Baby Formula, the Pandemic, and the Metric System

I recently got pushback from a media outlet because it recorded a podcast five years ago about the metric system, and it didn’t want to go over old territory. Brother.

U.S. ounces and U.K. ounces
are not the same size! As you can see from the “9,” U.S. ounces are bigger.

Not only is our metric system landscape constantly changing, but it impacts us in ways we don’t even see coming at us. When you heard about our shortage of infant formula in the United States, did you consider that our lack of metric system adoption added at least two new hurdles to our babies (and others) getting safe food? Well, it did.

From our unthinking perspective: Why just solve a dozen different urgent, life-saving problems when you can add two more due to our lack of metric system adoption in the United States? I think it is safe to say that the U.S.’s continued isolation in our measurement system does not bode well for the world in general. (My blog. My opinion.) However, it is a correctable problem. I think we all deserve more information about this measurement problem (see my request for a Congressional hearing with the House Subcommittee on Science, Space, & Technology) on our 200+ year measurement car wreck. But there are resources on this subject in the short term: National Institute of Standards and Technology.

We added at least two obstacles into our American baby formula crisis through our lack of international measurement standards

The Federal Trade Commission administers the Fair Packaging and Labeling Act (FPLA). The law itself directs the agency to put into place:

….additional regulations where necessary to prevent consumer deception (or to facilitate value comparisons) with respect to descriptions of ingredients, slack fill of packages, use of “cents-off” or lower price labeling, or characterization of package sizes.

https://www.ftc.gov/legal-library/browse/statutes/fair-packaging-labeling-act

Let’s face it, a global pandemic is horrible, and we’ve been going through it for almost three years. Just trying to keep everyone safe from invisible, evolving viruses is an emergency on its own.

Then, we created a situation we fundamentally shouldn’t have. Because of the COVID pandemic, supply chains broke down in many unanticipated ways. All over the place. One place parents really felt it was a loss of infant formula and mixes. While the problem had multiple factors, I only want to address a couple of the metric-system-adoption failures here.

Problem #1: Lack of dual labeling at a minimum as required by current law for product importation (U.S. customary and metric system [SI] units). At the minimum. Other laws are also at play here. I can’t possibly cite all of them. But, I’m sure that others in the government could produce this information if called upon to do so.

Problem #2: Potential conversions errors when mixing unfamiliar units associated with the metric system and U.S. customary units. Getting that information out to parents may, or may not, have been a successful/unsuccessful campaign. I have no idea, but what’s below should, to me, have been completely unnecessary.

Try to convince me this isn’t stupid and dangerous for everyone in this country.

As I understand it, the original problem started with the U.S. Food & Drug Administration missing contamination at an infant formula manufacturing site in the United States. This created a national supply-chain crisis. The manufacturer, Abbott was also to blame. It’s a huge outfit with more than 100,000 employees. The White House recognized this issue’s importance immediately and started working on it from various angles as children/infants (and others) suddenly couldn’t get the food they needed to live.

The Biden Administration went so far as to fly formula from other countries to the United States. Called “Operation Fly Formula,” A statement dated June 22, 2022, says:

In May, the Food and Drug Administration (FDA) announced that the agency is exercising enforcement discretion so that Nestlé can export additional infant formula into the U.S. Nestlé will import both standard and specialty infant formulas, including…

https://www.whitehouse.gov/briefing-room/statements-releases/2022/06/22/president-biden-announces-ninth-operation-fly-formula-mission/

Let’s look at the phrase “… the agency is exercising enforcement discretion…”

Since the FPLA is meant to avoid deception directed at consumers, and crooks have used units of measure since time immemorial*, so all commodities must state their contents in the prevailing units (be they metric, U.S. customary, or both), including for infant food. It’s a health a safety and a commerce issue.

Dual labeling

One problem we have is that packages in our country need to be “dual labeled” where there is enough room to do so, (see National Institute of Standards and Technology labeling site). This also involves the Uniform Packaging and Labeling Regulation.

Of those packages examined, 17% declared the net quantity of contents in only metric units. Almost 57.5% of those metric packages were found to be noncompliant with current FPLA dual labeling requirements. [Emphasis mine.]

https://www.nist.gov/pml/owm/laws-and-regulations/packaging-and-labeling

So, under the law, you have to dual-labeled products for distribution in the United States. Of course, infant formula never meant for export to the United States would only have metric system units on them. That was never a problem until we tried to import infant formula during a pandemic. Then, suddenly, it became part of a much larger problem. Completely unnecessary and avoidable.

As indicated by the FDA Guidance Document: “Guidance for Industry: Infant Formula Enforcement Discretion Policy, dated May 2022“:

FDA intends to temporarily exercise enforcement discretion concerning specific requirements for infant formulas that may not comply with certain statutory and regulatory requirements and is seeking information from manufacturers regarding their products’ safety and nutritional adequacy. 

Well, that solved one problem…

Conversion errors

So, the Administration did lots of things to supply our babies with food, and other countries tried to help us in an emergency. The White House lifted the dual labeling requirement for the time being. Of course, that leads to problems shifting from an import problem to a “consumer use” problem and the potential of conversion errors while mixing formulas. Such a problem would be Impossible in a solely SI world.

Here is my problem with writing about conversion errors. I couldn’t find any fundamental, accessible research on error rates. I found LOTS of things that said conversion errors are bad, but I could never get a good enough answer about what rates of conversion errors there are. But errors are made. Everyday. I assure you. We can’t stop all conversion errors, but we can stop the stupid ones like constantly trying to use two incompatible measurement systems side by side for 200+ years in this country.

So, what happens when Americans suddenly end up with only metric system units on hand? Easy. They get confused, so the federal government must then get the word out about using these mostly unfamiliar measurement units, so their kids don’t get sick and die from malnutrition. Whatever path led us here could not possibly be a good one. How much did it cost to whip up the poster above, and how much time and effort went into getting that conversion guidance into the right hands? If the efforts were successful, then lots and lots of resources, from the federal government right down to the doctors’ offices. Those are steep taxpayer dollars, my friend.

If we only used metric system units, both of these problems would disappear. Once and for all.

Please help get the word out.

Thanks,

Linda

Conversion errors and the metric system

A recent headline on a metric system conversion error

I recently received news that the Centers for Disease Control and Prevention (CDC) made a major conversion error relating to the metric system. The upshot is that it greatly underestimated the risk of formaldehyde in laminate flooring. The underlying mistake: it failed to convert between meters and feet initially reporting the estimated risk at one-third of what it should have been.

The organization did not come out and say lack of metric adoption was the cause of the error:

The CDC/ATSDR indoor air model used an incorrect value for ceiling height.  As a result, the health risks were calculated using airborne concentration estimates about 3 times lower than they should have been.

However, others were more than happy to point out the real root of the problem:

CDC fixes major error in flooring risk report: Not converting to metric – Retraction watch

CDC Revises Health Risk Assessment Of Flooring After Math Error: CDC recently announced that laminate floors are safe, only to realize that they forgot to convert from feet to meters—and that the cancer risk is three-fold higher – Vocative.com

There are some who believe that conversions are easy to make and therefore, living with two measurement systems shouldn’t be a problem.

Marciano’s book

In fact, in his book, Whatever happened to the metric system: How America kept its feet, John Bemelmans Marciano (Kindle location 2020 for both quotes), states:

Conversion is now as easy as speaking “seven ounces to grams” into your smartphone and immediately receiving the answer 198.446662g.

Marciano later goes on to say:

Why would Americans go metric when computers have done the job for them and they don’t even have to know about it?

How about a three times greater risk for potential negative health effects due to human unit-confusion error?

Luckily, the CDC was able to quickly make a correction but who knows how many other errors haven’t been caught and continue to put us at risk in one way or another?

The idea that technology will save us from conversion errors is flawed because it assumes that the human element won’t impose the error.

Surely the CDC has access to computers and other high-tech gadgets at least as good, if not better, than what I have access to in my smartphone and yet, the mistake was still made.

Again, it’s not a technology issue, it’s a human issue that will always occur even if the frequency of such mistakes is not currently well known.

Aside from outright errors, there’s the time it takes to make a conversion in the first place. Add up the time it takes to whip out the cell phone, ask the question, wait for the answer and read it. Then one needs to multiply that by how many people in this country need to do that in a year. All wasted time. One set of measures eliminates the entire issue.

I’ve previously pointed out people are already at risk every time their pharmacist converts a prescription written in milliliters (as they all are) into teaspoons and tablespoons. Why are we doing this to ourselves?

Conversion errors are inevitable  

While I so far have been unable to find any statistics on how often conversion errors occur, everyone seems to recognize they do happen and research seeks interfaces that try to minimize them. One paper I reviewed, Reducing number entry errors: solving a widespread, serious problem by Thimbleby and Cairns indicates:

Ironically, the more skilled a user, the less attention they will pay to what ought to be routine outcomes, so the more likely these types of error will go unnoticed until they have untoward consequences. The reason is, as users become skilled, they automate actions, so their attention can be used more selectively; thus as they become more skilled, they pay less attention to the display, whose routine behaviour they have learnt to expect (Wickens & Hollands 2000).

A conversion “helper” from the 1970s

Still, we can learn from our past. One of the things I’ve heard from people regarding our last attempt at metric adoption in the 1970s (I was a bit young at the time to remember) was students were taught difficult and confusing conversion formulas.

Next time, just have people start using the new, metric system measures and convert only those things that are absolutely necessary. Fewer conversions means fewer errors.

Thanks for reading.

More next month.

Linda

Medicine and the Metric System: Part 1

Note: If you care about metric system adoption, you really want to check out my post (10-12-22…National Metric Week) which includes my request to the U.S. House Subcommittee on Science, Space, & Technology for a hearing on the subject. You can see the 10-page report I submitted to Congress: https://milebehind.wordpress.com/2022/10/12/my-10-year-25000-report-to-the-house-subcommittee-on-science-space-technology-on-metric-system-adoption-in-honor-of-national-metric-week-october-10-2022/

Now the post begins:

Allow me to present my main point upfront: we are endangering our health by not adopting the metric system in this country.

Doctors write prescriptions in metric units. Conversions (and potential errors) are made at the pharmacy.

Let me offer up a couple of examples that hopefully makes this clear. It’s important to understand that the medical field depends on metric units (as does most of science, for that matter). If healthcare workers talk in metric units and the public at large relies on U.S. customary units there is bound to be confusion and misunderstandings. That’s best avoided where your health is concerned since the consequences could be dire.

Metric unit dosing is more precise

Last year Pediatrics (Official Journal of the American Academy of Pediatrics) published an article called “Unit of Measurement Used and Parent Medication Dosing Errors.”¹ One of the article’s bottom lines:

Parents who used milliliter-only unit made fewer dosing errors than those who used teaspoon or tablespoon units. Moving to a milliliter-only standard could reduce confusion and decrease medication errors, especially for parents with low health literacy and non-English speakers.

While a minor mistake (whether too much or too little medication) might not make a huge difference for an otherwise healthy adult, these errors can be magnified for babies or those whose health is already compromised.

Most of our teaspoons and tablespoons are meant for eating, not dosing

No on should use “silverware” as substitutes for measuring teaspoons and tablespoons for medicine if they want to avoid dosing errors.

Another issue brought up in the piece was that the use of teaspoon and tablespoon employed for liquid medicines “may endorse kitchen spoon use.” I don’t know about you, but I have three sets of measuring spoons and many more spoons that I use for eating commonly referred to as “teaspoons” and “tablespoons.” The problem is, it’s the eating spoons that are often used to measure medicines. (Yes, I used to do that too, without even thinking about it.) If you have a dosing cup with only milliliters, the potential for confusion is greatly reduced.

As if that’s not bad enough

Even your actual measuring spoons aren’t as precise as you think they are. At one point I came across information indicating that up to a 20 percent variance is allowed. Again, that 20 percent could cause dosing errors. In researching this article I came across a page called “Cooking for Engineers” with the post:

I’ve got three sets of measuring spoons, and their measurements differ from each other, up to 1/4 teaspoon! Is there a way to know which (if any), are accurate?

The suggestions that followed involved scales and the temperature at which one should measure the water used to determine volume. Too bad no one suggested going metric.

Additional endorsement of the metric system for health reasons

I also have a document from the Institute for Safe Medication Practices (ISMP) called 2014-15 Targeted Medication Safety Best Practices for Hospitals² . Two of its best practices mention the sole use of metric system units.

Best Practice 3: Measure and express patient weights in metric units only.

The rationale:

Significant medication errors have occurred when the patients’ weight is documented in non-metric units of measure (e.g., pounds) and it has been confused with kilograms (or grams). Numerous mistakes have been reported when practitioners convert weights from one measurement system to another, or weigh a patient in pounds but accidently document the value as kilograms in the medical record, resulting in more than a two-fold error.

Best Practice 5: Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.

ISMP has received more than 50 reports of mix-ups between milliliter (mL) and household measures such as drops and teaspoonfuls, some leading to injuries requiring hospitalization.

Beware of teaspoon and tablespoon instructions on prescriptions

Almost uniformly, prescriptions are written in metric units. However, if you pick up a liquid prescription and the dose on the bottle is not metric (and in reads teaspoon and tablespoons), the pharmacy has had to make a conversion. Where there are conversions, there is the potential for mistakes.

In addition, one of the top six recommendations in the 15th annual report of the National Coordinating Council for Medication Error Reporting and Prevention³ includes a “Statement of support for use of the metric system to dose medications.”

Advocate for the metric system and help make the country a healthy place!

Note: Don’t miss my exciting follow-up on this post: Medicine and the Metric System: Part 2

Thanks,

Linda

Notes: ¹ The article itself requires a subscription http://pediatrics.aappublications.org/content/134/2/e354.full.pdf. However, a summary is located here: http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Reducing-Medication-Dosing-Errors-by-Ditching-Teaspoons-and-Tablespoons.aspx.
² http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf
³  http://www.nccmerp.org/sites/default/files/fifteen_year_report.pdf