Preparing Powdered Formula Safely in an Emergency

EN ESPAÑOL: Preparación de leche de fórmula en polvo en una situación de emergencia

Breastfeeding and human milk feeding need no water, no power, no refrigeration and no equipment, and they carry antibodies against exactly the infections that spread in shelters and crowded housing. Where a parent is breastfeeding, protecting and supporting that is the first and best thing a response can do, and it is what most of this site is about.

This page is for the families who need formula, and for the people serving them. Some infants are formula-dependent. They are entitled to be fed as safely as everyone else, and the way a disaster response treats them should not depend on how they came to need it.

The handout to give families: CDC, Protect Your Baby from Cronobacter (PDF). It is one page, it is free, it prints well, and it opens by telling families to breastfeed if they can before it gives the formula preparation steps. It is the clearest thing published on this and we have not tried to improve on it. Everything below is that guidance placed in a disaster context.

Why this page has to exist at all. North Carolina’s child care rule on formula, 10A NCAC 09 .1706(n), says formula “shall be prepared according to the instructions on the package or label.” Package instructions do not tell you the water has to be at least 158°F. This page is what the package does not say.

The step that is easy to get backwards

Everywhere else in a disaster we teach the same rule about water: boil it, let it cool, then use it. For preparing powdered formula that rule is wrong, and getting it wrong is the whole problem.

Powdered infant formula is not sterile. It is not sterile when it leaves the factory and it cannot be made sterile in a shelter. Occasionally it carries Cronobacter sakazakii, a bacterium that is harmless to most people and can cause sepsis or meningitis in a young infant. The water is the control. Water hot enough to kill the organism is what makes the feed safe.

Boil the water, let it cool for no more than about 30 minutes so that it is still at least 158°F (70°C), and mix the powder at that temperature. Then cool the made-up bottle quickly until it is body temperature, and check it on the inside of your wrist before feeding.

Water that has cooled all the way to room temperature is comfortable to handle. That is exactly why people use it, and it is why this step gets skipped.

The steps

1. Wash your hands. Clean the surface you are working on.
2. Use bottles and teats that have been cleaned and sanitized.
3. Boil water and let it cool for 5 minutes, so it is still at least 158°F (70°C).
4. Measure the water into the bottle first, then add the exact amount of powder given on the label. Never add extra water and never add extra powder.
5. Cap and shake or swirl to mix.
6. Cool the bottle quickly, under running water or in a basin of cold water, keeping the water below the cap. Check the temperature on the inside of your wrist.
7. Feed within 1 hour of starting the feed, and within 2 hours of preparing it. Throw away whatever is left in the bottle afterwards.
8. If you must prepare in advance, cool it quickly, refrigerate it immediately and use it within 24 hours. Do not prepare in advance without reliable refrigeration, which in a power outage means do not prepare in advance.

Who is most at risk

Infants under two months old, infants born prematurely, and infants with weakened immune systems.

If the infant in front of you is in one of those groups, ready-to-feed liquid formula is the right answer and it is worth going to some trouble to get it. Liquid formula is sterile in the container. It needs no water, no measuring and no heating, which removes every step above except cleaning the bottle. This is why ready-to-feed belongs at the top of a shelter stocking list rather than powder, and it is the correction we ask counties to make to their commodity lists.

When you cannot get water to 158°F

Say so, and escalate rather than improvise. There is no safe household substitute for the temperature. What there is:

• Ready-to-feed liquid formula, which needs none of this.
• A mobile sink or hand-washing station with a propane heat source, of the kind sold for camping. This is a realistic thing for a county to pre-position, and a realistic ask when a shelter kitchen is closed to residents.
• A staff break room sink, which often has hot water when the kitchen is closed for liability reasons.

Cleaning the feeding items

Wash bottles, teats, rings and caps in hot soapy water in a basin used only for infant feeding items, not in a shared sink. Rinse, sanitize, and air dry on a clean surface. Our sanitation kit guide covers what this takes when the taps are not running.

A note on how we talk about this

We follow the International Code of Marketing of Breast-milk Substitutes. We name no brands, we recommend no product, we accept no industry funding for this material, and we do not present formula feeding as equivalent to breastfeeding. We publish these steps because families who use formula are entitled to accurate safety information, and because withholding it does not protect breastfeeding. It only endangers babies.

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Source

Adapted from the Centers for Disease Control and Prevention, Protect Your Baby from Cronobacter (2024), and World Health Organization guidance on the safe preparation, storage and handling of powdered infant formula.

CDC Cronobacter prevention guidance (PDF)

WHO Safe preparation, storage and handling of powdered infant formula: guidelines