Email sent on 2/15/12
Center Directors, On-Site Supervisors and Employees:
I want each and every one of my centers to make an informed decision on how they warm bottles. If a center
chooses to warm bottles, they should be warmed under running, warm tap water or by placing them in a container of
water that is no warmer than 120°F. I will ensure that the temperature does not exceed 120 degrees.
Best practice does discourage the use of crock pots. This is due to the fact that they can cause burns and are a
breeding ground for bacteria if not appropriately cleaned once a day.
If a slow-cooking device, such as a crock pot, is used for warming infant formula, human milk, or infant food, this
slow-cooking device should be out of children’s reach, should contain water at a temperature that does not exceed
120°F, and should be emptied, cleaned, sanitized, and refilled with fresh water daily.
If the center chooses to utilize a crock pot I will ensure that the temperature is below 120 degrees, that staff does not
hold a child while preparing the bottle, and that all cords are secured.
If a center warms bottles via running water, warm tap water in a container or a crock pot you must have a
thermometer in your infant room available for staff to take the temperature.
Please let me know if you have any questions.
Additional Email sent on 2/20/12
Best Practice:
If a caregiver/teacher chooses to warm bottles they should be warmed under running, warm tap water or
by placing them in a container of water that is no warmer than 120°F. Bottles should not be left in a pot of
water to warm for more than five minutes.
Other options:
-Bottle warmers




Secure the bottle warmer and all cords with straps
Provide detailed guidelines for use and cleaning near the device
If it has standing water place in a blocked-off area only accessible to adults
If it has standing water the temperature cannot exceed 120°F
-Crock pots




Secure the crock pot and all cords with straps
Place in a blocked-off area only accessible to adults
Provide detailed guidelines for use and cleaning near the device
Water temperatures cannot exceed 120°F
You can not use a microwave to warm milk at any time.
Caring for Our Children: Warming Bottles and Infant Foods
http://nrckids.org/CFOC3/CFOC3-grayscale.pdf
STANDARD 4.3.1.9: Warming Bottles and Infant Foods
Bottles and infant foods can be served cold from the refrigerator and do not have to be warmed.
If a caregiver/teacher chooses to warm them, bottles should be warmed under running, warm tap
water or by placing them in a container of water that is no warmer than 120°F. Bottles should not
be left in a pot of water to warm for more than five minutes. Bottles and infant foods should
never be warmed in a microwave oven. Infant foods should be stirred carefully to distribute the
heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food
from the container of warm water or while preparing a bottle or stirring infant food that has been
warmed in some other way. Only BPA-free plastic, plastic labeled #1, #2, #4 or #5, or glass
bottles should be used. If a slow-cooking device, such as a crock pot, is used for warming infant
formula, human milk, or infant food, this slow-cooking device should be out of children’s reach,
should contain water at a temperature that does not exceed 120°F, and should be emptied,
cleaned, sanitized, and refilled with fresh water daily.
RATIONALE: Bottles of human milk or infant formula that are warmed at room temperature or
in warm water for an extended time provide an ideal medium for bacteria to grow. Infants have
received burns from hot water dripping from an infant bottle that was removed from a crock pot
or by pulling the crock pot down on themselves by a dangling cord. Caution should be exercised
to avoid raising the water temperature above a safe level for warming infant formula or infant
food. Human milk, formula, or food fed to infants should never be heated in a microwave oven
as uneven hot spots in milk and/or food may burn the infant (1,2).
STANDARD 4.3.1.3: Preparing, Feeding, and Storing Human Milk
Expressed human milk should be placed in a clean and sanitary bottle with a nipple that fits
tightly or into an equivalent clean and sanitary sealed container to prevent spilling during
transport to home or to the facility. Only cleaned and sanitized bottles, or their equivalent, and
nipples should be used in feeding. The bottle or container should be properly labeled with the
infant’s full name and the date and time the milk was expressed. The bottle or container should
immediately be stored in the refrigerator on arrival. The mother’s own expressed milk should
only be used for her own infant. Likewise, infant formula should not be used for a breastfed
infant without the mother’s written permission. Bottles made of plastics containing BPA or
phthalates should be avoided (labeled with #3, #6, or #7). Glass bottles or plastic bottles labeled
BPA-free or with #1, #2, #4, or #5 are acceptable. Non-frozen human milk should be transported
and stored in the containers to be used to feed the infant, identified with a label which will not
come off in water or handling, bearing the date of collection and child’s full name. The filled,
labeled containers of human milk should be kept refrigerated. Human milk containers with
significant amount of contents remaining (greater than one ounce) may be returned to the mother
at the end of the day as long as the child has not fed directly from the bottle. Frozen human milk
may be transported and stored in single use plastic bags and placed in a freezer (not a
compartment within a refrigerator but either a freezer with a separate door or a standalone
freezer). Human milk should be defrosted in the refrigerator if frozen, and then heated briefly in
bottle warmers or under warm running water so that the temperature does not exceed 98.6°F. If
there is insufficient time to defrost the milk in the refrigerator before warming it, then it may be
defrosted in a container of running cool tap water, very gently swirling the bottle periodically to
evenly distribute the temperature in the milk. Some infants will not take their mother’s milk
unless it is warmed to body temperature, around 98.6°F. The caregiver/teacher should check for
the infant’s full name and the date on the bottle so that the oldest milk is used first. After
warming, bottles should be mixed gently (not shaken) and the temperature of the milk tested
before feeding. Expressed human milk that presents a threat to an infant, such as human milk that
is in an unsanitary bottle, is curdled, smells rotten, and/or has not been stored following the
storage guidelines of the Academy of Breastfeeding Medicine as shown later in this standard,
should be returned to the mother. Some children around six months to a year of age may be
developmentally ready to feed themselves and may want to drink from a cup. The transition from
bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The
caregiver/teacher should use a clean small cup without cracks or chips and should help the child
to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/ teacher and mother
should work together on cup feeding of human milk to ensure the child is receiving adequate
nourishment and to avoid having a large amount of human milk remaining at the end of feeding.
Two to three ounces of human milk can be placed in a clean cup and additional milk can be
offered as needed. Small amounts of human milk (about an ounce) can be discarded.
RATIONALE: Labels for containers of human milk should be resistant to loss of the name and
date/time when washing and handling. This is especially important when the frozen bottle is
thawed in running tap water. There may be several bottles from different mothers being thawed
and warmed at the same time in the same place. By following this standard, the staff is able,
when necessary, to prepare human milk and feed an infant safely, thereby reducing the risk of
inaccuracy or feeding the infant unsanitary or incorrect human milk (2,5). Written guidance for
both staff and parents/guardians should be available to determine when milk provided by
parents/guardians will not be served. Human milk cannot be served if it does not meet the
requirements for sanitary and safe milk. Excessive shaking of human milk may damage some of
the cellular components that are valuable to the infant. It is difficult to maintain 0°F consistently
in a freezer compartment of a refrigerator or freezer, so caregivers/teachers should carefully
monitor, with daily log sheets, temperature of freezers used to store human milk using an
appropriate working thermometer. Human milk contains components that are damaged by
excessive heating during or after thawing from the frozen state (1). Currently, there is nothing in
the research literature that states that feedings must be warmed at all prior to feeding. Frozen
milk should never be thawed in a microwave oven as 1) uneven hot spots in the milk may cause
burns in the infant and 2) excessive heat may destroy beneficial components of the milk. By
following safe preparation and storage techniques, nursing mothers and caregivers/teachers of
breastfed infants and children can maintain the high quality of expressed human milk and the
health of the infant (3,4,6).
Crock Pots and Microwave Ovens:
http://www.childcarecentersafety.com/tips/bottle-warmer-burns/
Reality Alert
A small facility had been using a crock pot to warm formula for several years. The device was in
the kitchen placed on top of a small mini-refrigerator and was plugged into a power
surge protector. The crock pot was powered on from 9am to 5pm everyday. Two children had
just been placed in high chairs for lunch, when one of the kids pulled at an exposed electrical
cord and was splashed with scalding hot water. The incident did not immediately appear to be
serious, but it quickly became clear the 18-month-old received 2nd and 3rd degree burns over
40% of her body! After therapy, skin grafting, and more than $200,000 in medical expenses, the
child will likely have scarring along her neck, back, hands, and legs for the rest of her life.
Defining the Exposure
While scald injuries similar to the bath tub incident on the previous page can and do happen,
researchers at the Department of Trauma and Burn Services at the Children’s National Medical
Center have identified the most common cause of unintentional scald burns as hot liquid spills
from a countertop or stove. In the childcare industry, most of these spills tend to be closely
connected to the improper heating of formula.
Microwaves – Most states have adopted regulatory restrictions on the use of microwaves to
heat formula. Although a microwave may get the job done quickly, it does so inconsistently.
Pockets of extremely hot formula can make the temperature vary greatly in between sips.
Microwaves can also damage bottles which result in piping hot formula spilling on a child.
THERE IS NEVER AN APPROPRIATE TIME TO USE A MICROWAVE TO HEAT
FORMULA.
Crock Pots – Many states prevent child care facilities from using crock pots for both
food preparation and bottle warming, and with good reason. Not only can the continuously
high temperatures cause a severe burn exposure if knocked over, they also attract armies of
bacteria.
Unnecessary Danger
There is no benefit to warming a child’s formula. With so little upside, and so much at stake,
why take the chance?
According to the British Medical Journal, “No differences related to sleep patterns, food intake,
weight gain, and frequency of crying and regurgitation have been found when compared between
infants given warm milk and others given milk from the refrigerator.” Efforts should be made to
share this valuable information with parents. With their support, infants can be weaned off of
warm formula and childcare facilities can become safer places to learn, play, and socialize.
Safest Solution
Alternative
Serve bottles at room
Heat bottle by running it under warm tap water.
temperature.
Never use microwaves to heat
None. Never use a microwave to heat formula.
formula.
Secure the crock pot and all cords with straps. Place in a blocked-off area only
Remove all crock pots.
accessible to adults. Provide detailed guidelines for use and cleaning near the
device. Water temperatures cannot exceed 120°F.
Proper Storage and Handling of Human Milk
http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm
By following safe preparation and storage techniques, nursing mothers and caretakers of
breastfed infants and children can maintain the high quality of expressed breast milk and the
health of the baby.
Safely Preparing And Storing Expressed Breast Milk
 Be sure to wash your hands before expressing or handling breast milk.
 When collecting milk, be sure to store it in clean containers, such as screw cap bottles,
hard plastic cups with tight caps, or heavy-duty bags that fit directly into nursery bottles.
Avoid using ordinary plastic storage bags or formula bottle bags, as these could easily
leak or spill.
 If delivering breast milk to a child care provider, clearly label the container with the
child's name and date.
 Clearly label the milk with the date it was expressed to facilitate using the oldest milk
first.
 Do not add fresh milk to already frozen milk within a storage container. It is best not to
mix the two.
 Do not save milk from a used bottle for use at another feeding.
Safely Thawing Breast Milk
 As time permits, thaw frozen breast milk by transferring it to the refrigerator for thawing
or by swirling it in a bowl of warm water.
 Avoid using a microwave oven to thaw or heat bottles of breast milk
o Microwave ovens do not heat liquids evenly. Uneven heating could easily scald a
baby or damage the milk
o Bottles may explode if left in the microwave too long.
o Excess heat can destroy the nutrient quality of the expressed milk.
 Do not re-freeze breast milk once it has been thawed.
Source: American Academy of Pediatrics .
Storage Duration of Fresh Human Milk for Use with Healt hy Full Term Infants
Location
Temperature
Duration Comments
Room
Containers should be covered and kept as
Countertop, table temperature (up 6–8 hours cool as possible; covering the container with
to 77°F or 25°C)
a cool towel may keep milk cooler.
Keep ice packs in contact with milk
5-39°F or -1524 hours containers at all times, limit opening cooler
Insulated cooler bag
4°C
bag.
Store milk in the back of the main body of
39°F or 4°C
5 days
Refrigerator
the refrigerator.
Freezer
Freezer
2 weeks Store milk toward the back of the freezer,
compartment of a 5°F or -15°C
refrigerator
where temperature is most constant. Milk
stored for longer durations in the ranges
Freezer
listed is safe, but some of the lipids in the
3–6
compartment of
0°F or -18°C
months milk undergo degradation resulting in lower
refrigerator with
quality.
separate doors
6–12
Chest or upright
-4°F or -20°C
months
deep freezer
Reference: Academy of Breastfeeding Medicine. (2004) Clinical Protocol Number #8: Human
Milk Storage Information for Home Use for Healthy Full Term Infants [PDF-125k] .
Princeton Junction, New Jersey: Academy of Breastfeeding Medicine. Available