/reconstitute powdered infant formula as safely as possible. Lead maternity carer midwives and Tamariki Ora Well Child Nurses continue the support for parents in their own homes. Are we really suggesting that the pharmacy is the only place where parents can get support with feeding bottles?
I’m pretty sure that midwives and well child health nurses would see checking the feeding bottle, if necessary, as being part of the essential information and support that they could give to families using infant formula/baby bottles. All it takes is a plastic syringe and some water. Do parents really need to go to pharmacies to get their bottles checked where they may also be charged a fee and potentially steered towards expensive bottle purchases? I don’t think so.
Another related issue – mothers who are expressing breast milk for their babies who are concerned about the accurate measurements of amounts being expressed, or being given to their babies. If you are a mother with a baby in a Neonatal Intensive Care Unit – you can be pretty certain that the amounts given to your premature or unwell baby will be measured accurately in the NICU so no need to add another worry into your life about bottles. Many NICUs use sterile, liquid ready to feed products as well. If women are expressing breast milk for a well baby at home the slightly inaccurate measurements on any bottles being used for expressed breast milk really don’t matter.
However, a serious issue related to scoops and water amounts, is the one of formula stretching. Nothing to do with bottle-markings but a lot to do with poverty – but wait, bottle markings do have something to do with poverty. Parents who are struggling with a low income do not tend to purchase the expensive feeding bottles which are more likely to be standardised with accurate measure markings, but the very cheap ones instead with inaccurate markings. These parents are also unlikely to pop into a pharmacy where there may be a charge for a bottle check.
But, back to formula-stretching; a study of families in the US in 2012 found that both food insecurity and formula stretching were common.  Formula stretching happens when parents try to make formula powder last longer and they hold back feeds or dilute them to the detriment of nutrition and infant development. One of the issues mentioned in this US study was that parents bought expensive branded formula products and saw the cheaper generic products as not being equivalent. Formula literacy can be elusive in the face of misleading industry marketing, but parents using formula should know that they do not need to purchase the expensive products, nor do they need to use any formula milk after their babies reach one year of age. Most unlikely they will get this information from industry of course – just more misleading health claims tempting parents towards the more expensive products and enticements to use formula products for longer than necessary (if formula feeding the formula is only necessary until the infant is one year old and a stage one product is suitable for that year).
Industry should not be providing feeding information of any kind to parents as they have an obvious commercial interest. Health workers need to get up to speed here, but they need support and access to good information themselves. In the UK it’s easy as the excellent First Steps Nutrition Trust provides all the information needed about the infant milks on the market. 
But wait – there’s more – one of the FAQs about inaccurate measurements on bottles does ask a pretty reasonable question about why do we (NZ) allow these faulty products that could harm babies into the country at all? This is a very good question. The Ministry of Business, Innovation and Employment says that this issue falls outside of the scope of current consumer law; “The provisions of the Fair Trading Act 1986 allow mandatory standards relating to products which may cause injury. Baby bottles which do not meet the EN14350 standard are not in themselves unsafe, rather they may have the potential in some cases to lead to adverse health effects.”  At this point I need a cup of tea and a lie down due to serious head banging activities. We can’t protect our babies from companies making faulty products? The smallest and most vulnerable of consumers?
I spotted a media report a few days ago from Canada about a self-feeding baby bottle. Health Canada announced a recall of an ILLEGAL hands-free baby bottle system.  Yes, illegal. “Products that position infant feeding bottles and enable infants to feed themselves without supervision are prohibited by law, Health Canada said, adding that babies could choke or inhale the liquid in the bottles. Unattended infant feeding practices are discouraged by Health Canada and Canadian professional medical associations the alert said.”  I may be out of order here, but I have searched for a similar regulation in New Zealand without success. Feel free to inform me if I am wrong – that snippet of news would be very welcome.
So, in the end there’s more to be concerned about alongside baby bottle-markings. Recently in New Zealand we’ve had another scare about contaminated formula powder (to add to the real melamine tragedy, the terrifying botulism concern, the nitrates worry, and the fertiliser aid dicyandiamide (DCD) in milk powder). This latest concern is related to an individual, or individuals, [who must be seriously deranged], threatening to add the poison 1080 to infant formula powder. No 1080 has been found yet in any products but this threat has been terrifying for parents using formula products. Suddenly the tins on the supermarket shelves have their own rather bored bodyguards (young employees who have to stand next to the shelves watching the formula tins), there are big signs telling parents how very safe formula products are and reassurances about all the checks the ultra-processed baby food goes through from the cow to the shelf. Worried parents have found suspicious looking defects in the foil lids but no contamination of 1080 in any of these tins has been found, thank goodness. I thought it interesting to note there were quite a few processing issues blamed for these faulty looking products– but nobody pursued that manufacturing concern.
Another thing never mentioned is that the powder in the tins is not actually sterile. I noted a recent media report from the UK where a baby was admitted to hospital with a serious campylobacter infection and parents said the baby’s diet was just one brand of formula. In a media statement the company involved said that “the milk was pasteurised and heat treated to very high temperatures.” That would reassure parents and make them think it was a sterile product wouldn’t it? But the company is talking about the MILK, not the end result powder. Formula powder cannot be sterilised as the temperature would destroy some ingredients. That means that contamination with bacteria such as chronobacter sakazakii, campylobacter and salmonella is possible during the many processing stages. If the feeds are made up and used correctly then any bacterial contamination will be dealt to, but in many countries parents are not given the correct information and it’s certainly not on the tins I’ve looked at in New Zealand. Here’s a link to the real story from the World Health Organisation where it explains clearly why the temperature of the water used to reconstitute the non-sterile powder needs to be at 70 degrees centigrade. Some countries, including the UK, are following these optimal recommendations.  
In 2013 I had a look at the products on the shelves in some NZ supermarkets (I wouldn’t want to be doing this now). In total I examined the labels on nine different companies’ tins. Instructions ranged from stating fresh or safe drinking water should be boiled and allowed to cool, to instructions stating that water temperatures should to be from 40 to 60 degrees C, but despite the diverse range of instructions not one was optimal. There is also no such thing as a standard scoop across all brands, so scoop-water ratio varies from brand to brand.
It’s time for a re-examination of the recommendations for making up a powdered formula feed in New Zealand, and time to look at consumer protection laws and regulations with infant advocacy and protection in mind.
Oh, BTW, avoid Googling ‘scoops of formula.’ It’s not very helpful, you get ‘extra scoops’, ‘3 scoops’, ‘5 scoops’, and ‘per ounce.’ Talk to a midwife or well child nurse about infant feeding concerns, scoops and bottle measurements. Check out First Steps Nutrition Trust as well for some great information. 
 Ministry of Health. (2013). Inaccurate volume markings on baby feeding bottles. http://www.health.govt.nz/our-work/preventative-health-wellness/nutrition/inaccurate-volume-markings-baby-feeding-bottles
 Inaccurate baby bottle markings. (2013). Media release. http://www.health.govt.nz/news-media/media-releases/inaccurate-baby-bottle-markings
 Consumer Affairs. Inaccurate baby bottle markings. http://www.consumeraffairs.govt.nz/news/product-safety-alerts/innacurate-baby-bottle-markings/?searchterm=baby%20feeding%20bottles*
 Burkhardt, M. C., Beck, A, F., Khan, R. S., & Klein, M. D. (2012). Are our babies hungry? Food insecurity among infants in urban clinics. Clinical Pediatrics, 51(3):238-243.
 First Steps Nutrition Trust. (2015). Infant milks in the UK: A practical guide for health professionals. http://www.firststepsnutrition.org/newpages/Infants/infant_feeding_infant_milks_UK.html
 Ministry of Health NZ. Questions and answers on inaccurate markings on baby bottles. http://www.health.govt.nz/our-work/preventative-health-wellness/nutrition/inaccurate-volume-markings-baby-feeding-bottles/questions-and-answers-inaccurate-markings-baby-bottles#mandatory
 Health Canada. (2015). Bed Bath & Beyond Canada L.P. recalls Podee® Hands Free Baby Bottle System.
 Bed Bath & Beyond recalls illegal self-feeding baby bottle
 Aptamil infant formula linked to UK Campylobacter case given all clear at plant. http://www.dairyreporter.com/Regulation-Safety/Aptamil-infant-formula-linked-to-UK-Campylobacter-case-given-all-clear-at-plant
 World Health Organisation. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf
 NHS Choices. Making up infant formula. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/making-up-infant-formula.aspx#close
 NHS Guide to bottle feeding: How to prepare infant formula and sterilise feeding equipment to minimise the risks to your baby. NHS, UNICEF UK, The Baby Friendly Initiative, Start for Life. http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/guide_to_bottle_feeding.pdf