Since E Sak is in the powdered cow's milk with additives (PCMA) itself, not in the water, I fail to see how using sterile water does anything to decrease the potential growth of this pathogen.  The cleanest water in the world is not going to kill the germs already in the powder.  

I also fail to see that there is any evidence to support adding powdered cow's milk with additives to human milk.  In 99.9% of the cases I've seen, insufficient intake was the cause of the problem, not density of mom's milk.  Without doing a test of the mother's milk, which may be at a HIGHER concentration of fat if the supply is low because the baby isn't feeding well, it seems to me that this is a nonevidence based practice with potential risks.  The burden of proof is on ensuring that additives to human milk are safe.  

Sincerely, Susan E. Burger

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