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Indian Journal of Community Medicine

Powdered Infant Formula - How Safe is It?

Author(s): SB Neogi, A Linnecar

Vol. 32, No. 1 (2007-01 - 2007-03)

SB Neogi, A Linnecar

IBFAN – the International Baby Food Action Network -consists of more than 200 public interest groups working around the world to promote the health and well-being of infants, young children and their mothers through the protection, promotion and support of optimal infant and young child feeding practices. IBFAN works to eliminate the irresponsible marketing of breast milk substitutes and feeding bottles through full and universal implementation of the International Code of Marketing of Breast milk Substitutes and subsequent, relevant World Health Assembly Resolutions. In 1998, IBFAN was a recipient of the Right Livelihood Award.

Breast feeding is a rule rather than exception in most parts of India. It is now established that examining not only if an infant was breast fed but also how (in terms of duration and exclusivily) is essential to our understanding of the impact of breast feeding on human health(1). Infants partially breast fed (breast milk along with animal milk or infant formula) or not breast fed have a signifi cantly higher risk of hospitalization and death as compared to infants predominantly breast fed (breast milk and water) or exclusively breast fed(2).

Data from India states that only 55% of children less than 4 months of age are exclusively breast fed, 23% predominantly breast fed and 20% receive supplements along with breast milk. Powdered milk is given infrequently to young children at any age, but other milk (such as cow’s / buffalo’s milk) is given more often. Around 10% of breast fed infants less than 6 months receive powdered milk. This fi gure increases considerably with increasing age and also among non breast feeding children(3).

Enterobacter sakazakii in powdered infant formula has been implicated in outbreaks causing sepsis, meningitis or necrotizing enterocolitis(4-6).While the organism has been detected in different types of food, only powdered infant formula has been linked to outbreaks of diseases(7). Based on the available information, in 50-80% of cases, powdered infant formula is both the source and vehicle of E. sakazakii induced illness, and in 20-50% of the cases, the formula was the vehicle but poor hygiene during reconstitution and handling was the source(8). Powdered milk has also been shown to cause infections by Clostridium botulinum, S.aureus and Salmonella(8,9).

E.sakazakii is a gram negative rod within the family Enterobacteriaceae. It has a propensity to infect the central nervous system to cause meningitis, cysts or brain abscess. Subsequent development delay and hydrocephalus is a well recognized sequel. Although exact virulence mechanisms are unknown, it is known that a small percentage of E.sakazakii cells can survive for extended periods in dehydrated powdered infant formula. Reported recovery of members of Enterobacteriaceae from more than 50% of 141 products obtained from 35 countries and E.sakazakii from 14% of the samples reiterates this fact. All were in compliance with Codex Alimentarius since the concentration of the organism did not exceed 1 colony forming unit / gram dry powder(10).

Information regarding E.sakazakii is limited to a relatively small number of case reports of sporadic cases and outbreaks. The risk of potentially fatal infections appears to be highest for low birth weight infants, immunocompromised infants at any age and term infants hospitalized in level 2 and level 3 neonatal intensive care units. There is probably a low, but as yet unquantifi ed risk in healthy term infants, which cannot be described with data available at this time(11).

Considering the limitations of current surveillance systems in most countries and the fact that infant formula is widely used, the presence of E.sakazakii in infant formula and its potential effects in infants could well be a signifi cant public health problem. There is a pressing need to obtain additional information on what public health impact E.sakazakii has in developing countries.

References

  1. Wambach K, Campbell SH, Gill SL, Dodgson JE, Abiona TC, Heinig MJ. Clinical lactation practice: 20 years of evidence. J Hum Lact 2005;21:245-258.
  2. Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, Bhandari N, Arthur P. Infant feeding patterns and risks of death and hospitalization in the fi rst half of infancy: multicentre cohort study. Bull World Health Organ 2005;83:418-426.
  3. Nutrition and prevalence of anemia. In: National Family Health Survey (NFHS-2) India. Available at: www.nfhsindia.org.
  4. van Acker J, de Smet F, Muyldermans G, Bougatef A, Naessens A, Lauwers S. Outbreak of necrotizing enterocolitis associated with Enterobacter sakazakii in powdered milk formula. J Clin Microbiol 2001;39:293-7.
  5. Simmons BP, Gelfand MS, Haas M, Metts L, Ferguson J. Enterobacter sakazakii infections in neonates associated with intrinsic contamination of a powdered infant formula. Infect Control Hosp Epidemiol 1989;10:398-401.
  6. Biering G, Karlsson S, Clark NC, Jonsdottir KE, Ludvigsson P, Steingrimsson O. Three cases of neonatal meningitis caused by Enterobacter sakazakii in powdered milk. J Clin Microbiol 1989;27:2054-6.
  7. Nazarowec- White M, Farber JM. Enterobacter sakazakii: a review. Int J Food Microbiol 1997;34:103-13.
  8. Enterobacter sakazakii and other microorganisms in powdered infant formula. Geneva FAO/WHO 2004. (Microbiological Risk Assessment Series, No. 6, ISBN: 92 4 156262 5).
  9. CAC. (Codex Alimentarius Commission). Report of the 35th session of the Codex Committee on Food Hygiene. Orlando FL, 27 January – 1 February 2003.
  10. Muytjens HL, Roelofs -Willemse H, Jasper GHJ. Quality of powdered substitutes for breast milk with regard to members of the family Enterobacteriaceae. J Clin Microbiol 1988;26:743-6.
  11. Codex Committee on food hygiene. Report of Joint FAO/WHO food standards programme. Washington DC, United States of America, 29 March- 3 April 2004.

Member, IBFAN, C3A/33A, Janakpuri, New Delhi- 110058.
E Mail: [email protected]
International Coordinator, IBFAN-GIFA, Avenue de la Paix 11, 1202
Geneva, Switzerland.
Received: 20.4.06

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