E Sakazakii is a cause of invasive infection with high death rates in neonates. This report summarizes the investigation of infections associated with the presence of the organism in commercial powdered formula fed to the infant. The organism was detected in either prepared formula, the environment in wich it was prepared, or unopened products. Clinicians should be aware of the potential risk for infection from use of nonsterile formula in the neonatal health-care setting.