PEN® eNews 14(8) August 2024 – Evidence-based answers to your practice-based questions

Infant Formula Preparation, Use, Handling and Storage – Do you know the Latest?  

The Question

Key Practice Point #1 - Education and Support

While health care professionals should encourage breastfeeding, parents and caregivers need instruction on the safe preparation, use, handling and storage and handling of infant formula if formula is chosen. Gaps in parent/caregiver education exist and safe practices are not always followed. It is important that education and support be provided in a non-judgmental manner. Grade of Evidence C

• Tap or well water:
  • Charcoal (or activated carbon) filters could increase mineral/chemical and pathogen contamination in the filtered water via buildup and so should be changed regularly.
  • Water softeners can contribute sodium levels to the water that is not safe for infants.
  • Well water should be tested regularly (at least twice yearly) for mineral levels and contaminants.
• Bottled water that is not fortified (such as with minerals or vitamins) and is not carbonated. 
  • Formula reconstituted with mineral water has been implicated in infant electrolyte disturbances. Sodium and sulphate levels are of particular concern and must be low.
• Water treated using reverse osmosis, ultrafiltration, distillation or ion exchange. 
  • This can remove some but not all chemicals (e.g. arsenic, copper and nitrate but not lead).

• Fluoride
  • Fluoride can be found in tap, well or bottled water and concentrations are quite variable (even within the same country). Too much fluoride can increase the risk of dental fluorosis (primarily cosmetic concern).
  • While it is not currently recommended that fluoridated tap water be avoided for infant formula reconstitution, parents and caregivers who are concerned can contact their municipality to find out the level of water fluoridation in their area, can talk to their dentist or doctor about their concerns, could turn to ready-to-feed formula or could use water with lower levels of fluoride for formula reconstitution.
  • Canadian and UK recommendations state that if the water has fluoride levels in excess of 1.5 mg/L than a different source of drinking water with a lower fluoride concentration should be used to reconstitute infant formula.
• Nitrates
  • Well water should be tested for nitrates, especially in farming zones. If high, the water should not be used to make infant formula because of the risk of infant methemoglobinemia.
  • Canadian recommendations state that nitrate levels in well water should be below 45 mg/L (or 10 mg/L measured as nitrate-nitrogen) to decrease risk to infants.
• Sodium
  • Water that has gone through water softeners and some bottled waters can contain too much sodium for infants. Increases in infant blood pressure have been observed with high sodium intakes.
• Lead and copper
  • Cases of lead and copper intoxication among infants have occurred when lead or copper has leached into the water from water pipes, kettles/urns/pots and from over boiling of water. Remove the lead source.
  • Water should be taken from cold water taps only and it should run until it becomes cold (to flush the pipes), especially first thing in the morning.
  • Old urns, kettles and cookware that could contain lead should not be used.

Grade of Evidence C

To see the full practice question (with additional Key Practice Points), including the Evidence Statements, Comments and References, click here.

How do I… Customize and Send PEN^® Client Handouts?  

 The PEN Client Handouts are one of the most popular features of the PEN System, but did you know you can customize the handouts and email them directly to your clients from the PEN System? You can add your organization/company logo to the handout, add a personalize note to your client and/or remove the additional resources section. Read the steps below to become a PEN Client Handout aficionado!

How do I customize the “Distributed by” box in PEN Client Handouts?

*Skip to Step 4 if your logo is already uploaded or if you do not want your logo included.

Step 1: Click on ‘My Profile’.

Step 2: Under “My Handout Distribution Preferences”, click on “Upload New Photo” and find the logo you want to add. If desired, add a distribution message.  

Step 3: Click “SAVE & UPDATE” at the bottom right-hand side of the page.

Step 4: Navigate to the PEN client handout you wish to customize.

Step 5: Click on “Customize and Share this Resource” phrase or the  icon.    

Step 6: On the Share this Resource pop-up page, make sure that the “Include” bubble corresponding with “Distributed By” is checked.

Step 7: Text in the “Distributed By” box can be added or edited. The “Distributed By” box will not accept images.

Step 8: Click "PDF PREVIEW" to view this content on the last page of the handout. Make sure the “Include” bubble is checked if you want your logo displayed.

Step 9: A hard copy of the handout including your “Distributed By” information can be printed from the PDF preview, or click SEND to e-mail a copy to your client or yourself.

How do I customize the editable "Notes" feature in PEN Client Handouts?

Step 1: Access a PEN handout from the Search, or the Related Tools and Resources section within a Knowledge Pathway, or from the PEN Client Handout Collection.

Step 2: Click on “Customize and Share this Resource” phrase or the  icon.

Step 3: A Customize and Share this Resource pop-up window will appear that will allow you to enter a message in the “Notes” section (up to six lines of text). Make sure that the ‘Include’ bubble corresponding with the “Notes” section has been checked.
 

Step 4: Once you have entered the information, you can click ‘PDF Preview’ to check that information is correct, and then you can click "Send". If you want to provide a hard copy to your client, you can e-mail the handout to yourself, and then print.

How do I suppress the Additional Resources, Notes and/or Distributed By section from displaying in a Handout?

Step 1: Access a PEN Handout using the Search, or the Related Tools and Resources section within a Knowledge Pathway, or from the PEN Handout Collection.

Step 2: Click on the ‘Customize and Share this Resource’ phrase or the  icon.  

Step 3: A Customize and Share this Resource pop-up window will appear. To exclude any of the “Additional Resources”, “Notes” or “Distributed By” sections, make sure that the corresponding bubbles are cleared of check marks.  

You can click the PDF PREVIEW button to view the handout and print a hard copy, or click the SEND button to e-mail a copy to your client or yourself.

How do I send a PEN^® Handout to a client via email?

Step 1: Click on “Customize and Share this Resource” phrase or the  icon 

Step 2: Fill in your e-mail address, your client’s e-mail address, the message you wish to send to your client to accompany the handout and press Send.

PEN^® Team Surprising Findings 

Megan Charlish was previously an Evidence Analyst with the PEN team where she analyzed and summarized evidence on a variety of topics to support dietitians in their everyday practice. Now, as the Manager of Health Policy on Dietitians of Canada’s Professional Practice team, she is using evidence from the PEN system to advance policy issues important to dietitians across the country.

The Second Recipient of the Armour Morgan Memorial Convocation Prize has Been awarded

Practice guidance toolkits make access to essential information on nutrition assessment, diagnosis, intervention, monitoring, associated tools and education materials based on nutrition-related conditions/diseases more 'up-front' and easier to retrieve. The toolkits present information in a format consistent with Nutrition Care Process Terminology (NCPT) with direct access to succinct information that dietitians use in their practice. The toolkits are a stand-alone tool used primarily for clinical knowledge pathways and also include the associated Summary of Recommendations and Evidence.  

To find toolkits on the PEN home page, click on the Toolkits icon, which leads to all of the available toolkits.

They can also be found on the Knowledge Pathways Table of Contents page. Click on any of the icons under the Practice Guidance Toolkit column. Alternatively, within a knowledge pathway, click on the “Toolkit “ tab on the right-hand side of the page. The Toolkit tab will only display as an option if the knowledge pathway has a toolkit.

Helpful Features in the Toolkits  

• Click on any of the items on the Table of Contents on the right-hand side of a toolkit to get quick, direct access to any section within the toolkit.  
• Flags! Where information is specific to a particular country, you can see only your country’s information or view other’s information as well. Simply click the box at the top of the page for the country information that you would like to view, and it will be displayed (or alternatively unclick the box to hide it).

Stay tuned! Some of our most popular toolkits will soon be updated with the latest evidence:

• Cardiovascular Disease Practice Guidance Toolkit
• Gastrointestinal System - Irritable Bowel Syndrome (IBS) Practice Guidance Toolkit
• Gastrointestinal System - Inflammatory Bowel Disease (IBD) Practice Guidance Toolkit