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## Complete Summary

#### GUIDELINE TITLE

Infant methemoglobinemia: the role of dietary nitrate in food and water.

#### BIBLIOGRAPHIC SOURCE(S)

Greer FR, Shannon M. Infant methemoglobinemia: the role of dietary
nitrate in food and water. Pediatrics 2005 Sep;116(3):784-6. \[23
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16140723)

#### GUIDELINE STATUS

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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Infant methemoglobinemia

#### GUIDELINE CATEGORY

Prevention\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   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

#### TARGET POPULATION

Infants

#### INTERVENTIONS AND PRACTICES CONSIDERED

**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

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Treatment and Prevention]{.underline}**

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.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Effective prevention and appropriate treatment of infant
methemoglobinemia

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Greer FR, Shannon M. Infant methemoglobinemia: the role of dietary
nitrate in food and water. Pediatrics 2005 Sep;116(3):784-6. \[23
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16140723)

#### ADAPTATION

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

#### DATE RELEASED

2005 Sep

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Nutrition\
Committee on Environmental Health

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

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.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://pediatrics.aappublications.org/cgi/content/full/116/3/784).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

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

#### COPYRIGHT STATEMENT

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.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008