Prevention of Invasive Cronobacter Infections in Young Infants Fed Powdered Infant Formulas

Abstract

BACKGROUND: Invasive Cronobacter infection is rare, devastating, and epidemiologically/microbiologically linked to powdered infant formulas (PIFs). In 2002–2004, the US Food and Drug Administration advised health care professionals to minimize PIF and powdered human milk fortifier (HMF)’s preparation, feeding, and storage times and avoid feeding them to hospitalized premature or immunocompromised neonates. Labels for PIF used at home imply PIF is safe for healthy, term infants if label instructions are followed. METHODS: 1) Medical, public health, Centers for Disease Control and Prevention, US Food and Drug Administration, and World Health Organization records, publications, and personal communications were used to compare 68 (1958–2003) and 30 (2004–2010) cases of invasive Cronobacter disease in children without underlying disorders. 2) The costs of PIFs and ready-to-feed formulas (RTFs) were compared. RESULTS: Ninety-nine percent (95/96) of all infected infants were <2 months old. In 2004–2010, 59% (17/29) were term, versus 24% (15/63) in 1958–2003; 52% (15/29) became symptomatic at home, versus 21% (13/61). Of all infected infants, 26% (22/83) had received breast milk (BM), 23% (19/82) RTF, and 90% (76/84) PIF or HMF. Eight percent received BM and not PIF/HMF; 5%, RTF without PIF/HMF. For at least 10 PIF-fed infants, label instructions were reportedly followed. Twenty-four ounces of milk-based RTF cost $0.84 more than milk-based PIF; 24 ounces of soy-based RTF cost $0.24 less than soy-based PIF. CONCLUSIONS: Cronobacter can infect healthy, term (not just hospitalized preterm) young infants. Invasive Cronobacter infection is extremely unusual in infants not fed PIF/HMF. RTFs are commercially sterile, require minimal preparation, and are competitively priced. The exclusive use of BM and/or RTF for infants <2 months old should be encouraged.