Ready-to-feed formula may prevent Cronobacter infection in babies

I love when I’m right. I mean, it happens so infrequently (at least according to Fearless Husband).

Even before the Cronobacter scare of 2011, I’d dramatically changed my tune about formula preparation and safety. The research I read surrounding bacterial infection in babies due to formula or bottle use made me see just how piss poor our education on bottle feeding truly is; this is what spurred my interest in starting some sort of pre or post-natal educational workshop/literature for bottle feeders, and also made me suspect that there was an astonishingly simple – albeit prohibitively expensive – solution to the bacteria problem.

Safety, thy name is Ready-To-Feed.

Until now I’ve merely been able to suggest that my personal belief is that ready-to-feed nursettes are the safest bet for newborns, and especially for late pre-term babies or those with any sort of compromised immune system. Now, a study published in Pediatrics gives scientific credit to my completely unscientific gut feeling.

I’d say squeeeand do a little dance of egotistical joy,

but unfortunately I can’t. Because we are talking about infant safety here, and the solution which this study is suggesting is not going to be feasible for many parents due to the cost involved. This is turning my happy ego dance into a sad waltz. Which sucks, because who doesn’t enjoy a good happy ego dance?

The study, Prevention of Invasive Cronobacter Infection in Young Infants Fed Powdered  Infant Formulas, looked at the records of 68 babies infected with invasive cronobacter between 1958-2003, and 30 babies between 2004-2010. A couple of things to note before we get into the nitty-gritty of the study:

1. Invasive Cronobacter infection is extremely rare, and usually affects pre-term babies and very young neonates (all of the infants reflected in these records were under two months old).

2. This study had some significant limitations, considering that it was conducted using records from a variety of international organizations (CDC, USDA, WHO, as well as “personal communications” and “publications”. Definitions might have varied, as well as the quality of the information. This might explain the shocking disparity between the cases reported in the older batch (1958-2003) and the newer batch (2004-2010).

Now that the caveats are out of the way, let’s continue. The study found very different statistics in the two chronological batches. In the older batch, only 24% of the babies were full term; out of the more recent cases, 58% were full term. That’s a radical leap. Plus, while in the 1958-2003 group only 21% became symptomatic at home, that percentage jumped to 52% between 2004-2010. This may have something to do with the fact that there were half the number of cases in the more modern group versus the older one; if bacterial contamination was becoming more rare, then perhaps we’re dealing with a newer or more virulent strain in the new millennium. But I also wonder if part of the disparity between the characteristics of the cases has to do with the lack of formula feeding guidance. The resurgence of breastfeeding since 2000 has led to many fantastic outcomes, but the downside, as we’ve discussed before, is a refusal to address the needs of formula feeding parents. Historically, concerns about bacterial infection were focused on NICUs; the tubing used to deliver food to the tiniest babies could easily become contaminated if the utmost care wasn’t taken, and given the fragile systems of premature or sick infants… well, it wasn’t a great combination of risk factors. But looking at the statistics used in this study, it seems that in the past 12 years, full-term babies in their parent’s care – at home – were equally at risk. I think it merits further reflection, at least, to consider if these cases might have been due to parents being given no guidance or support with formula feeding. We know from our numerous conversations here, and on the FFF Facebook page, that most of us were given ample education on breastfeeding (even if we didn’t get much practical support); very few of us were instructed on how to formula feed safely, sometimes with the excuse from more intolerant healthcare professionals that there was no “safe” way to formula feed.

Regardless, even if we were given better instruction on safe bottle feeding practices, very young infants fed powdered formula are at significantly higher risk of becoming ill from invasive cronobacter. The Pediatrics study found that out of all infected infants studied, 26% had received breastmilk, 23% had received RTF, and 90% had received either powdered infant formula or human milk fortifier (which is another caveat I forgot to mention – powdered human milk also posed a significant risk, not just powdered formula. Apparently Cronobacter loves powder of any sort).

Okay- just so we are crystal clear here – the lowest percentage of infected babies came in the group fed ready-to-feed formula only. It even beat breastmilk (not by much, but I think it should be mentioned, since it would be if it were the opposite). So it’s a no-brainer that the study’s author then recommends the following:

Invasive Cronobacter infection is extremely unusual in infants not fed powdered infant formula/Human Milk Fortifier. RTFs are commercially sterile, require minimal preparation, and are competitively priced. The exclusive use of breastmilk and/or RTF for infants <2 months old should be encouraged.

I’ve been advising that newborns use RTF whenever possible for awhile now, but every time I do I feel like a classist a-hole. Because let’s be honest – the stuff is expensive. Even if you buy the 32-oz containers rather than the more costly (but sterile) nursettes, you’re still talking a major difference in cost for the recommended two months of use. And those first 2 months, there is a lot of wasted formula – babies are erratic, not on a schedule, parents are still figuring out hunger cues… it takes a few months before you know Junior will take exactly 4 oz every 4 hours. Powdered formula is significantly cheaper. And god help you if your baby ends up on a hypoallergenic – buying the RTF version of that stuff will seriously kill your bank account.

The big elephant in the room, of course, is that the formula typically given away in those controversial hospital swag bags is ready to feed – often in the form of sterile nursettes. Not that the amount in the bags would feed a baby for the entire two month window of risk, but the bags I received – generously “supplemented” by the maternity ward nurses since our breastfeeding-friendly hospital didn’t have many formula feeding mothers and there were plenty of leftover bags – gave me enough formula to get us through the first few weeks. Every little bit counts.

Now, I’m not naive enough to believe that the formula companies are giving away RTF out of the kindness of their hearts. But considering that the Ban the Bags movement has grown in popularity, and hospitals are going Baby-Friendly right and left – they are going to need an alternative way to market their products. Why couldn’t we set up a program which would give parents that have chosen to formula feed (or supplement) before leaving the maternity ward to request a “gift” of ready to feed formula? Formula companies could still reap the rewards of brand loyalty, and look somewhat altruistic in the meantime. The parents who receive these samples could be the same ones who already were forced to sign documentation which labeled them as formula feeders, so what would be the harm?

There needs to be a way to provide supplementing and exclusively formula-feeding parents with the safest breastfeeding substitutes possible. In the first two months of life, ready-to-feed formula is the safest commercial alternative. If the formula companies would be wiling to provide at least a few weeks of RTF to take the financial edge off, it might help parents afford RTF for the subsequent 6-7 weeks.

Seems like a no-brainer to me, but then again… you know what Fearless Husband says. I’m hardly ever right.



Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.

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15 thoughts on “Ready-to-feed formula may prevent Cronobacter infection in babies

  1. THANKYOU! I too have always *wanted* to suggest RTF to parents but felt all the same things you have about not having source to back up my thoughts and cost etc. The other HUGE issue here in Australia is that only ONE company produce RTF for sale and it only comes in one form (individual 250ml cartons which need to be poured into a bottle – no nursettes here) and can be difficult to find 🙁 Obviously something that needs to be addressed.

    Some thing else I was thinking as to why the increase in infection of full term babies; could it have to do with the hospitals now instructing parents who decide not to breastfeed from birth to supply their own formula? Previously if a mother did not want/could not breastfeed the hospital supplied formula while they were at least there – which was RTF, and also usually gave a small supply to take home. Now parents are taking in and preparing their own formula (usually powdered) and so there is an increased risk of infection. Just a thought. Again thanks for all your hard work in finding these sorts of studies and presenting them the awesome way you do 🙂

  2. I never considered there was no research… I only assumed…

    When my daughter was hospitalized they brought out the ready to feed formulas and when I asked why they told me that they were more sterile and better for a hospitalized baby than powder formula, plus they were easy to keep track of how much was eaten, and you tossed the unused portion. They just said it was less of a risk, and that newborns should always be fed ready-to-feed. I just assumed that they had basis for that, and have been recommending for 4+ years now that when folks head to the hospital planning to formula feed they should buy the ready-to-feed nurselettes and not a can of powder. I thought this was just standard. Maybe my hospital was just ahead of the time or recognized the trends?


    • My babies were also given RTF at a (non-BFHI) hospital. I didn’t think about it, just assumed that that is what they had, because it was convenient and sterile. They gave us a few cases of the nursettes, and someone gave me a case of the large RTF jugs as a shower gift, which was very useful. I think I left one jug (unopened) in the car, in case of emergency. But, the hospital didn’t stress feeding RTF, and mostly my babies got powdered formula, with no problems.

      I loved the convenience factor of the RTF, but the cost was prohibitive (twins), which is why I didn’t buy any myself. So yeah, it would be helpful for insurance to reimburse for the 1st 2months, or be able to get large discounts from the various formula companies. The day we went to BJs and didn’t have to buy a case for formula because the boys had outgrown it, was a day for rejoicing. Cut our grocery bill at the time, in half.

  3. Yeah, “competitively priced” makes me snort. RTF should be cheaper, but hey, it’s not, and if what it’s going to take for people to feed their babies safely is the occasional free sample, or getting insurance to reimburse it for the first two months after birth, let’s support that. I wonder, though, if this will be seen by those who want to encourage women to push through with BFing as yet another “booby trap.” Sigh.

  4. That totally makes sense. Besides the fact that rtf is often more easily digested it doesn’t require prep and all. We are using rtf alimentum because it is the only version of hypoallgenic she seems to do well on and it costs us 280 a month. While the ped said we warrented a script due to our history, insurance is slow and may refuse. The price makes me shudder though and I seriously wish it were more affordable. I don’t know why it’s not, but I guess it’s the process on how it’s made and likely because it is corn free. However with my son rtf similac sensitive was actually cneaper than the powder. I’m not sure how, but I remember calculatng the cost repeatedly and it repeatedly came out cheaper.

  5. Cronobacter (then known as E.sakazakii) was in the news here in New Zealand in 2004 when a prem baby died from it. After this, RTF became standard in NICUs, and personally, I have seen it used in Starship Hospital (children’s hospital in Auckland) As far as I can ascertain, there has only been one reported death from cronobacter (the one in 2004) and an anecdotal report of illness and subsequent disability. Cronobacter was made a notifiable disease in 2005.

    This is an interesting little document. Currently, only NICU babies (and hospitalised babies) receive RTF, and healthy, full term newborns receive powdered formula, as RTF is not available commercially here, other than in the Wyeth S-26 range – but they are tetra paks, not single serve nursettes.

    From my perspective of living in a different country, with the information I have, I see cronobacter as a risk that its important to be aware of – and this is where education for bottle feeding parents on correct preparation and storage of formula is vital – but its not something to worry about.

  6. My brain feels like it’s filled with cotton candy right now because I’m so pregnant, but I have what may be an exceedingly obvious question about the percentages of who was fed what. You said 23% received RTF, 26% were breastfed, and 90% were given powdered formula — so I’m assuming only 10% of the babies were exclusive breastfed or exclusively receiving RTF or a combination of both? Did they break this out in the study at all? I’m sure it’s not a big focus because it would be a very small number, but I’m curious about it.

    Also, I may have completely missed it, but I didn’t see an overall risk for contracting Cronobacter or changes in the rate over the two time periods. Obviously *any* risk is justification for increased education about safe formula feeding, but surely there must be a better way than just expecting hospitals to provide handouts (of which the cost is eventually transferred to the overall cost of formula anyway, right?) of RTF to reduce risk and make up for the increased cost.

    • Suchada – at least you have an excuse for having cotton-candy brain right now. Mine is always like that.

      Here is the info given in the abstract:

      “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."

      I haven't gotten my hands on the full text yet (hope to have it by the weekend) so I am piecing this all together from what is in the abstract and other articles about the study. The overall risk question is a good one, and I'm interested to see if the full text discusses this at all. I suspect that they will say it is tough to determine b/c of the factors I mentioned at the beginning of my post (the variety of sources of data, and the differences in definitions and diagnoses over a 50-year span) but I'd hope they'd give at least a ballpark assessment. I have a feeling that the overall risk has either stayed the same or decreased; however, the fact that the ratio of full-term babies infected at home was so dramatically different is troubling.

      I totally understand your point about the increased cost to consumers, but quite honestly, I think formula companies will ALWAYS find a way to market their products- leading to higher cost for formula feeding parents. I'd love for them to find a way to market that doesn't affect breastfeeding moms, and could help formula feeding parents feed their babies safely. The risk of cronobacter infection may be exceedingly low, but it's a risk all the same - and far more of a known, proven risk than any other detrimental effect of formula mentioned in the typical anti-formula literature. We KNOW that this bacteria affects formula fed kids more than breastfed kids (in fact I don;t think an exclusively breastfed child has even been documented as contracting this strain of bacteria - babies bottle-fed with breastmilk, and those using powdered human milk fortifiers are at similar risk to powdered formula fed kids, at least according to this study, but direct from the breast feeding is definitely protective in this case), and we know that the risk is negligible after 2 months of age, so it seems like a smart idea to be extra cautious when formula feeding in the first 8 weeks. I can't see there being another solution, but it would be lovely if there was one!

      • I had a similar question (I think). Of the small percentage receiving breastmilk-were they receiving ONLY breastmilk? (i.e. was the breastmilk the medium that carried the infection or did they also receive infected formula or milk fortifier-powdered or otherwise?). Because like you, I had also read that there were no documented cases of exclusively breastfed babies ever contracting this infection. Does that mean exclusively from the tap and no bottled breastmilk? Sorry to be firing off questions but I guess I’m just confused… I also recall reading some really nasty comments at the end of the articles discussing the 2011 cronobacteria case where people were saying how if the baby had drank his mother’s milk, this wouldn’t have happened and how the protective properties of the breastmilk would have killed the cronobacteria. Um really? Obviously not.

        On a positive note, I really liked how this study did not go on a breast is best tirade and seemed to acknowledge that some degree of formula feeding is often necessary for the vast majority of babies and recommended breast milk AND/OR RTF formula. Definetly a more encouraging tone on that subject than we typically see. ‘

        Let’s be honest, whether it’s formula only, some combination of BM and formula, or BM only, bottles are a reality for 99.9% of moms and babies in this day and age. So I’m all for any info that can lessen the risk-however negligible-without demonizing the formula itself. It does suck that RTF is so damn expensive. I think someone said RTF Alimentum costs them $280 per month. That wouldn’t be beyond our reach personally (though we would defnetly notice it), but for many it would be and that’s really unfortunate. I seriously wonder if it’s THAT much more expensive for the formula companies to make/sell RTF and if they really need to charge the amount that they do for it.

  7. What I find terrifying is that I used powder formula with my oldest and I have never heard of this infection until today. Yikes.

    • Me neither! Planning to have another one in the next 3 years. So I guess I should probably start saving for the RTF’s now. 🙂

  8. I can’t imagine mixing formula directly after labor. I just happend to buy some RTF bottles in case we needed it. I didn’t want to deal with measuring and mixing etc…

    • I remember trying to mix formula for my newborn twins in the middle of the night and losing count of the (two) scoops about five times before being sure I got it right. It’s pretty bad when you’re so tired you can’t count to two, but that’s how exhausted I was! I was terrified that I wouldn’t mix it right and my babies would get sick. RTF would have been much safer and easier – especially in those early days!

      • Yep! And if you ever have twins again, (or any baby really), mix up overnight bottles before you go to bed. (I also have twins, and know of which you speak. After a couple of weeks, we always set up o/n bottles, so all we needed to do was put in micwav for 10secs.) 🙂

  9. The CDC states that there are 13 “reported” cases of infants contracting Cronobacter sakazakii in 2011. In the USA, I believe Minnesota is the only state in which “reporting” of this disease is mandatory. Thus, the prevalence of this problem caused by our food industry is hidden.

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