Making up formula feeds
Making up formula feeds Michael Golden 09.11.99
Re: Making up formula feeds Ted Greiner 09.11.99
Re: Making up formula feeds Lola Gostelow 12.11.99

Date: Tue, 09 Nov 1999 14:35:21 +0000

From: Michael Golden <>

Subject: Making up formula feeds


Dear Ngonuts,

We should be concerned that caretakers may be asked to make up and use formula diets where the tolerable margin of error, before causing serious metabolic harm or death to children, is narrow.

Bacterial contamination is not the only serious hazard with formula feeds, incorrect formulation is just as dangerous - the two often go together to compound the hazard.

In the 50s and 60s a common problem was "hypernatraemic dehydration" caused by making formula to concentrated. This condition carried a high mortality. It often occurred with diarrhoea because mothers thought that "strengthening" the feed would alleviate the diarrhoea - to one seeing watery faeces coming out this is quite a logical thought. It is now rarely seen in UK because of high adult literacy, sustained education, alterations to formulation, standardization of scoops and bottles with very clear instructions for dry powder - and, most importantly, the marketing of already made up and correctly diluted liquid formula. The latter is not an option for most of the world.

In much of the world formula is so expensive that the opposite problem is common - highly dilute feeds - where the mother adds small amounts as if it is a medicinal powder - single tins frequently last for several weeks (asking how long a tin lasts is much more accurate than asking how it is made up) and the infant becomes severely malnourished.

The numbers of children who are not going to be breast-fed is set to rise.

1) Orphans and "separated children" are becoming common in complex emergencies as women and civilians are targeted.

2) There is set to be a massive increase in numbers of orphans - if the maternal to child transmission of HIV is somewhere from 10-25% this means that 75-90% of infants of HIV+ mothers will end up to be HIV- with a sick and then dead mother. The extended family, losing its economic members, can only "absorb" so many of these children. How will the rest be cared for and fed? (before they reach the age of street children, another massive time bomb) - HIV will lead to a great increase in the numbers of malnourished children in the coming decade - most have thought that HIV+ children will cause the increase - but this is unlikely to be the case - there will be a great increase in HIV- malnourished children as the breadwinners and carers succumb.

3) More immediately we have some HIV positive mothers choosing to formula feed their children.

Some time ago Lola sent a very sensible message about the "order" of desirability of different types of diet that can be used in an emergency situation for infants that cannot be breastfed - Generic formula came top of the list. There was a presumption that these alternatives were to be made up and dispensed by properly trained NGO staff, although this was not explicit. This point should have been made absolutely clear.

Formulae have been published showing how various types of dried or whole animal milk can be modified, when there is no generic formula, to make an "acceptable" diet - that is adding skim milk, oil, sugar, a mineral/vitamin mix and water together, or fresh cow's milk, sugar, water and mineral/vitamin mix - etc.

I would like to emphasise that mothers very frequently make mistakes when they simply have to add a scoop of powder to a measured volume of water in a feeding bottle. Making up diets from several ingredients (milk, sugar, oil, vitamin/mineral mix, water etc) is a highly skilled process that requires accurate measuring equipment, knowledge and a high degree of training - as well as hygienic conditions. No mother should ever be expected to make up such a diet for her child. If there are not funds for generic ready-compounded formula for the categories of infants where there is no alternative to formula feeding then such funds will simply have to be found - the alternative is a nightmare. "sachets of mineral mix should never be distributed to mothers to add to the diets of young infants.

Refugee mothers who have all be traumatized, destabilised, disorientated, confused and psychologically bludgeoned are even less likely to manage to "follow instructions" than those in stable situations.

I totally agree that cups and not bottles should be used for infant feeding. However, one advantage of the bottle is that it is of relatively standard size and the instructions on tins of formula refer to how the diet is made up using the gradations on a bottle - cups on the other hand come in all shapes and sizes and do not have graduations on them. The "generic" formulae that are now being ordered and supplied should have not only a scoop in them to measure the powder - but should also include a measure for the water! To my knowledge this has never been done, but is essential.

Low birth weight infants, infected infants, very young infants, and malnourished children and infants are all much more susceptible to errors of formulation than normal children. This is because they do not have the same concentrating and diluting ability in their kidneys so that an excess solute load is particularly dangerous - the water requirements increase exponentially with decreasing renal concentrating ability.

Furthermore, the experience with hypernatraemic dehydration in Europe 30 years ago was in a temperate climate - the margin of safety is much less in hot and dry conditions. After recognising several hypernatraemic children who were being fed recommended diets in Tchad, an Aberdeen student (Jackie Burt) did a study measuring water turnover in malnourished children in an ACF - TFC (humidity about 10% temp about 43oC). These children had concentrated urines and lost one third of their body water per day - in the hot, dry tropics the margin for safety in formulation of diets is even more critical.

Before any recommendations on infant feeding in either poor or emergency situations are promulgated they need to be thoroughly tested under diverse real conditions and cultures by people familiar and experienced with all the multitude of problems that occur under field realities as well as a knowledge of the critical points in nutritional physiology in different classes of infant to judge the both the formulae and the tolerable margins or error.


Already in some programs special medical diets such as F100 are being given to mothers to take home for treatment of their malnourished children. This diet is a medicine for the severely wasted and oedematous patient of any age. It is not a breast-milk substitute and should never be used for feeding the less than 6 month old child. Special modification is required for the severely wasted or oedematous small infant which can only be done by those who receive proper training. This category of patient is not covered in the WHO manual for the treatment of severe malnutrition. F100 should never be used for stunted children and thus never used for children who have been classified by weight-for-age criteria alone. It should never be given to a mother for home-preparation. Milk based diets for the treatment of severely malnourished children must always be made up under supervision, on each occasion, by those that have been fully trained in their correct use. I would be grateful if those working in the field would let me know of instances where F100 is being used dangerously and I will make discrete and confidential representation to those responsible in the organisations involved.

Mike Golden.


Prof. Michael H.N.Golden

Date: Tue, 09 Nov 1999 16:23:47 +0000

From: Ted Greiner <>

Subject: Re: Making up formula feeds Sender


Dear Ngonuts,

I would like to make a few comments in response to Mike Golden's excellent input on this issue.

In the 1960s and early 70s, it was common to assume that breastfeeding was doomed. Its decline was seen as an unavoidable consequence of development.

Much attention was given to how to achieve safe artificial feeding instead of "wasting time" on breastfeeding promotion which did not seem to work.

(Indeed, promotion that does not deal with the underlying causes of the problem still fails to work, as I document in an article coming out in the next issue of J Trop Pediatrics.)

Let's be careful we do not sink into that same trap of assuming that under certain conditions artificial feeding is the only option. In none of the circumstances Professor Golden mentions is artificial feeding (much less the use of commercial infant formula in bottles) the only or most desirable option. Already in 1977, Roy Brown published an article in Pediatrics (Vol 60, pp 116-120) detailing his work in Vietnam and elsewhere using relactation and induced lactation rather than artificial feeding to deal with situations in which large number of orphan babies must be dealt with.

Large numbers of women were recruited as wet nurses and given three meals a day and low doses of chlorpromazine. (But see Gupta AP and Gupta PK, Metoclopramide as a lactogogue. Clinical Pediatrics24:269-272, 1985, for a better option for women who really need help relactating. Otherwise unfamiliar calcium or vitamin tablets not to be given to others could perhaps be given, if only a placebo effect is required.) WHO has recently issued a booklet called "Relactation, review of experience and recommendations for practice" WHO/CHS/CAH/98.14 which includes practical recommendations and instructions.

When fluids are to be fed to babies by cup, especially small babies, the cups to be used should be quite small. In Sweden the little cups used to give patients pills are sometimes used. These cups are so small that they could equally well be included in generic tins of powdered milk. Perhaps they could also be used for measuring water.

It is interesting to note the field conditions that Burt worked under when she found such huge water losses in artificially fed infants in Tchad.

Almroth and Bidinger (Almroth S; Bidinger PD, No need for water supplementation for exclusively breast-fed infants under hot and arid conditions.Trans R Soc Trop Med Hyg 1990 Jul-Aug;84(4):602-4) studied exclusively breast-fed infants under almost identical conditions in India and found that urine production was very small--but still dilute! We sometimes forget that death from dehydration is not due to lack of water, but electrolyte imbalance. These babies have a diet with such a low renal solute load that they have a large margin of safety. (As Almroth shows in theoretical calculations in Almroth SG. Water requirements of breast-fed infants in a hot climate. Am J Clin Nutr 1978 Jul;31(7):1154-7.)

I have not studied mothers' ability to make up formula accurately, but have studied how bottles were cleaned among educated women in St. Vincent in 1975. (Greiner T. Regulation and Education: Strategies for Solving the Bottle Feeding Problem. Cornell International Nutrition Monograph No. 4, 1977, Appendix 2.) In spite of decades of effort by a health care system which saw the swing to bottle feeding occur already in the 1940s, it was nearly impossible for women who could not afford bottle brushes or who cooked over three-stone fires to keep bottles clean, let alone sterile.



Ted Greiner, Research Advisor, Nutrition

Entrance 11, Section for International Maternal and Child Health Department of Women's and Chidren's Health Uppsala University

751 85 Uppsala, Sweden

phone +46 18 511598 or 665937, fax +46 18 508013 or 515380

email, website:

Date: Fri, 12 Nov 1999 13:27:59 +0000

From: Lola Gostelow <>

Subject: RE: Making up formula feeds


Mike's insights and advice are, as usual, spot on. The one thing I would like to clarify concerns his point about the use of F100. In preparing "Infant Feeding in Emergencies - Policy, Strategy and Practice" (copies are available from the Emergency Nutrition Network, FOREILLYatTCD.IE) the ad hoc group attempted to outline essential information, appropriate operational options and outstanding research questions. One critical element was the practical question of what to do when neither breast nor formula milk is available. As has already been highlighted in this most recent exchange on NGONUT, local recipes are important potential options which we often overlook. Mixes based on cow's/evaporated/full cream/DSM milks are also given. In addition, and specifically in extreme situations where nothing else is readily available (for example, in acute emergencies dealing with unaccompanied infants), F100 is put forward as a possible stop gap measure until more appropriate solutions can be found. Mike stressed that F100 has NOT been formulated nor tested for such use, and called for a cautious approach. If used, the mixture would need to be diluted in 2.8l water rather than the usual 2l (see Appendix VI of the booklet) and careful monitoring be put in place.

I and the rest of the ad hoc group would be interested to hear of any experience in using F100 with non-malnourished infants below 6 months in an emergency.


Lola Gostelow, Emergencies Adviser

Save the Children