Milk Poisoning From Tetrapaks

What do you mean by tetrapak-like. Does this mean it is not tetrapak, and could have contaminants in the metal layer. Have you looked at the possibility that it isn't the milk but another cause that was concurrent with the period of milk ingestion. Water in the third world is a common general source of many ailments. What were the children poisoned by, metals, e coli, organophosphates, etc.? I would assume someone tested the childrens blood and determined the cause of the poisoning. Keep in mind that because some of the sealed milk cartons tested were negative for pathogens, this does not mean that all were, or that they were used properly to maintain the clean pathogen-free condition.

There could be several causes. One is that only certain packages were spoiled and none of the tested packs were spoiled.

You said "I have been told...". Does that mean that you haven't confirmed it? A proper investigation needs to be done and second-hand information isn't going to cut it.

I work in a food-manufacturing factory and we do exhaustive investigations on any complaints. Sometimes, we trace things back to the factory but mostly it's during transit from the factory to the store where things go wrong.

Be aware also that counterfeit products are easily produced and it's not easy for the consumer to tell if a product is fake or not.

some contaminant, like ethylene glycol, in the milk?

milk in tetrapaks should be chilled after pasterrizing for best flavor.

the ultra high temperature sterilized milk lasts long in a sealed tetrapak, but it is prey to anaerobic contamination hidden in the pak from before that the short UHT does not kill. = botulism potential.

ultra filtered milk also works, sterile by fine filtration.

in all cases for long term storage, sterile handling is mandatory.

dittos to guest and dittos to vulcan, especially his closing quote/tag line.

Pathogens is only one possibility; Contaminants are another.

And they need not be on the INSIDE ofthe package, but could be surface contact borne.

Did not say the nature of the illness caused.

I would suggest that a good starting point would be to create an is / isnot matrix and describe all the facts/factors known by hardside and softside of the process.

Materials & machinery would be hardside; man and methods would be softside;

After first creating a concise and fully descriptive statement of the problem that includes batch numbers, times ran, on which lines, from which dairies came feedstock etc. for both affected, and not affected product. This will give boundary and scope to your problem space.

Then contrasting 'IS' column parameters to "IS NOT' column parameters gives the investigator logical place to further investigate.

There are, of course, many other methods of problem solving, but based on the sparse description provided, this looks like a good fit.

I'll be happy to assist if you like. contact me directly by emailing through CR4 by clicking on my name/link at top of this message.

milo

Milk should better be consumed with minimum possible time gap between milking and its consumption. Quest for prolonging the shelf life of natural products is always fraught with dangers and is suspect from probiotic nutrition considerations also.

Very confusing question! Children? Your friend's children? Large numbers fo children across India? How is it determined to be "milk poisoning" when clinical tests thus far have not determined cause? Or even poisoning?

How do you suppose it will be possible for you to do epidemiological testing to help your friend? Or for your friend...to help himself?

Assuming India law requires reporting of suspected poisoning--and someone has done so because investigation apparently is in progress--do you expect that your friend will be able to guide or assist with a diagnosis based on what his friend told him after asking some strangers? Seems doubtful.

Additionally, did the child succumb? Or recover? Either way, what help will guess-work from us about what might be possible due to packaging provide for the child or for you and your friend.

Doc Wundring.

Also, you didn't mention any symptoms. Symptoms are usually step one in differential diagnosis of metal, or any other poisoning. From what you describe, your friend's children's clinicians don't seem to be differentiating in that direction. If it is metal poisoning, be careful...you could be helping your friend get himself under unwanted official scrutiny. And you didn't say if your friend really want such help...discovering an illness that might not be affecting the children.

Expiry dates are sell-by dates, not consume by. Some children are allergic to milk and reactions can be severe. This seems a likely case so far. Or a sensitivity to preservative or flavoring/coloring in the milk. Metal poisoning is so improbable as to be not worth consideration; unless the child has consumed hundreds, even thousands, of tetrapaks in a very short time span.

If you want to help friend, talk about milk/lactose sensitivity...maybe that will at least ease his mind...and yours as well.

For kind information of all who have participated in discussions. In Mumbai India there was incident in public school during last month, when around 24 children who were given free milk packed in tetrapack became sick and hospitalised. The contractor was punished. Contmenation could be due to various reasons such as improper storage, packing etc.

Guest, Vulcan, Aurizon, Milo, Surmil, Clear Blue, Randall, Suresh:

Thanks a ton for your replies. Let me clarify the situation a bit. My friend is working in a hospital as a dietetics intern. They had this group of children admitted who fell sick after consuming milk given to them in public school(s). Most of them were did not show symptoms more severe than throwing up. Maybe Suresh is referring to the same incident.

Microbial reports - negative
All packs were within use by date

We were discussing this trying to figure out what could have happened - purely for understanding's sake - neither of us are in any danger of being blame for the poisoning.

I was initially thought that this might have caused due to some interaction with the packing materials (if the vendor had used some cheap tetrapak imitation) or by some contamination or adulteration. I couldn't find much on the net that could give me any directions. So I thought I could see what the experts in this forum have to say on this. Thanks again.

Platinum,

Thank you for the needed clarification; everything is more in focus now. Reviewing the facts--outbreak was localized--symptoms limited to milk consumers, all children--no evidence of tampering or anything else improper--no reported reactions to other offered foods--no pathogens found--rapid recovery following some instances of emesis--may I suggest a very likely explanation.

Tetrapak contents are most often ingested using tiny straws attached to the pak which is then pierced through the "foil" covering a hole in the top of the package. Many, if not most, persons will simply stab the carton once and begin sucking out the liquid--I, for one, pierce the pak more than once to provide additional opening around the straw through which air can enter to relieve "vacuum" as the pak contents are drawn out and swallowed. Most using the single-stab method quickly learn to be satisfied to swallow only what the pak will allow before removing straw from mouth to let the pak's internal pressure neutralize. However, in this case, it is likely that some, if not all, of the children attempted to continue sucking out the contents--drawing ever harder as the vacuum inside the paks made it harder and harder to "get at the rest." It is to be reasonably expected that during these attempts to draw out more liquid against "package resistance," children drew air into their stomachs as they sucked or as they inhaled between suck attempts. As a result of this air inspiration, children reflexively began to burp, or worse, to "upchuck" the liquids just swallowed--much as infants will burp and/or puke after bottle feeding if not "burped" by Mother. The temperature of the milk, if cold, could have had an additional irritating effect. An additional component of the "outbreak" could have come by suggestion, as one or more children who cried or otherwise expressed discomfort after swallowing/vomiting might have frightened other children and induced them to breath more heavily and/or otherwise bring about the impulse to also vomit.

In the future (for your dietetics friend), the school masters should be advised to instruct children in the safe way to consume from tetrapaks: by additional piercing to provide pak ventilation; by not sucking with force or consuming too rapidly; or by emptying contents into a "normal" drinking vessel.

Hope this proves useful to you and to other children.

Here's more:

It might be good if your friends "employer" notified other health clinics and school authorities in the various local and state principalities around India about this problem; how to prevent it from happening; and what to do when it happens.

It would also be useful for teachers to be advised to watch for signs of air ingestion in pupils using tetrapaks, and be prepared to deliver first aid. Signs would include facial expressions of discomfort/distress accompanied with sudden cessation of talking, and "guarding" of the abdominal area by posture or with hands. Facial expression would not be too unlike that of infants in need of being burped.

First aid in the form of gentle "burping" (back patting)--as with an infant--and instructing/reassuring the child to relax will go a long way towards minimizing "outbreaks" of the magnitude your intern friend experienced. Children who vomit will need to be reassured, that vomiting is a natural body function and need not cause undue alarm--if it leads to feeling better/relieved. Above all--and this is where advance training of teachers comes in--the teacher should demonstrate she/he knows what's happening and how to deal with it. It is possible, in the incident your friend described to you, that the teachers became part of the problem by not remaining calm themselves--anxiety in adults is sensed by children and can lead them to have panic reactions that will make such a situation even worse than it needs to be.

Here we have a case where it seems being on-topic is off topic; and being off-topic is on topic. Just one of my specialties.

Swallowing air.

Good point. I have a tendency to do that since I drink in gulps rather than trickling it down. And, yes, it does produce discomfort if done in excess.

I've also read about that suggestion thing. A bunch of school kids suddenly collapsed in hysterics in Thailand I think it was. The investigators think that one kid started it and "infected" the other kids. There was a technical term used for it but I can't recall what it was.

You should register, Guest. You seem to have a knack for offering good answers.

I had also read that NEWS regarding TETRAPACK MILK following might be the REASONS

1.The REPORT is TESTED samples were –ve for PATHGEN that means that might be like this that if the INFECTION is in starting stage DUE to " BAD STORAGE CONTIONS (NOT MAINTAINING THE PRESCRIBED TEMPERATURE CONDITIONS) the No. of PATOGENS might not be STATISTICALLY SIGNIFICANT ENOUGH in No.s to give test +ve & also DURING TRANSPORTATION also if PROPER TEMP. is not maintained the MILK MIGHT START BREWING BACTERIA This can BE AVOIDE using I have FORMULATED and DEVELOPED a " SMART TAG" WHICH CHAGES the COLOR if the PACKING is not kept in the REQUIRED TEMPERATURE for the certain time (TIME VARIABLE) & also the UHT (ULTRA HIGH TEMPERATURE MILK ) also remains in good condtion

My mail:anantranade@aol.in

REGARDS

RANADE

Now that's something I had never heard of. (I dont mean I dont buy it ... sounds plausible enough.) Thanks for this different perspective on what might have happened.

Thanks back, Platinum.

On further consideration...please allow me to elaborate further...on the physiological mechanics that could have been "in play" leading to the clinic visit. Remember that these, are with respect to a child's (in this case I deduce these were probably very young pupils--kindergarten up to first one or two grades) stage of development. (For age-related example, after a certain age a straw user always uses the tongue while sucking to block against inspiration of liquid into lungs; a younger person would be more inclined when sucking hard/vigorously to suck directly. or at least partially, from the lungs.)

If you think about a small child sucking through a tiny, "tetrapak-orifice-sealed" straw, you can perceive a kind of contest between child and container. As the child draws ever harder to pull liquid out and into stomach, the pak "tries" equally hard to pull the liquid back (in,) out of the child's tract (mount, esophagus...), including stomach. Along with any liquid thus pulled back by the pak could be stomach content other than milk, including acid. Such a forcefully induced reflux into child's esophagus would be a cause of immediate, and sharp pain. If reflux reached as far as the trachea where it could be drawn towards the lungs...even more-excruciating pain. These actions are likely to be accompanied as well be gag reflexes--from misdirected liquids at epiglottis. (And even where there is no reflux, a gag reflex can still induce vomiting!) So, you have an immediate situation where intense, unrelieved transitory pain, and gagging/coughing reflexes in some children are being observed by other children...it takes little more to imagine sympathetic fear reactions--and, with it, hyperventilation--among children not as yet affected. Very quickly, as a result of all these and previously mentioned possible mechanisms by which a tetrapak could defeat a small child's sucking efforts, you have the makings of a growing outbreak of "sucking poisoning." But that's not all...

In order for an extendable tetrapak straw to work, it is must be extended firmly to its full length, at which point the junction between concentric straw segments is sealed. Moreover, this sealing of the straw segments must be firm enough to permit stabbing of the tertrapak carton without the straw collapsing--this even if one (a child one) stabs with the un-pointed end of the straw. Now, if the straw is not fully erected, the result of sucking with the straw end in the milk will be that both milk, and air entering between the straw segments, will be drawn into the mouth and swallowed. Moreover, when the straw itself is not adequately extended/sealed, the natural first reaction (to inadequate liquid delivery through the "impaired" straw) is to suck even harder--this even in adults (if this subject is any indicator). So here you have a case where plastic (the plastic straw) could have contributed to the Indian children's unfortunate experience (by drinking air). A teacher's responsibility in this wise might have been to assist/verify that all straws were properly extended and inserted in the paks.

I now believe the pak manufacturer has some responsibility to alert... as to the hazards attending use of the dispensers by young/small children...at least when it is known that schools/teachers will be distributing the paks. A notice on tetrapak shipping cases would be a ready, inexpensive, and convenient means to advise all teachers and caretakers of children of the hazards.

It is too bad that the Indian schoolteacher(s), a person at that clinic, &or your friend could not have also participated, say by proxy or sponsorship, in this discussion. That could have been a true forum of all concerned adult parties.

Just as an afterthought: when you open a can of fizzy drink you leave a "torn edge" of aluminium, which you then drink/pour a mildly corrosive (compared to milk) liquid through, and, I'd guess that many people average more than one a day; people often cook in aluminium foil, and, before cling-film many used to wrap their sandwiches in it. On the whole I don't think aluminium is likely to be the culprit.

In the first incident 34 (out of 104) older secondary school children became sick about 30 minutes after drinking the milk. In the second incident it was 14 children around the age of 11 or 12. Both schools had been on the scheme for over a month before the incidents. But the first school had just changed from cardamom to strawberry flavoured milk: I wonder if this was also the case with the second school.

(A lakh is 100,000 and a crore is 10,000,000)

http://timesofindia.indiatimes.com/Cities/14_Mumbai_kids_hit_by_milk_poisoning/rssarticleshow/2635935.cms

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http://www.dnaindia.com/report.asp?newsid=1140493

"I was fine in the morning. The ache started in the afternoon after we drank the milk," said Sanjay Kawale, 11.

"Of the nine samples of the milk from the earlier batch sent for testing, five tested negative for bacterial contamination," said additional municipal commissioner Mahadeo Sangle. "Tests will be conducted on samples from this batch as well," he added.

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http://www.expressindia.com/latest-news/34-civic-school-students-taken-ill-after-drinking-flavoured-milk/250431/

"Around 8.30 am on Friday, 104 students of standards VIII and IX were supplied tetra-packs of flavoured milk. Half-an-hour later, some of them started complaining of headache and stomach ache. Their eyes started watering and they even felt like vomiting.Additional Municipal Commissioner Mahadeo Sangle said, "Earlier, the school was supplied elaichi flavour but today it was provided the strawberry flavour.

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