This is the current release of the guideline.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Infant methemoglobinemia

Prevention
Treatment

Emergency Medicine
Family Practice
Pediatrics
Preventive Medicine

Health Care Providers
Physicians

• To provide guidance to the clinician in recognizing the role of dietary nitrate in the pathophysiology of infant methemoglobinemia
• To reinforce the need for testing of well water for nitrate content for the prevention of infant methemoglobinemia

Infants

Treatment

1. Consultation with local poison control center or toxicologist
2. Identifying and eliminating source of exposure (asymptomatic infant with cyanosis who has a methemoglobin level <20%)

Prevention

1. Assessment of potential nitrate exposure
2. Recommendations for testing well water for nitrate contamination during prenatal and newborn care for patients with private wells
3. Use of alternative sources of water including deeper well water, public water supplies, or bottled water free of nitrate when well water is determined to have high levels of nitrates
4. Effective in-home systems for nitrate removal:
   • Ion-exchange resins
   • Reverse osmosis
5. Avoidance of home-prepared infant foods from vegetables until infants are 3 months or older

Not stated

Searches of Electronic Databases

Not stated

Not stated

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Treatment and Prevention

Health care professionals who suspect that an infant has methemoglobinemia are advised to consult with the local poison control center or a toxicologist to help guide management. An asymptomatic infant with cyanosis who has a methemoglobin concentration of <20% usually requires no treatment other than identifying and eliminating the source of exposure (assuming a normal hematocrit). Anemic children will display toxicity at lower methemoglobin concentrations. More detailed information on diagnosis and treatment has been reviewed elsewhere.

Clinical diagnosis and treatment for methemoglobinemia is not sufficient. Preventive strategies are needed to identify and eliminate the sources of exposure. Assessment of potential nitrate exposure includes questions about the family residence, parental occupations, drinking water, foods ingested, topical medications, and folk remedies. Prenatal and newborn care for patients with private wells should include recommendation for testing well water for nitrate contamination. Water with high nitrate concentrations should not be ingested by the infant or used for preparation of infant formulas or infant foods. Use of alternative sources of water should be advised, including deeper wells, public water supplies, or bottled water free of nitrate. Boiling water with nitrate nitrogen concentrations of <10 ppm for 1 minute generally is sufficient to kill microorganisms without over concentrating nitrate.

Effective in-home systems for nitrate removal include ion-exchange resins and reverse osmosis; however, these systems can be expensive. Ordinary water softeners used in the home do not remove nitrates. Water testing for nitrate can be obtained from any reference or public health laboratory using laboratory methods approved by the US Environmental Protection Agency. Most state health departments have listings of these certified laboratories.

There is limited information on the nitrate content of commercial infant foods, although the highest concentrations (>100 ppm of nitrate nitrogen) are found in beets, carrots, spinach, squash, and green beans. Preventive strategy would be not to introduce home preparations of these vegetables to infants before 3 months of age, although there is no nutritional indication to add complementary foods to the diet of the healthy term infant before 4 to 6 months of age. Infants fed commercially prepared infant foods after 3 months of age generally are not at risk of nitrate poisoning, although the containers should be refrigerated after first use and discarded within 24 hours of opening.

Summary

1. The greatest risk of nitrate poisoning (methemoglobinemia) occurs in infants fed well water contaminated with nitrates. All prenatal and well-infant visits should include questions about the home water supply. If the source is a private well, the water should be tested for nitrate. The nitrate nitrogen concentration of the water should be <10 ppm.
2. Infants fed commercially prepared infant foods generally are not at risk of nitrate poisoning. However, home-prepared infant foods from vegetables (e.g., spinach, beets, green beans, squash, carrots) should be avoided until infants are 3 months or older, although there is no nutritional indication to add complementary foods to the diet of the healthy term infant before 4 to 6 months of age.
3. Breastfed infants are not at risk of nitrate poisoning from mothers who ingest water with high nitrate content (up to 100 ppm nitrate nitrogen), because nitrate concentration does not increase significantly in the milk.

None provided

The type of evidence supporting the recommendations is not specifically stated.

Effective prevention and appropriate treatment of infant methemoglobinemia

Not stated

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2005 Sep

American Academy of Pediatrics - Medical Specialty Society

American Academy of Pediatrics

Committee on Nutrition
Committee on Environmental Health

Committee on Nutrition, 2003-2004: Nancy F. Krebs, MD, MS, Chairperson; Robert D. Baker, Jr, MD, PhD; Jatinder J. S. Bhatia, MD; *Frank R. Greer, MD; Melvin B. Heyman, MD; Fima Lifshitz, MD

Liaisons: Donna Blum-Kemelor, MS, RD, US Department of Agriculture; Margaret P. Boland, MD, Canadian Paediatric Society; William Dietz, MD, PhD, Centers for Disease Control and Prevention; Capt Van Saxton Hubbard, MD, PhD, National Institutes of Health; Benson M Silverman, MD, US Food and Drug Administration

Staff: Pamela T. Kanda, MPH

Committee on Environmental Health, 2003-2004: *Michael W. Shannon, MD, MPH, Chairperson; Dana Best, MD, MPH; Helen J. Binns, MD, MPH; Christine L. Johnson, MD; Janice J. Kim, MD, PhD, MPH; Lynnette J. Mazur, MD, MPH; James R. Roberts, MD, MPH; William B. Weil, Jr, MD

Liaisons: Elizabeth Blackburn, RN, US Environmental Protection Agency; Robert H. Johnson, MD, Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry; Martha Linet, MD, National Cancer Institute; Walter Rogan, MD, National Institute of Environmental Health Sciences

Staff: Paul Spire

*Lead Authors

Not stated

This is the current release of the guideline.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

None available

None available

This NGC summary was completed by ECRI on September 20, 2005. The information was verified by the guideline developer on October 24, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.