Table 6 risk management areas

(a) Lack of clarity around glove usage

A majority of services required gloves for preparation of EBM, formula and food with particular emphasis on handling EBM. Some services also required educators to wear gloves while feeding. “…use a glove on the hand holding the bottle, if baby regurgitates any feed this will protect the educator” L2, p. 1. Only one service described international recommendations in ECEC—WHO-IYCF, Centre for Disease Control (CDC) and AIF guidelines which indicate that gloves are not required if hands are thoroughly washed:

“Responsibilities of educators when bottle feeding infants: Wash and dry hands before and after feeding. There is no need to wear gloves if hands are clean and dry.” L9, p. 3. The term “body fluids” does not include EBM as an example in any policies or legislation however is implied with the recommended use of gloves to handle breast milk

(b) Handling EBM

Few policies addressed correct heating, handling or storage for formula and EBM with protecting components or immunological properties. There is no guideline to shake for 5 s while information lacked contexts:

“After heating, shake the bottle well (at least 5 s) to avoid hot-spots, which could cause burns to the baby’s mouth and throat.” L4, p. 1.

Only one service stated the correct heating temperature “to body temperature” for EBM while one other lacked specificity: “Do not boil breast milk.”

(c) Reducing bacterial proliferation in formula

There was only one specific reference to powdered infant formula bacterial proliferation—a potential hazard with few heating/feeding times, temperatures or testing listed. There was no warning in any policies in line with AIF and WHO recommendations regarding potentially fatal bacteria for pre-term, young, or immunocompromised infants at most risk from Cronobacter (Enterobacter Sakazakii) if heating/feeding guidelines are not carefully adhered to. Three services mentioned both powdered infant formula (PIF) and pre-packaged formula but omit specific heating/handling differences. Sterile foods, “…include canned foods and liquid baby formula” L2

(d) Heating and microwave use

Emphasis for EBM/formula concentrated on correct temperature and containers for cartage to the service rather than heating temperature and time or testing prior to feeding—all of which affect the nutritional quality of the food for infants as well as posing health and safety risks. Terminology ambiguities increase this risk

All but three policies disallowed microwave use for heating infant formula or cow’s milk while most used bottle warmers. Two allowed microwave heating in consultation with parents

“Our service will use microwaves to heat infant formula/cow’s milk unless the parents state otherwise.” L13, p. 6

In line with AIF all policies described that EBM should not be heated in the microwave while microwave or heating for complementary foods had specific temperature testing instructions

(e) Sterilisation

Analysis shows continued terminology ambiguity in all policies with the lack of distinction between exclusively breastfed infants who do not require sterilised bottles according to WHO international recommendations and those mixed feeding or exclusively formula feeding. The AIF recommends sterilisation for all equipment. Some services have a policy to not sterilise or clean and re-use bottles which is potentially indirect discrimination for exclusively breastfed infants if they run out of feeding containers during the course of the day. One service (part of a large chain of ECEC services) denotes the responsibilities of parents to “Ensure all bottles and teats are sterilised and cleaned before use. Educators will rinse and wash bottles after use, but are unable to sterilise.” L9, p. 5. Educators are told, “Do not attempt to sterilise bottles.” L9, p. 5. However, some service policies communicate that parents will be contacted if the infant runs out of EBM or bottles. One describes how to sterilise a bottle for re-use:

“If a bottle needs to be used twice, staff will sterilise all parts in antibacterial solution.” L10, p. 1

Sterilisation of any water given to infants is rarely discussed in policies.

(f) Water intake

All services described that water should be available to all children:

“For All Children; provide water for children continually throughout the day.” F1 p. 2

Only one service makes the distinction with being careful not to displace an infant’s milk intake but no service outlines why this is an important practice to reduce risks of malnutrition or hyponatremia with infant water intake particularly for infants under 6 months of age

“Care should be taken not to replace an infant’s milk intake with water.” L5, p. 4. There is no mention of exclusively breastfed infants not requiring water. There is no direct mention of the impact upon the breastfeeding mother-infant dyad and mother’s supply

(g) Choking hazards

All service policies included frequent mention of health and safety policy around nuts as a choking hazard and allergies however no differentiation of crushed nuts contained in foods (or foods labelled with “traces of nuts”) which are acceptable from 6 months and advised for the reduction of allergy without fear of choking. Policies didn’t outline risks of propping bottles but two services allowed infants to feed themselves or have the bottle in the bed with supervision

“Educators will hold the infants during feeding until such time they are physically able to safely hold their own bottles.” L14, p. 1

(h) Other risks

There was no mention in any policies of the clear need in AIF guidelines to avoid honey for infants until 12 months of age due to botulism; to avoid unpasteurized milks; to avoid cow’s milk as a main drink under 12 months of age due to protein and electrolyte differences and an increased risk of iron deficiency; or the documented short and long-term increased health risks of early introduction of complementary foods prior to around 6 months of age