By Sara DePierre, PA-C, IBCLC, Pediatric Alliance — Jefferson Hills.



The CDC has recently revisited the long-standing warning regarding the potential for infant powered formula to be contaminated with potentially dangerous bacteria. It has been well established for years that powered infant formula is not sterile and that despite the best techniques and tight controls on the manufacturing level, not all bacteria can be eliminated in infant powered formula. The CDC has decided to reissue this warning to help draw attention to an issue that, while not common, can be quite dangerous.

The most common bacteria found in powered formula is Enterobacter sakazakii, otherwise known as Cronobacter. This is a naturally-occurring germ in our environment that lives in dry places such as powered formula, powered milk, starches, and even some herbal teas. While infection or sickness from this bacteria is not commonplace (4-6 reported cases/year in the US, although reporting is not required so the true number of cases is likely not represented), it is quite serious for babies, leading to blood infections and even meningitis, which is an infection in the membrane surrounding the brain. The latter condition can be life threatening, which is why many hospitals in our Pittsburgh area are changing their protocols and recommendations for infant feeding. While the updated recommendations are for all babies, those at greatest risk of infection are infants less than 2 months of age, those who are born prematurely, and those with compromised immune states.

As pediatricians, we do our best to pass on “best practice” recommendations like these to our patients, and thus I thought I would give an outline today on what the recommendations are and what signs and symptoms would alert you to a possible Cronobacter infection.

1. The earliest signs of Cronobacter infection include fever, poor appetite/poor feeding, crying, and lethargy or very low energy. Because these symptoms are very non-specific and can occur with many other viral or bacterial illnesses, you should call your pediatrician if you have any concerns about your baby exhibiting the above symptoms.

2. The World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and American Academy of Pediatrics (AAP) all recommend exclusively breastfeeding for the first 6 months of life. This significantly reduces the risk of illness from not only Cronobacter but also from many other types of infections. If using a breast pump to express breast milk, it is important that you wash all parts that are meant to be washed in the dishwasher or with water hot enough to kill bacteria, and that good hygiene is maintained during the act of pumping and in storing the breast milk.

3. If formula feeding, it is recommended that “ready to feed” or liquid formula is used since this type of formula is sterile and thus should not be contaminated with Cronobacter.

4. If powered infant formula is the only available option, there are things that can be done to lessen the risk of infection. First, wash your hands with hot water and soap along with all surfaces that will be used for preparation. Ensure that bottles have been washed in the dishwasher or with hot water and soap and then sterilized. Next, prepare formula by using hot water that has been boiled to 158 degrees Fahrenheit. This is the step that I feel most families are not informed about. It takes this temperature of water in order to kill any bacteria that may be in the powered formula. The bottle should then be capped, shaken rather than stirred, and cooled by running under cold water or soaking in ice water bath (ensuring no water gets into the bottle). It is crucial that the temperature of the bottle is tested by applying a few drops to the caregiver’s wrist to ensure that the temperature is cool enough for consumption.  Click here for full details of each of the steps.

5. Use prepared formula within 2 hours. If any formula is unused, it should be discarded. If the prepared formula will not be used immediately, it should be placed in the back of the refrigerator and kept for no longer than 24 hours.


While it is clear that these steps are important to keep infants safe, it is unclear how long infants should be given sterile, liquid formula rather than powered formula. Neither the CDC nor the WHO make specific recommendations for how long to continue this practice, so I advise that you discuss this recommendation or any concerns at your next scheduled appointment with your pediatrician.


*** Sara DePierre sees patients at the Pediatric Alliance — Jefferson Hills office. You can read more from Sara on The PediaBlog here.