UNUSUAL CASE OF BLUE BABY SYNDROME (METHEMOGLOBINEMIA ) IN A NEONATE DUE TO WATER CONTAMINATION

UNUSUAL CASE OF BLUE BABY SYNDROME (METHEMOGLOBINEMIA ) IN A NEONATE  DUE TO WATER CONTAMINATION

UNUSUAL CASE OF BLUE BABY SYNDROME (METHEMOGLOBINEMIA ) IN A NEONATE

DUE TO WATER CONTAMINATION

A 23 days old baby was referred to Department of Neonatology , Sir Ganga Ram Hospital on 20 th May 2013 who suddenly turned blue and was referred to SGRH with a possible diagnosis of Cyanotic Heart Disease (hole in the heart ).  Till one day prior to admission the baby was well and healthy . On arrival doctors found that the whole body of the baby was blue in colour including lips , hands , feet etc .   A blood sample of the baby was then treated with oxygen . The idea was that if the cause was heart related then the blood will change its colour from brown to red . It did not happen . His  ECHO test was also normal  . The other cause would have been if the breast feeding mother was on some medicine like  anti leprosy medication . But that was also not the case .

The baby’s Methemoglobin level when checked was found to be 67 % against a normal of less than 1 % . If the levels of Methemoglobin is more than 80 % then the chances of survival is very slim.

Haemoglobin in human body has ferrous form which is changed to ferric form by chemicals and also by  pollutants , which makes methemoglobin and changes the colour of the blood from red to blue . This leads to poor oxygen supply to the tissues .

Doctors  used  Methyline blue which  has the property to reverse  ferric form of the blood to ferrous form . This was given orally to the child . The results were quick and satisfactory  , as with in 12 hours , the colour of the baby changed from blue to normal .

Now the question was what pollutant could have caused this problem .

When enquired , it was found that since birth of baby , the mother was not able to breast feed  the baby  . Therefore she started giving her packaged formula milk mixing it with the underground boring water( as village does not use  normal clean drinking water supply ). Doctors suspected that the water may have been contaminated with nitrate content . A sample of the water was brought and sent to FICCI LABORATORY ( Federation of Indian Chambers of Commerce and Industry ) , Sector 8 , Dwarka ,  for testing .

The report received yesterday (13th June , 2013) , confirmed the worst fears of the doctors . The boring water used by the villagers was found to have 27 p.p.m of Nitrate levels against a normal levels of less than 10 p.p.m

Infants for whom formula may be prepared with boring or  well water remain a high-risk group for nitrate poisoning due to mixing of sewage or fertilizers in the water  . This clinical report reinforces the need for testing of ground water for nitrate content.

Methemoglobinemia generally manifests with few clinical signs other than cyanosis. Methemoglobin represents only 1% of the total hemoglobin of the healthy adult, although it can be slightly higher in preterm and term newborn infants. Obvious cyanosis can occur with methemoglobin concentrations as low as 3% in infants with low hemoglobin concentrations. Symptoms are usually minimal until methemoglobin concentrations exceed 20%. The mucous membranes of infants with methemoglobinemia tend to have brown (rather than blue) discoloration. This discoloration increases with the concentration of methemoglobin, as do the manifestations of irritability, tachypnea, and altered mental status. In the absence of respiratory symptoms, history of cardiovascular disease, abnormal pulse, or abnormal pulse oximetry, a diagnosis of methemoglobinemia should be considered in a child who becomes acutely cyanotic and fails to respond to oxygen administration. When significant concentrations of methemoglobin (>30%) are present, a pulse oximeter is very misleading and will detect only mild to moderate oxygen desaturations in the 82% to 86% range.

Recommendations :

1.       The greatest risk of nitrate poisoning (methemoglobinemia) occurs in infants who are fed well / boring water contaminated with nitrates. All prenatal and well-infant visits to doctors 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 (eg, 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 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.

4.       All areas which are near site of usage of pesticides or industrial waste , the underground water should be compulsorily tested for nitrate and other contamination

 

Source: Sir Ganga Ram Hospital

Dr Sastish Saluja , Vice-Chairperson

Deaprtment of Neonatology , Sir Ganga Ram Hospital

Dr Pankaj Garg , Sr. Consulatant

Department of Neonatology , Sir Ganga Ram Hospital

Author: sarkarimirror