SDMS ID: P2010/0174-001 WACSClinProc6.

12/09 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Artificial Infant Milk: Safe Preparation, Storage and Handling in 4K New Guideline Safe preparation, storage and handling of artificial infant milk Nurses, 4K Sterilising, bottles, teats, infant feeding, preparation, storage and handling of artificial infant milk P2010/0395-001 Artificial Infant Milk: Safe preparation, storage and handling P2010/0383-001 Sterilising Artificial Infant Milk Feeding Equipment Purpose: Powdered artificial infant milk is not a sterile product and may be contaminated with pathogens that can cause serious illness. Correct preparation, storage and handling reduces the risk of illness. The pathogens of most concern in artificial infant milk are E. sakazakii and Salmonella which can cause serious illness in infants, with those less than two months of age at greatest risk. Newborns at greatest risk include preterm, low birth weight or immunocompromised. Ready-to-use sterile formula is recommended for these infants and should be used after discussion with the paediatrician. E. sakazakii and Salmonella do not grow in dried powdered milk but are able to survive there for long periods. Reconstituted artificial infant milk provides an ideal environment for the growth of pathogens. Recommendations for preparation, storage and handling of artificial infant milk in the health care setting: Recommendation Rationale

Use water at no less than 70C to Water at no less then 70C will inactivate E. sakazakii reconstitute artificial infant milk present in powdered artificial infant milk. Prepare fresh feeds each time Artificial infant milk provides ideal conditions for the and feed immediately growth of bacteria. When water at less than 70C is used to reconstitute artificial infant milk the feed should be used immediately and any feed not consumed within one hour of preparation should be discarded. Warm feed for no longer than 15 Feeds should not be left warming for more than 15 minutes in warm water or bottle minutes as warming for extended periods means that warmer. the feed will be held at a temperature that is ideal for
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the growth of bacteria. Cleaning and sterilisation of feeding and preparation equipment: All equipment used for preparing and feeding infants must be thoroughly cleaned by washing in hot soapy water and then disinfected using thermo-disinfection. The Miele Compact Disinfector G7735 CD ensures hospital / commercial standard thermal disinfection at 80 for 10 minutes or 90 for 1 minute during the last cycle (as per the current standard AS/NZS 4187:2003 Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities) All items to be placed upside-down appropriately in baskets. At the end of washer cycle, use clean hands to remove items from Miele and place lid and cap onto bottle. Be careful not to contaminate inside of bottle. Items should be DRY when removed from the Miele. If they are not, seek technical advice through LGH or Miele representative at Technolab Marketing. Miele to have annual Bio-medical inspection and filters changed as indicated. If Miele is out of service or inoperable at any time, disposable bottles should be used. Quality control: assured by installation of probe to ensure adequate temperature reached. Infection control: random plates for culture to be taken from inside washer surface. Parents own bottles / teats: Parents may elect to use their own bottles and teat during hospitalisation. If appropriately labelled this equipment can be disinfected using the ward dishwasher. Alternatively, sterilisation of an infants own equipment, maybe undertaken using a microwave or steam sterilising unit. All equipment must be washed thoroughly in warm soapy water and rinsed prior to sterilising. Microwave Steriliser Pour 200ml of water into base of the steriliser Place bottles, lids and teats in steriliser Place lid over steriliser base and lock the clips into place Microwave on high setting for 5 minutes When removing from microwave be sure to hold the steriliser level to avoid leaking or spilling hot water Wait at least 2 minutes before removing the lid to avoid steam burns Drain excess water from the steriliser, rinse and dry. Steam Steriliser Pour exactly 90ml of water into the steriliser body (Avent Steam Steriliser) Place bottles with the neck facing downwards on lower rack Place teats, caps etc on upper rack Put the lid on the unit and turn on After sterilisation wait 3 minutes before removing the lid to reduce the risk of burns Shake of excess water and assemble bottles Contents will remain sterile in the steam steriliser for up to six hours, following the end of the cycle, provided the lid is not removed The steriliser must be left to cool for at least 10 minutes between each use to allow the thermostat to reset After each use, pour away any remaining water, rinse and wipe dry.

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Preparing Artificial Infant Milk by Hospital Staff for Storage or Later Use: Clean and disinfect the surface on which to prepare the feed Wash hands Taking care to avoid scalds, pour the appropriate amount of boiled water into the jug (no larger than 1 Litre capacity) or bottle. Allow to cool for no longer than 30 minutes. Water should not be below 70C. A thermometer is available to check water temperature Add correct amount of artificial infant milk powder. Stir or mix gently until contents are thoroughly mixed. Pour into sterilised bottles or place lid on one litre jug. Cool feeds quickly by placing in a container of water or iced water Dry the outside of the bottle or container and label with the type of formula, child name and medical record number and the date and time prepared. Placed cooled feeds in the refrigerator. Prepared feeds can be held in the refrigerator (5C) for up to 24 hours. Fridge temperature should be monitored daily. Rewarming feeds Remove form fridge just before they are needed Re-warm for no more than 15 minutes Microwave ovens must not be used to re-warm feeds Check feeding temperature Discard any re-warmed feed that has not been consumed within two hours. Preparing Special Artificial Infant Milk Some special artificial infant milk can not be prepared in advanced. When water greater than 70C is used to reconstitute artificial infant milk care must be taken to ensure the feed has cooled adequately prior to feeding to prevent burns. When water at less than 70C is used to reconstitute artificial infant milk the feed should be used immediately and any feed not consumed within one hour of preparation should be discarded. Parental Education All parents and carers of children who elect to use artificial infant milk or who give supplementary or complementary feeds to an otherwise breastfed baby should be provided with individualised information and education on the preparation, storage and handling of artificial infant milk. Staff should avoid giving demonstrations and/or education on the preparation and use of artificial infant milks when breastfeeding mothers are present. The information and education provided to parents should included cleaning and sterilising feeding equipment, preparing a feed using artificial infant milk powder, preparing artificial milk feeds for later use, rewarming stored feeds and transporting feeds (attachment 2). Resources WACS Patient Information Handout Artificial Infant Milk: A Guide to Safe Preparation, Storage and Handling

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Attachments Attachment 1 Attachment 2 Attachment 3

Poster: Preparing Formula in Health Care Settings Parent Education: Safe preparation, storage and handling of artificial infant milk References

Performance Indicators: Evaluation of compliance with guideline to be achieved through audit Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years, January 2012. Nursing staff, 4K Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Date: 6 May 2009

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ATTACHMENT 1

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ATTACHMENT 2 Parent Education: Safe preparation, storage and handling of artificial infant milk at home Cleaning and Sterilising Feeding Equipment: It is important that all equipment used for feeding and preparing feeds has been thoroughly cleaned and sterilised before use. Wash hands thoroughly before cleaning and sterilising feeding equipment Wash feeding and preparation equipment thoroughly in hot soapy water Bottle and teat brushes should be used to scrub inside and outside the bottles and teats to ensure that all remaining feed is removed After washing feeding equipment rinse thoroughly under the tap If using a commercial steriliser, follow the manufacturers instructions. If bottles are suitable for sterilising by boiling: fill a large pan with water and completely submerge all feeding equipment, ensuring there are no air bubbles trapped; cover the pan and bring to a rolling boil, making sure the pan does not boil dry. Keep the pan covered until equipment is needed. Wash hands thoroughly and clean the surface around the steriliser before removing equipment. It is best to remove the bottles just before they are used. If the bottles are not being used immediately, they should be fully assembled with the teat and lid in place to prevent the inside of the sterilised bottle and the inside and outside of the teat from being contaminated. Preparing a Feed Using Artificial Infant Milk Powder Each bottle should be made up fresh for each feed. Storing made-up milk may increase the chance of bacterial contamination and should be avoided. Clean the surface thoroughly on which to prepare the feed. Wash hands with soap and water and then dry. Boil fresh (or bottled) water in a kettle. Pour the amount of cooled boiled water required into the sterilised bottle. Add the exact amount of powdered milk as instructed on the label always using the scoop provided. Re-assemble the bottle and shake well to mix the contents. Warm the bottle for no longer than 15 minutes in a bottle warmer or container of warm water. Check the temperature by shaking a few drops onto the inside of the wrist. Check the flow rate. Milk should drip easily at a steady rate, without pouring out in a great stream. Tightening the cap that holds the teat in place will slow the flow, loosening it will increase the flow. Discard any feed that has not been used within one hour. Preparing Artificial Milk Feeds for Later Use It is the length of time for which the reconstituted formula is stored that increases the risk of bacterial growth. Reducing the storage time will therefore reduce the risk. Refrigerate prepared sterilised bottles of boiled water. When feed required, warm water in bottle by standing in a container of warm water. Add artificial infant milk to warm water. Use immediately and discard any feed remaining after one hour. Alternatively if travelling or away from home: Boiled water may be sealed in a vacuum flask and used to make up fresh milk when needed. Care should be taken to avoid scalds when making up the feed.
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ATTACHMENT 3 References Australian Standards AS4187 2003 Cleaning, disinfecting and sterilising reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities. European Food Safety Authority 2004 Opinion of the Scientific Panel on biological hazards (BIOHAZ) related to the microbiological risks in infant formulae and follow-on formulae. Online: http://www.efsa.europa.eu/EFSA/efsa_locale1178620753812_1178620777466.htm Kidsafe (2008) Hot Water Burns Like Fire http://www.kidsafewa.com.au/_product_37015/Hot_Water_burns_like_fire_(Hot_Food_and _Drinks) Phillips Avent Express II Microwave Steam Sterilizer Instructions Online: http://www.usa.philips.com/c/avent-baby-preparing-for-feeding/scf271_07/prd/ Phillips Avent Express Electric Steam Sterilizer Instructions Online: http://www.p4c.philips.com/cgi-bin/dcbint/cpindex.pl?ctn=SCF274/23&scy=gb&slg=en NH&MRC 2003 Infant Feeding Guidelines for Health Workers (2003), in Food for Health: Dietary Guidelines for Children and Adolescents in Australia, Online: http://nhmrc.gov.au/publications/synopses/n20syn.htm World Health Organisation2007 Safe Preparation, storage and handling of powdered infant formula: Guidelines Online: http://www.who.int/foodsafety/publications/micro/pif2007/en/index.html UK Department of Health & Food Standards Agency 2007 Guidance for health professionals on safe preparation, storage and handling of powdered infant formula. Online: http://www.food.gov.uk/multimedia/pdfs/formulaguidance.pdf

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