Thiamine-deficient infant formula: what happened and what have we learned?

In 2003, a thiamine-deficient soy infant formula was produced in Germany and marketed exclusively in Israel. Between October and November 2003, infants with encephalopathy were admitted to several intensive care units in Israel and were later diagnosed as suffering from thiamine deficiency. The soy formula consumed by these children was found to be the cause of these admissions.

A Medline search using the terms 'thiamine deficiency' and 'formula' or 'feeding' without year limit identified relevant published data on that event. Newspapers from Israel were screened from November 2003 until April 2011.

On November 2003, 2-6% of infants in Israel consumed this formula. The consumption of this thiamine-deficient formula was associated with the death of 3 infants and with more than 20 infants manifesting neurologic damage. In this report, we summarize the chain of events, the neurologic outcome, and discuss the lessons needed to be learned from this sad event.

Based on difficulties in diagnosis of subtle deficiencies, we suggest that apparent history of safe use is not a reliable source for establishing adequate intake. Infant formulae can be produced or imported only under stringent criteria with the manufacturer/importer having total responsibility for the product.