Cronobacter Illnesses Associated With Powdered Infant Formula Consumption

Introduction

Cronobacter sakazakii is a bacteria naturally present in the environment. These organisms are associated with sporadic (infrequent) infections and diseases, specifically in premature and immunocompromised infants. They can exist on almost all surfaces in the kitchen, yards, living rooms, etc., and primarily survive in dry foods, milk powder, powdered infant formula (PIF), starches, and herbal teas. Cronobacter species are part of a large family of bacteria; therefore, it can be challenging to identify the specific source of the infection. Research suggests an association between Cronobacter infections and several cases of necrotizing enterocolitis in hospitalized premature infants.

What Are Cronobacter Infections?

Cronobacter sakazakii is a gram-negative bacteria belonging to the family Enterobacteriaceae that causes infections, especially in neonates. These microorganisms have natural habitats, predominantly found in plants and organic material. Though Cronobacter infections are rare, if they occur, they can be life-threatening for young infants. These infections can cause intestinal diseases, severe sepsis (bloodstream infections), meningitis (inflammation of the membranes of the brain and the spinal cord), or they can even result in neurological disabilities.

Who Is at Risk for Cronobacter Infections?

According to a comprehensive review of the United States Food and Drug Administration (USFDA), World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC), the following are at risk for Cronobacter illness;

• Premature babies or low birthweight infants.

• Infants (less than two months).

• Infants with weakened immune systems.

• Infants with certain medical conditions or under treatment for diseases such as cancer.

• People above 65 years of age can get infected due to cuts and scrapes, on the skin surfaces or by urinary tract infections.

• Adults who have weak immune systems due to genetic conditions, human immunodeficiency virus (HIV), and cancer have undergone surgery or organ transplantation.

What Are the Causes of Cronobacter Illnesses in Infants?

Cronobacter sakazakii, previously known as Enterobacter sakazakii, is the bacteria that causes Cronobater illness in formula-fed infants. It may be found in powdered milk, formula foods, breast pump equipment, potatoes, rice, herbal teas, etc. Once the bacteria enters the body, the incubation period is around six to eight hours.

• Opened formula boxes or inappropriate storage conditions are more susceptible to bacterial contamination; however, they may also occur in unopened containers and in manufacturing facilities due to the use of old or uncleaned ingredients, improper handling of materials, etc.

• Placing the lids or scoops of the formula on contaminated surfaces.

• Mix the formula in a contaminated container or a bottle.

What Are the Signs and Symptoms of Cronobacter Infections in Infants?

Cronobacter infections usually occur in the initial weeks of life, and around two to four cases are reported to the CDC every year. Signs and symptoms include;

• Fever.

• Excessive crying.

• Poor feeding.

• Low energy or tiredness.

• Seizures can also occur in some rare cases.

How Can Cronobacter Illnesses Be Prevented?

Cronobacter illnesses can be prevented in infants by following the below measures:

• Breastfeeding must be done as much as possible, as very few cases are reported among infants who are fed only breast milk.

• Feeding items must be cleaned, sanitized, and stored safely. Bacteria can grow quickly in partially cleaned or only rinsed bottles.

• Breast pump components, pacifiers, and teethers must be cleaned and thoroughly sanitized.

• Kitchen surfaces or surfaces in contact with the infant’s items must be disinfected using a disinfectant wipe or a paper towel sprayed with a cleaning solution.

• Feeding items must not be placed directly in the sink, as the germs in the drain could contaminate these things.

• Hands must be thoroughly washed with soap and water at least for 20 seconds before preparing the feed, before touching or feeding the baby, and after changing diapers. Hands must be dried using a clean towel or a paper napkin. An alcohol-based sanitizer (at least 60 percent alcohol) can be beneficial against Cronobacter.

• When preparing the formula feed, water must be thoroughly boiled and cooled for a few minutes. The formula must be mixed while the water is still hot so that it can kill the germs, if any.

• Water must be poured into a washed and cleaned bottle or a feeding cup.

• The exact amount of formula listed on the box must be added and mixed by shaking thoroughly.

• The formula must be cooled to room temperature to ensure it is not too hot while feeding.

• The prepared infant formula must be used within one hour from the start of feeding and within two hours of preparation.

• Any unused infant formula must be discarded, and it must not be refrigerated, as the combination of the baby’s saliva and the formula contents can allow the growth of germs.

• For infants with a high risk of infections, the FDA recommends ready-to-feed (RTF) liquid formula as the powdered formula may not be completely sterile.

• The infant formula need not be warmed, and microwaves must not be used to warm the milk, as it can result in uneven heating and result in hot spots that can burn the infant’s mouth and throat. The bottle may be warmed by placing it under warm running water, but care must be taken not to allow the water to enter the feeding bottle.

• Quality control standards have been issued by the FDA for safer powdered infant formula production, by including the manufacturers to frequently test for Salmonella and Cronobacter species before distributing the products.

How Can Cronobacter Illnesses Be Managed?

Cronobacter can cause various types of infections; however, the severity depends on the child’s age, health, and the part of the body affected. The doctor must be contacted immediately if the baby shows any of the signs and symptoms of infection. A healthcare provider can diagnose the infection through the signs and symptoms, physical examination of the infant, and blood investigations.

• An initial resuscitation and prompt administration of intravenous (IV) antibiotics such as Ampicillin and Gentamicin are performed. Broad-spectrum antibiotics or antimicrobials are selected based on the culture and sensitivity reports.

• Carbapenems such as Imipenem-cilastatin, Meropenem, Ertapenem, etc., or newer cephalosporins such as Cefepime can be administered.

• A computed tomography scan of the head is recommended, especially in immunocompromised infants.

Conclusion

Cronobacter organisms are gram-negative bacteria that may be found in dry food substances, powdered infant formula, starches, etc. As bacteria are naturally found in the environment, it is quite challenging to eliminate the microorganisms. Various preventive measures can be followed to avoid contamination of infant formula. However, a better understanding of the cause of the disease and its progression is required for the development of newer strategies against the bacteria.