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Water in Hong Kong and its use in making up infant feeds

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Water in Hong Kong and its use in making up infant feeds

Posted on 12 September 2014 by Kristrun

Here at Annerley, we are frequently asked by parents for information on which water to use for making up bottles of infant formula and for using on its own for baby to bagsofBreastmilkdrink. This is a very difficult area to look into with no definitive evidence for blanket recommendations. A quick search on the Internet will show you that there is a lot of confusing and contradictory information which does not help in any way to quell the concerns of many parents with young babies.  The following information is based on our research into this area and we hope that it will help to answer some of your questions. Nicole Edwards, Peadiatric Dietitian, has worked with us to provide the following information.

Choosing which water source to use for making up infant feeds can be a difficult and confusing task for parents in Hong Kong. In most countries using boiled, cooled tap water to mix with feeds is the ideal choice but many people in Hong Kong express their concern over the quality of our tap water, in particular how it is delivered to the domestic tap. Some parents have opted to use bottled or mineral water. However, this option does not come without its own potential problems and costs. There are no international evidence-based guidelines regarding the use of mineral or spring waters in infant formula feeding therefore it is difficult to make  recommendations regarding which brand to use.

The responsibility of which water to choose still falls on the shoulders of the parent especially as there is essentially no ideal solution to be recommended.

It is important to note that in all cases, any water which is to be used for making up infant feeds (tap/filtered/bottled/spring/mineral) MUST be boiled and then cooled with the best water cooler prior to using.

If parents are happy to use tap water, they may want to invest in commercially available water filters which are fitted to the domestic tap and consist of an activated carbon filter through which the water flows. It is important to note however that they are not recommended by the Water Supplies Department (WSD) as it is felt that they may become an ideal breeding ground for bacteria and may represent a health hazard if not maintained properly. If these filters are used, it is recommended that parents follow the manufacturer’s instructions and ensure that the filter cartridges are replaced regularly (at least once a month). It is essential that water from the tap (even if it first passes through a self-fitted filter) is boiled before it is used to make up infant formula feeds.

Reverse osmosis (RO) filters claim to be a more effective type of filter, removing pathogens and chemicals from the tap water. The system is permanently fixed to the domestic tap. Specialist companies in HK provide this service and will return to check and replace the filters. The installation and service of these filters is considerably more expensive than attaching a commercial filter to the domestic tap. The filter process removes chemicals, 95% of the water’s mineral content and metals and pesticides. Some bacteria and viruses are also removed however, this is not guaranteed and thus RO water should still be boiled if it is to be used for making up infant formulas. Consult Lenser for more.

Regarding distilled water, there is conflicting advice (none of which appears to be scientifically based) on whether distilled water has the ‘leaching out’ effect of minerals in the body. Distilled water has been said to act like a ‘magnet’ which collects rejected, discarded, and unusable minerals in the body and, assisted by the blood and the lymph, carries them to the lungs and kidneys for elimination from the body (from the book “Fit for Life II: Living Health” by Harvey & Marilyn Diamond) The same authors feel that it is impossible for distilled water to remove minerals which are already part of the cell structure, thus the ‘leaching out’ of essential minerals does not occur as these are already part of the cell.  It is uncertain whether adding minerals back into the water (for example in a brand such as Watsons Water with Minerals) after the distillation process would counteract this suggested property of distilled water.

Guidelines on maximum mineral concentrations acceptable for drinking water (UK Dept of Health figures)

Bottled water is not recommended to make up a feed as it is not sterile and may contain too much salt (sodium) or sulphate. If you have to use bottled water to make up a feed, check the label to make sure the sodium (also written as Na) level is less than 200 milligrams (mg) per litre, and the sulphate (also written as SO or SO4) content is not higher than 250mg per litre. It is not usually sterile, so it will still need to be boiled, like tap water, before you prepare the feed.  However you may need to use bottled water to make up a feed if:

• your drinking water has been contaminated because of flooding
• you’re travelling abroad and drinking the local water is not recommended.

(Ref: NHS 2012)The mineral composition of many mineral/spring waters does however fall well below the guidelines above thus parents may question why these cannot be used. As there are no other guidelines apart from the DOH ones above, parents must know that  they use mineral waters at their own risk, but assuming they choose waters which conform to the above standards, the risk of solute overload may be small. Due to this lack of clarity on the suitability of various waters whose mineral content actually does fall under the above recommendations, plus the large variety of waters on the market, it is impossible to endorse or recommend specific brands.

In summary:

  1. All water used for infant formula MUST be boiled and cooled before using to make up infant feeds.
  2. The quality of HK Water is considered safe for use in making up infant formula feeds provided the pipes and holding tanks within the building structure are up to standard which is the responsibility of the building management and parents to check.
  3. If parents opt to use tap water for feeds it is probably a good idea to fit a commercial water filter or Reverse Osmosis water filter to the domestic tap. If this is the chosen option parents must be aware of the potential hazards of the filter becoming a breeding ground for bacteria. Commercial filters therefore must be changed as regularly as recommended by the manufacturing company. The RO filter will also need to be cleaned and checked regularly by the providing company.
  4. Distilled bottled water with added minerals may be a safe alternative to tap water provided parents are aware of the conflicting advice given regarding its suitability and safety when bottled in plastic bottles. There is insufficient scientific information, as noted by the WHO, on the benefits or hazards of regularly consuming distilled water.
  5. Choosing other bottled waters for the regular use of mixing with infant formula may be confusing and costly. It is likely that choosing water which is simply labeled ‘bottled water’ (as opposed to spring or mineral water) may be the safest option as these waters are expected to conform to essentially the same standards as the public water supply and they are therefore suitable for giving to infants or for preparing feeds.
  6. If it is absolutely necessary to use ‘spring or mineral water’ for example if one is abroad and the tap water is not safe, then the composition of the water should be checked and avoided if the levels of minerals exceed the guidelines given above. As generally bottled water is not sterile, this MUST be boiled before use with infants.

Thanks to Nicole Edwards BSc RD, Clinical & Freelance Paediatric Dietitian based in Hong Kong, for her contribution to this article, first published in 2008 in the Annerley Newsletter.  

Comments regarding NHS guidelines added by Conchita Amende, 2014.

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