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"Blue Baby" Syndrome Methemoglobinemia

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University of Nebraska - Lincoln DigitalCommons@University of Nebraska - Lincoln Historical Materials from University of Nebraska-Lincoln Extension Extension 1991 NF91-49 Well Water, Nitrates and the "Blue Baby" Syndrome Methemoglobinemia Ann Ziebarth University of Nebraska - Lincoln Follow this and additional works at: https://digitalcommons.unl.edu/extensionhist Part of the Curriculum and Instruction Commons Ziebarth, Ann, "NF91-49 Well Water, Nitrates and the "Blue Baby" Syndrome Methemoglobinemia" (1991). Historical Materials from University of Nebraska-Lincoln Extension. 2058. https://digitalcommons.unl.edu/extensionhist/2058 This Article is brought to you for free and open access by the Extension at DigitalCommons@University of Nebraska - Lincoln. It has been accepted for inclusion in Historical Materials from University of Nebraska-Lincoln Extension by an authorized administrator of DigitalCommons@University of Nebraska - Lincoln. NF 91-49 WelI Water, I\itrates and the "Blue Baby" Syndrome Methemoglobinemia by Ann Ziebarth, Extension Housing Specialist The Environmental Protection Agency (EPA) has set a that human or bovine milk is a source of infant methemo- maximum contaminant level (MCL) of 1 0 parts-per-million globinemia. One study showed that cows drinking from @pm) for nioate-nirogen in public water supplies. This water with 177 ppm nirate produced milk with less than 0.5 level provides a margin of safety regarding a significant risk ppm nitrate concentration. for human healttr. EPA believes that water containing ni' Most adults have the ability to rapidly convert methe- trate-nirogen atorbelow this level is acceptable for drinking moglobin back to oxyhemoglobin so that even with rela- every day over the course of one's lifetime and does not pose tively high levels of nitrate/nitrite intake the red blood cells any health concerns. can still carry enough oxygen to the body's cells. However Nirate is relatively non-toxic substance that occurs adults with an hereditary predisposition, those being reated naturally as part of the nitrogen cycle. However, nitrate can for peptic ulcers, and persons with chronic gastritis, or be converted readily by bacteria into nitrite. This occurs in dialysis patients are at a higher risk of methemoglobinemia. the environment, in foods, and in the human mouth and Older persons may be at a higher risk for methemo- gastrointestinal tract. Once nitrogen is converted into nifate globinemia as their gastrointestinal systems again produces it can have harmful health effects. For example, high nitrates a pH level which allows for increased bacterial growth in the in drinking water can cause methemoglobinemia resulting gasrointestinal ract. While the research is less certain from the reaction of nitrites with hemoglobin in red blood regarding the possible increased risk to older persons ofhigh cells affecting the ability of the blood to ciury sufficient nitrate levels in drinking water older Nebraskans should use oxygen to individual cells of the body. water which meets the health standards. Methemoglobinemia Health Risks Signs and Symptoms Until infants reach about six months of age their diges- Infants suffering from methemoglobinemia may seem tive system has a diminished capability to secrete gasric healthy but show intermittent signs of blueness around the acid, thus the pH level can rise to 5-7. At this pH level mouth, hands and feet. They may have episodes of breathing bacteria proliferates increasing the transformation of nitrate trouble, and some diarrhea and vomiting. In some cases an to nitrates. Thus, exposure to nitrate at levels in excess of 10 infant with methemoglobinemia has a peculiar lavender ppm canresult in higherrisk of methemoglobinemia- Methe- color but shows little disress. If blood samples are taken they moglobinemia, also known as blue baby syndrome, is char- will be chocolate brown and won't turn pink when exposed acterized by a reduced ability of the blood to qury oxygen. to air. If the methemoglobin level is over 60 percent there is The higher risks associated with nitrate contamination for a marked lethargy, excessive salivaiion, and loss of con- infants is related to the pH levels in the gastrointestinal mcL sciousness. Convulsions are also common at extreme levels. grcater total fluid intake per unit of body weight, the larger amounts of nitrate relative !o the total hemoglobin for a given Case Histories nifate concentration in water. Health professionals often advise pregnant women and A number of cases of infant methemoglobinemia have those who are breast feeding to not use water with nitrate- been reported in the U.S. A Nebraska survey of physicians nitrogen levels above therecommended maximum contami- reported in the Nebraska Medical Joumal in 1981 indicated nant levels. This is a precautionary measure. It is unlikely that at least eight cases of infant methemoglobinemia were A-1 treated in Nebraska between 1973 and 1978 (Grant, 1981). Acknowledgements Morerecently, two South Dakota infana with the bluebaby syndrome were identified by the State Departrnent of Health. The critical review and suggestions of ttre following In onecase the farm's well waterwas found to have 150 ppm people is greatly appreciated: nirate-nitrogen concentration while the level was 54 ppm in Adi Pour, Toxicologist, Nebraska State Department of the other. Although these levels of nirate-nirogen are ex- Health tremely high, a case of methemoglobinemia in Colorado Delynn Hay, Extension \Yater Resources Specialist, involved an infant ingesting municipal system water con- [,NL taining 13.3 ppm nitrate-nirogen (Fan, et al. 1984. No cases Leon Rottmann, E:rtension Human Development Spe- havebeenidentified with watertestingbelow the MCL of 10 cialist, UNL ppm for nirate-nitrogen. References Treatment and Prevention Davis, Richard B. (1990) Nitrates, Nirites and Methe- If the condition is identified early and is not life- moglobinemiain Perspectives on Nitrates. Nebraska Coop- threatening, no treatment is needed other than a change to erative Extension EC 9A-25U, pp. 10- 13. drinking water with less than 10 ppm nirate-nitrogen. The Fan, Anna M.; Willhite, Calvin C.; and Book, Steven A. methemoglobin will be reduced spontaneously to hemoglo- (1987) Evaluation of the Nirate Drinking Water Standard bin within two !o three days. For severely affected infans with Reference !o Infant Methemoglobinemia and Potential treatment with an intravenously administered solution of Reproductive Toxicity. Regulatory Toxicology and Plar- methylene blue usually brings prompt recovery. rnacology. Vol7. pp. 135-148. Testing the drinking water for nitrate-nitrogen levels is Grant, Robert S. (1981) Well Water Nitrate Poisoning a good precautionary step when providing an infant with Review: A Survey in Nebraska 1973-1978. The Nebraska mixed formula. Infants under six months of age are at the Medical lournal.Yol.66, No. 8, p. 197. highestrisk Providing waterfrom a uncontaminated source, Johnson, Cal J. (1988) Medremoglobinemia Is it Coming using bottled water, or treating the water with a distiller, ion Back to Haunt Us? Health and Environment Digest. Vol. l, exchange unit or reverse osmosis system are alternatives to No. 12, pp.34. consider if the water test indicates the nitrate-nirogen levels Kies, Constance and Bender, Carolyn. (1990) Nitrates, are above 10 ppm. Nitrites, N-Nitroso Compounds and Nuridon in Perspec- tives on Nitrates. Nebraska Cooperative Extension EC 90- 2502,pp.14-ZI. File Under: WATER RESOT RCE MANAGEMENT A-l,IVater Quality Issued November 1991 Issoed in furrherancc of C-ooperative Extctsion wort, Acts of May E and June 30, 1914, in cooperrtion with thc U.S. Department of Agricultura Kenneth R. Bolen, Director of Coopcrrtive Extansion, Univcrsity of Ncbnska. Instiurtc of Agriculturc rnd Naurral Resources. C.oopcretivc E:rorim povidcs infoortio rnd cduotimd prognur to dl pccplc rithorr rcgud to ncq, olc. mtiod *i8", rcr cr budiop..
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