The issue of chemicals leaching into bottled breast milk or infant formula or being introduced into powered infant formula is the subject of this issue's column; the specific chemical is melamine. In 2008, we first heard about the adulteration of milk in China, with reports that 50,000 children in China were affected by the practice of putting melamine in infant powered milk products. Are the families in your practice at risk for having purchased powdered milk or formula contaminated with melamine? As globalization increases, more of our patients could be purchasing formula from far flung geographical areas, and therefore the issue of what they are feeding their infants becomes ever more relevant.

What is Melamine and Why Would It Be Used?

Melamine is "a synthetic chemical used in a variety of inedible commercial products including cleaning supplies, dry erase boards, and other plastics" (Bhalla, Grimm, Chertow, & Pao, 2009, p. 3). It has a very high "non-protein nitrogen content" (p. 3) and is used primarily to alter the measured protein content of a product. In China, melamine has been used to dilute infant formula while allowing it to still meet tests of quality control (Ingelfinger, 2008). The case publicized in China resulted in the FDA withdrawing several products from the US market including baby cookies and powdered milk. Such withdrawals reinforce the ubiquitous nature of the use of melamine, which has also been found in eggs and wheat gluten, due in part to the use of melamine in animal feed.

What is the Result of Putting Melamine in Infant Formula?

There are two major outcomes for infants exposed to melamine in formula: (1) infants are exposed to a toxic chemical and (2) the infants ingest a milk product that has been diluted and thus does not provide adequate nutrition. The major physiologic consequence of ingesting melamine is nephrotoxicity. Although the exact mechanism is unknown, acute kidney injury occurs when the chemical forms stones in the distal portion of the renal tubules; these stones are not consistently radio-opaque, but are easily visualized using ultrasound (Langman et al., 2009).

How Can Nurses Help Families Affected By This?

According to Langman et al. (2009), there are specific symptoms in formula-fed infants that could be warning signs of melamine ingestion, including vomiting, unexplained crying associated with urinating, high blood pressure, edema, elicitable flank pain, and unexplained fever that is "secondary to urinary tract infection, or bacteremia secondary to urinary stasis resulting from obstruction" (n.p.). When a clinician sees these symptoms, it is important to assess what products the infant has been fed and to consider the possibility of melamine toxicity. An initial first step is to perform a complete physical examination, with special attention directed toward blood pressure and general hydration and nutrition status. Additional assessments should include a complete urinalysis, a renal function panel, and evaluation of glomerular filtration rate. An abdominal ultrasound of the urinary bladder and kidneys may also be appropriate; referral to pediatric nephrologist may be required. According to Bhalla, Grimm, Chertow, and Pao (2009), treatment for melamine ingestion is "hydration, urinary alkanization, conservative pain management, renal replacement therapy, and surgical treatment if necessary" (p. 4). Prevention, however, remains a key approach to avoiding the nephrotoxic outcome associated with melamine, so nurses should be proactive in educating parents about the safety of infant milk or formula. Parents should be encouraged to ask questions about the origin of formula, to purchase formula from well-known and regulated sources, and to understand the symptoms of melamine ingestion.

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