Dear Lactnet Friends:

Our friendly neonatologist, Nancy Wight, shares clinical insights with us
about PIF (powdered infant formula).

I imagine that the preparation of PIF in a NICU would be the ideal way:
 clean, careful, and attentive. Parents need to do this.

As for the contamination of PIF with virulent organisms, the WHO, along
with other public health organizations and published studies, are making
the recommendations about delaying the use of PIF until an infant is a
month or two old. I've put together a list of resources.

(1) <
http://www.foodsafetynews.com/2009/11/bacteria-in-formula-poses-risk-for-infants/
>

(2) Clin Infect Dis. 2008 Jan 15;46(2):268-73. doi: 10.1086/524737.
Powdered infant formula as a source of Salmonella infection in infants.

Cahill SM, Wachsmuth IK, Costarrica Mde L, Ben Embarek PK.
Source
Food and Agriculture Organization of the United Nations, Rome, Italy.
[log in to unmask]

Abstract
Powdered infant formula is not sterile and may be intrinsically
contaminated with pathogens, such as Salmonella enterica, that can cause
serious illness in infants. In recent years, at least 6 outbreaks of
Salmonella infection in infants that have been linked to the consumption of
powdered infant formula have been reported. Many of these outbreaks were
identified because the Salmonella strains were unique in some way (e.g., a
rare serotype) and a well-established Salmonella surveillance network,
supported by laboratories capable of serotyping isolates, was in place.
Another common feature of the outbreaks was the low level of salmonellae
detected in the implicated formula (salmonellae may be missed in routine
testing). These outbreaks likely represent only a small proportion of the
actual number of Salmonella infections in infants that have been linked to
powdered infant formula. Managing this problem requires a multidimensional
approach in which manufacturers, regulators, and caregivers to infants can
all play a role.

(3) J Pediatr. 2010 Mar;156(3):402-8. doi: 10.1016/j.jpeds.2009.09.072.
Epub 2009 Dec 9.
Presence of soil-dwelling clostridia in commercial powdered infant formulas.
Barash JR, Hsia JK, Arnon SS.
Source
Infant Botulism Treatment and Prevention Program, Division of Communicable
Disease Control, Center for Infectious Diseases, California Department of
Public Health, Richmond, CA 94804, USA.
Abstract

OBJECTIVE:
Because Clostridium botulinum was isolated from powdered infant formula
(PIF) fed to an infant in the United Kingdom who subsequently developed
infant botulism and from unopened PIF from the same manufacturer, we tested
PIF manufactured in the United States for the presence of clostridial
spores.

STUDY DESIGN:
Thirty PIF ingested by 19 California infants with botulism within 4 weeks
of onset of illness (48% of all patients fed PIF during study) in 2006-2007
were cultured anaerobically to isolate clostridia. All isolated clostridia
were identified to the species level and enumerated with standard
microbiologic and molecular methods.

RESULTS:
Five of 30 (17%) PIF samples ingested by patients contained clostridial
spores. Spores were also found in 7 of 9 (78%) market-purchased PIF
samples. Clostridium sporogenes was isolated most frequently, followed by
Clostridium butyricum and at least 10 other soil-dwelling clostridial
species. No neurotoxigenic clostridia were isolated. The most probable
number of clostridial spores in PIF ranged between 1.1 to >23 per 100 g.

CONCLUSIONS:
With the notable exception of production of botulinum neurotoxin, C
sporogenes is physiologically comparable with proteolytic strains of C
botulinum, and both share the same natural reservoir (soils and dust
worldwide). The isolation of C sporogenes and potentially pathogenic
clostridia from U.S.-manufactured PIF suggests that neurotoxigenic
clostridial spores have the potential to be present in these products.


(4) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291213/

*Enterobacter sakazakii* kills 40%–80% of infected infants and has been
associated with powdered formula. We analyzed 46 cases of invasive infant *E.
sakazakii* infection to define risk factors and guide prevention and
treatment. Twelve infants had bacteremia, 33 had meningitis, and 1 had a
urinary tract infection. Compared with infants with isolated bacteremia,
infants with meningitis had greater birthweight (2,454 g vs. 850 g, p =
0.002) and gestational age (37 weeks vs. 27.8 weeks, p = 0.02), and
infection developed at a younger age (6 days vs. 35 days, p<0.001). Among
meningitis patients, 11 (33%) had seizures, 7 (21%) had brain abscess, and
14 (42%) died. Twenty-four (92%) of 26 infants with feeding patterns
specified were fed powdered formula. Formula samples associated with 15
(68%) of 22 cases yielded *E. sakazakii*; in 13 cases, clinical and formula
strains were indistinguishable. Further clarification of clinical risk
factors and improved powdered formula safety is needed.

(5) AAP on powdered infant formula Pediatrics 2012;130:1–9

(6) “Powdered formula shouldn’t be given to any infant under 4 weeks of
age”    Bowen and Braden 2006

(7) http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf(from
the WHO)

1.3 Populations at greatest risk of infection
Although E. sakazakii can cause illness in all age groups, infants
(children <1 year) are at most risk with
neonates and infants under two months at greatest risk. The groups of
infants at greatest risk includes in
particular pre-term infants, low-birth-weight (<2.5 kg) infants or
immunocompromised infants. However, infants
who are compromised for any other reason may also be at greater risk of E.
sakazakii infection. Infants of
HIV-positive mothers are also at risk because they may be immunocompromised
and may specifically require
PIF (FAO/WHO, 2004).  There appear to be two distinct infant risk groups
for E. sakazakii infection: premature
infants who develop bacteraemia after one month of age, and term infants
who develop meningitis during the
neonatal period. Therefore, the FAO/WHO expert working group (2006)
concluded that while infants appear to
be the group at particular risk, neonates and also those less than two
months of age are at greatest risk (FAO/
WHO, 2006).

It is very important to note that, although high-risk groups of infants
have been identified, E. sakazakii infection
has occurred in previously healthy infants outside the neonatal period
(Gurtler, Kornacki and Beuchat, 2005).
Furthermore, infections have occurred in both hospital and outpatient
settings. For this reason, educational
messages on the safe preparation and handling of PIF are required for
health-care workers, parents and other
infant carers.

In the case of salmonellosis, infants are more likely than the general
population to experience severe illness or
death. Immunocompromised infants are particularly vulnerable. While infants
who are breastfed are 50% less
likely to contract salmonellosis, a few reports have described the
transmission of Salmonella via expressed breast
milk (FAO/WHO, 2006).

warmly,
Nikki Lee RN, BSN, Mother of 2, MS, IBCLC, CCE, CIMI, ANLC, CKC
craniosacral therapy practitioner
www.breastfeedingalwaysbest.com
 https://www.facebook.com/nikkileehealth

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