Formula preparation IC guidelines for NICUs
The American Dietetic Association in Washington, DC, has issued guidelines to prevent infections and contamination via infant formula in neonatal intensive care units and other medical settings. Highlights from the guidelines are summarized as follows:1
In reported outbreaks of foodborne infection due to the use of contaminated powdered infant formula, problems have included inadequate control of storage, improper handling, or keeping a product beyond the recommended time that allows for bacterial multiplication. Thus, although proper preparation of formulas for infants is essential in health care facilities, it is also equally important that there be recommended guidelines for storage and appropriate discarding of prepared infant formula. These recommendations should be clearly outlined and adhered to in order to prevent foodborne infection.
In addition, exclusion policies for staff who are ill should be clearly defined. No one with any illness that is known or suspected to be due to communicable pathogens should be allowed to work in the facility until they are known to be clear of infection. This would include all employees with symptoms of gastrointestinal infection. Individuals with chronic dermatitis involving the hands or arms may have difficulty working in the infant formula preparation room due to the need for repeated hand washing. The presence of these conditions would not automatically mean strict exclusion for the individual unless there was a superimposed infection. An ability to comply with hand washing requirements may be difficult for these individuals and should be considered in determining job assignments.
Ideally, individuals with minor illnesses (such as the common cold or bronchitis) should not work in the infant formula preparation room. If staffing demands make this policy difficult to enforce, strict compliance with gloving, masking, and hand washing must be ensured.
Federal guidelines mandate that commercially prepared, liquid infant formulas be commercially sterile, and that powder formulas must be microbiologically acceptable. Powdered formula products are not sterile; therefore, they may contain certain nonpathogenic bacteria, including spore-forming bacteria, coagulase-negative staphylococci, and diphtheroids. These organisms are all considered harmless, and are usually present in very small numbers. Potential pathogens that may be present in the powdered product in small umbers include E. coli, Klebsiella spp, and Enterobacter spp.
Gastroenteritis is the most commonly recognized form of food- or waterborne illness. The symptoms may predominantly reflect upper (vomiting, nausea) or lower gastrointestinal tract (cramps and abdominal pain, diarrhea with or without blood and mucus) involvement or a mixture of the two. Illness may arise from ingestion of live organisms (e.g., Salmonella, Shigella), or from ingestion of preformed toxin that has been produced by organisms multiplying in the food prior to ingestion (e.g., enterotoxin produced by Staphylococcus aureus, Clostridium botulinum, Bacillus cereus). Illness may not be confined to the gastrointestinal tract, however, because some of the organisms present in the food or water may invade beyond the mucosal barrier to cause serious systemic disease. This is an important concern in all immunocompromised individuals, including newborn infants (especially those who are very premature).
While programs and resources will vary, infection control measures for infant formula preparation should include the following key elements:
• Prevention of exogenous contamination of infant formula products during preparation, storage, delivery, and feeding.
• Prevention of an overgrowth of organisms present in the prepared formula during preparation, storage, delivery, and feeding.
• Detection, as soon as possible, of any infection or intoxication that may be due to contaminated formula.
• Prompt investigation of any potential foodborne epidemic and institution of control procedures, if needed, as soon as possible.
• Microbiological surveillance, as appropriate, to ensure the prevention of overgrowth or contamination in the formula.
• Written policies on hand washing, aseptic technique, formula preparation, housekeeping, and cleaning of infant formula preparation room and areas where infants are fed; storage and expiration date and time for all infant formula products; sanitation of all equipment and containers used for infant formula preparation and storage (including refrigerators in patient care areas); and quality control checks for all heating, cooling, and cleaning equipment.
Reference
1. American Dietetic Association. Preparation of Formula for Infants: Guidelines for Healthcare Facilities. Washington, DC; 1991.
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