This NebGuide discusses the blood disorder methemoglobinemia, its effect on infants and prevention methods. Methemoglobinemia is a blood disorder caused when nitrite interacts with the hemoglobin in red blood cells. Unlike hemoglobin, the methemoglobin formed in this interaction cannot carry sufficient oxygen to the body\u27s cells and tissues. Although methemoglobinemia is rare among adults, cases have been reported among infants, where nitrate-contaminated well water was used to prepare formula and other baby foods. Nitrate in well water may result from point sources such as sewage disposal systems and livestock facilities, from nonpoint sources such as fertilized cropland, parks, golf courses, lawns and gardens or from naturally occurring sources of nitrogen

Hay, DeLynn

Skipton, Sharon

English

UNL | Libraries

University of Nebraska - Lincoln 
DigitalCommons@University of Nebraska - Lincoln 
Historical Materials from University of 
Nebraska-Lincoln Extension Extension 
1998 
G98-1369 Drinking Water: Nitrate and Methemoglobinemia ("Blue 
Baby" Syndrome) 
Sharon Skipton 
University of Nebraska–Lincoln, sskipton1@unl.edu 
DeLynn Hay 
University of Nebraska-Lincoln, dhay1@unl.edu 
Follow this and additional works at: https://digitalcommons.unl.edu/extensionhist 
 Part of the Agriculture Commons, and the Curriculum and Instruction Commons 
Skipton, Sharon and Hay, DeLynn, "G98-1369 Drinking Water: Nitrate and Methemoglobinemia ("Blue Baby" 
Syndrome)" (1998). Historical Materials from University of Nebraska-Lincoln Extension. 1435. 
https://digitalcommons.unl.edu/extensionhist/1435 
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. 
Nebraska Cooperative Extension G98-1369
 
Drinking Water: Nitrate and 
Methemoglobinemia 
("Blue Baby" Syndrome) 
This NebGuide discusses the blood disorder methemoglobinemia, its effect on infants and 
prevention methods.. 
Sharon Skipton, Extension Educator 
DeLynn Hay, Extension Water Resources Specialist  
Methemoglobinemia  
Methemoglobinemia Signs and Symptoms  
Methemoglobinemia Treatment  
Methemoglobinemia Prevention  
Methemoglobinemia Case Histories  
Additional Information  
Summary  
Other Related Publications  
 
Methemoglobinemia is a blood disorder caused when nitrite interacts with the hemoglobin in red blood 
cells. Unlike hemoglobin, the methemoglobin formed in this interaction cannot carry sufficient oxygen 
to the body's cells and tissues. Although methemoglobinemia is rare among adults, cases have been 
reported among infants, where nitrate-contaminated well water was used to prepare formula and other 
baby foods. Nitrate in well water may result from point sources such as sewage disposal systems and 
livestock facilities, from nonpoint sources such as fertilized cropland, parks, golf courses, lawns and 
gardens or from naturally occurring sources of nitrogen. For additional information on nitrate in well 
water, read NebGuide G96-1279, Drinking Water: Nitrate-Nitrogen. 
Methemoglobinemia 
Nitrate, a relatively non-toxic substance, occurs naturally as part of the nitrogen cycle. However, 
bacteria can convert nitrate to nitrite in the environment, in foods and in the human body. 
Until infants reach about six months of age, their digestive system secretes lower amounts of gastric acid 
and the pH level in their digestive system is higher than most adults. Adults with a diminished capability 
to secrete gastric acid also can experience a rise in pH in their digestive system. In both situations, 
bacteria can proliferate, increasing the transformation of nitrate to nitrite. 
Once in the blood, nitrite oxidizes iron in the hemoglobin of red blood cells to form methemoglobin, 
which lacks hemoglobin's oxygen-carrying ability. The nitrite can come from nitrate in drinking water or 
from food, some drugs or other sources. For additional information on hemoglobin oxidizing agents, 
read Extension Circular EC90-2502, Perspectives on Nitrates and consult your physician. 
Although methemoglobin is continually produced in humans, an enzyme in the human body reduces 
methemoglobin to hemoglobin. In most individuals, methemoglobin is rapidly converted back to 
hemoglobin. Typically, less than 1 percent of the total circulating hemoglobin in a healthy adult is 
present in the form of methemoglobin. Infants, however, have a low concentration (about 60 percent of 
the adult concentration) of the reducing enzyme, as do some older individuals with an enzyme 
deficiency. In these people, methemoglobin is not converted to hemoglobin as readily. 
When methemoglobin levels are elevated, the condition known as methemoglobinemia, often referred to 
as "blue baby syndrome", can result as the blood lacks the ability to carry sufficient oxygen to individual 
body cells. 
Methemoglobinemia Signs and Symptoms 
Infants suffering from methemoglobinemia may seem healthy but show intermittent signs of blueness 
around the mouth, hands and feet. They may have episodes of breathing trouble, some diarrhea and 
vomiting. In some cases, an infant with methemoglobinemia has a peculiar lavender color but shows 
little distress. Blood samples appear chocolate brown and don't turn pink when exposed to air. When the 
methemoglobin level is high, infants express a marked lethargy, excessive salivation and loss of 
consciousness. Convulsions and death can occur at extreme methemoglobin levels. 
Consult your physician for additional information on methemoglobinemia signs and symptoms or 
for diagnosis if methemoglobinemia is suspected. Do not attempt to self-diagnose this condition. 
Methemoglobinemia Treatment 
If the condition is identified early and is not life-threatening, a change of drinking water to water with 
less than 10 milligrams per liter of nitrate-nitrogen is usually the only needed treatment. This will reduce 
methemoglobin to hemoglobin in two to three days. Severely affected infants may be treated with an 
intravenously administered solution of methylene blue. 
Methemoglobinemia Prevention 
The Environmental Protection Agency (EPA) has set a public water supply maximum contaminant level 
(MCL) of 10 milligrams per liter (mg/l) which is equal to 10 parts per million (ppm) for nitrate-nitrogen. 
This level provides a margin of safety against a significant risk for human health. EPA believes water 
containing nitrate-nitrogen at or below this level is acceptable for daily drinking over a lifetime and does 
not pose a methemoglobinemia health risk for infants or adults. 
Methemoglobinemia prevention is especially important for infants under six months of age, although 
preventative measures are also encouraged for pregnant women, women who are breast feeding and 
other high-risk individuals. Use water from a source containing nitrate-nitrogen at or below 10 mg/l. If 
the drinking water source contains nitrate-nitrogen above 10 mg/l, use bottled water or treat the water 
with a distiller, ion exchange unit or reverse osmosis unit to reduce the nitrate-nitrogen level. Boiling 
water containing nitrate-nitrogen does not reduce nitrate-nitrogen levels. In fact, boiling can concentrate 
nitrate-nitrogen levels in water as some water evaporates as steam. 
Methemoglobinemia Case Histories 
Cases of infant methemoglobinemia have been reported in the United States. The majority of reported 
cases were in infants under the age of four months and who were fed milk formulas prepared with 
contaminated well water. A Nebraska survey of physicians reported in the Nebraska Medical Journal in 
1981 indicated at least eight cases of infant methemoglobinemia were treated in Nebraska between 1973 
and 1978. More recently, two infants with methemoglobinemia were identified by the South Dakota 
Department of Health. The private well water was found to have a nitrate-nitrogen concentration of 150 
mg/l in one instance and 54 mg/l in the other. In Colorado, a case of methemoglobinemia involved an 
infant ingesting water containing 13.3 mg/l nitrate-nitrogen. No cases have been identified with water at 
or below the MCL of 10 mg/l nitrate-nitrogen. 
Additional Information 
Not only does consuming drinking water contaminated with nitrate-nitrogen above 10 mg/l have the 
potential to result in methemoglobinemia, but newer studies also have indicated a possible risk of 
cancer, as well as the potential to be a contributing factor in spontaneous abortions. For additional 
information on drinking water and nitrates, read NebGuide G96-1279, Drinking Water: Nitrate-Nitrogen
and Extension Circular EC90-2502, Perspectives on Nitrates. This publication does not provide or 
substitute for professional medical advice. If you have any questions or concerns related to nitrate 
consumption and health effects or the condition known as methemoglobinemia consult your physician. 
Summary 
The methemoglobinemia hazard from drinking water with nitrate-nitrogen occurs when bacteria in the 
digestive system transform nitrate to nitrite and the nitrite oxidizes iron in hemoglobin of red blood cells 
to form methemoglobin. Methemoglobin lacks oxygen-carrying capacity and the condition known as 
methemoglobinemia occurs. Because infants under six months of age have a higher concentration of the 
digestive system bacteria known to transform nitrate to nitrite, and a lower than normal concentration of 
the enzyme known to reduce methemoglobin back to hemoglobin, they are at higher risk for 
methemoglobinemia. Consuming water from a source containing 10 or less mg/l nitrate-nitrogen 
provides assurance that methemoglobinemia should not result from drinking water. Consult your 
physician for information on methemoglobinemia or for professional diagnosis if methemoglobinemia is 
suspected. 
Other Related Publications 
EC94-135, Understanding Pesticides and Water Quality in Nebraska  
EC98-765, Improving Drinking Well Condition  
EC98-766, Drinking Water Well Condition  
EC90-2502, Perspectives on Nitrates  
G89-946, Water Treatment Equipment: Water Softeners  
G90-976, Water Treatment Equipment: A Buyer's Guide  
G90-989, Drinking Water: Bacteria  
G92-1079, Home Water Treatment Equipment: An Overview
G95-1255, Shock Chlorination of Domestic Water Supplies
G96-1274, Drinking Water: Hard Water  
G96-1275, Drinking Water: Sulfates and Hydrogen Sulfide  
G96-1279, Drinking Water: Nitrate-Nitrogen  
G96-1280, Drinking Water: Iron and Manganese  
G96-1282, Drinking Water: Man-made Chemicals  
G97-1333, Drinking Water: Lead  
G98-1360, Drinking Water: Copper  
Adapted in part from:  
Ziebarth A. (1991), NF91-49, Well Water, Nitrates and the "Blue Baby" Syndrome 
Methemoglobinemia; Lincoln, NE; University of Nebraska Cooperative Extension. 
 
Davis, R. (1990), EC 90-2502, Perspectives on Nitrates, Chapter 4 - Nitrates, Nitrites and 
Methemoglobinemia; Lincoln, NE; University of Nebraska Cooperative Extension. 
File: G1369 under: WATER RESOURCE MANAGEMENT 
A-25, Water Quality, 5,000 printed 
Issued December 1998 
 
 
Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation 
with the U.S. Department of Agriculture. Elbert C. Dickey, Director of Cooperative Extension, 
University of Nebraska, Institute of Agriculture and Natural Resources.  
University of Nebraska Cooperative Extension educational programs abide with the non-discrimination 
policies of the University of Nebraska-Lincoln and the United States Department of Agriculture. 


G98-1369 Drinking Water: Nitrate and Methemoglobinemia \u3cem\u3e( Blue Baby  Syndrome)\u3c/em\u3e

DigitalCommons@University of Nebraska

University of Nebraska - Lincoln DigitalCommons@University of Nebraska - Lincoln Historical Materials from University of Nebraska-Lincoln Extension Extension 1998 G98-1369 Drinking Water: Nitrate and Methemoglobinemia ("Blue Baby" Syndrome) Sharon Skipton University of Nebraska–Lincoln, sskipton1@unl.edu DeLynn Hay University of Nebraska-Lincoln, dhay1@unl.edu Follow this and additional works at: https://digitalcommons.unl.edu/extensionhist  Part of the Agriculture Commons, and the Curriculum and Instruction Commons Skipton, Sharon and Hay, DeLynn, "G98-1369 Drinking Water: Nitrate and Methemoglobinemia ("Blue Baby" Syndrome)" (1998). Historical Materials from University of Nebraska-Lincoln Extension. 1435. https://digitalcommons.unl.edu/extensionhist/1435 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. Nebraska Cooperative Extension G98-1369 Drinking Water: Nitrate and Methemoglobinemia ("Blue Baby" Syndrome) This NebGuide discusses the blood disorder methemoglobinemia, its effect on infants and prevention methods.. Sharon Skipton, Extension Educator DeLynn Hay, Extension Water Resources Specialist  Methemoglobinemia  Methemoglobinemia Signs and Symptoms  Methemoglobinemia Treatment  Methemoglobinemia Prevention  Methemoglobinemia Case Histories  Additional Information  Summary  Other Related Publications   Methemoglobinemia is a blood disorder caused when nitrite interacts with the hemoglobin in red blood cells. Unlike hemoglobin, the methemoglobin formed in this interaction cannot carry sufficient oxygen to the body's cells and tissues. Although methemoglobinemia is rare among adults, cases have been reported among infants, where nitrate-contaminated well water was used to prepare formula and other baby foods. Nitrate in well water may result from point sources such as sewage disposal systems and livestock facilities, from nonpoint sources such as fertilized cropland, parks, golf courses, lawns and gardens or from naturally occurring sources of nitrogen. For additional information on nitrate in well water, read NebGuide G96-1279, Drinking Water: Nitrate-Nitrogen. Methemoglobinemia Nitrate, a relatively non-toxic substance, occurs naturally as part of the nitrogen cycle. However, bacteria can convert nitrate to nitrite in the environment, in foods and in the human body. Until infants reach about six months of age, their digestive system secretes lower amounts of gastric acid and the pH level in their digestive system is higher than most adults. Adults with a diminished capability to secrete gastric acid also can experience a rise in pH in their digestive system. In both situations, bacteria can proliferate, increasing the transformation of nitrate to nitrite. Once in the blood, nitrite oxidizes iron in the hemoglobin of red blood cells to form methemoglobin, which lacks hemoglobin's oxygen-carrying ability. The nitrite can come from nitrate in drinking water or from food, some drugs or other sources. For additional information on hemoglobin oxidizing agents, read Extension Circular EC90-2502, Perspectives on Nitrates and consult your physician. Although methemoglobin is continually produced in humans, an enzyme in the human body reduces methemoglobin to hemoglobin. In most individuals, methemoglobin is rapidly converted back to hemoglobin. Typically, less than 1 percent of the total circulating hemoglobin in a healthy adult is present in the form of methemoglobin. Infants, however, have a low concentration (about 60 percent of the adult concentration) of the reducing enzyme, as do some older individuals with an enzyme deficiency. In these people, methemoglobin is not converted to hemoglobin as readily. When methemoglobin levels are elevated, the condition known as methemoglobinemia, often referred to as "blue baby syndrome", can result as the blood lacks the ability to carry sufficient oxygen to individual body cells. Methemoglobinemia Signs and Symptoms Infants suffering from methemoglobinemia may seem healthy but show intermittent signs of blueness around the mouth, hands and feet. They may have episodes of breathing trouble, some diarrhea and vomiting. In some cases, an infant with methemoglobinemia has a peculiar lavender color but shows little distress. Blood samples appear chocolate brown and don't turn pink when exposed to air. When the methemoglobin level is high, infants express a marked lethargy, excessive salivation and loss of consciousness. Convulsions and death can occur at extreme methemoglobin levels. Consult your physician for additional information on methemoglobinemia signs and symptoms or for diagnosis if methemoglobinemia is suspected. Do not attempt to self-diagnose this condition. Methemoglobinemia Treatment If the condition is identified early and is not life-threatening, a change of drinking water to water with less than 10 milligrams per liter of nitrate-nitrogen is usually the only needed treatment. This will reduce methemoglobin to hemoglobin in two to three days. Severely affected infants may be treated with an intravenously administered solution of methylene blue. Methemoglobinemia Prevention The Environmental Protection Agency (EPA) has set a public water supply maximum contaminant level (MCL) of 10 milligrams per liter (mg/l) which is equal to 10 parts per million (ppm) for nitrate-nitrogen. This level provides a margin of safety against a significant risk for human health. EPA believes water containing nitrate-nitrogen at or below this level is acceptable for daily drinking over a lifetime and does not pose a methemoglobinemia health risk for infants or adults. Methemoglobinemia prevention is especially important for infants under six months of age, although preventative measures are also encouraged for pregnant women, women who are breast feeding and other high-risk individuals. Use water from a source containing nitrate-nitrogen at or below 10 mg/l. If the drinking water source contains nitrate-nitrogen above 10 mg/l, use bottled water or treat the water with a distiller, ion exchange unit or reverse osmosis unit to reduce the nitrate-nitrogen level. Boiling water containing nitrate-nitrogen does not reduce nitrate-nitrogen levels. In fact, boiling can concentrate nitrate-nitrogen levels in water as some water evaporates as steam. Methemoglobinemia Case Histories Cases of infant methemoglobinemia have been reported in the United States. The majority of reported cases were in infants under the age of four months and who were fed milk formulas prepared with contaminated well water. A Nebraska survey of physicians reported in the Nebraska Medical Journal in 1981 indicated at least eight cases of infant methemoglobinemia were treated in Nebraska between 1973 and 1978. More recently, two infants with methemoglobinemia were identified by the South Dakota Department of Health. The private well water was found to have a nitrate-nitrogen concentration of 150 mg/l in one instance and 54 mg/l in the other. In Colorado, a case of methemoglobinemia involved an infant ingesting water containing 13.3 mg/l nitrate-nitrogen. No cases have been identified with water at or below the MCL of 10 mg/l nitrate-nitrogen. Additional Information Not only does consuming drinking water contaminated with nitrate-nitrogen above 10 mg/l have the potential to result in methemoglobinemia, but newer studies also have indicated a possible risk of cancer, as well as the potential to be a contributing factor in spontaneous abortions. For additional information on drinking water and nitrates, read NebGuide G96-1279, Drinking Water: Nitrate-Nitrogenand Extension Circular EC90-2502, Perspectives on Nitrates. This publication does not provide or substitute for professional medical advice. If you have any questions or concerns related to nitrate consumption and health effects or the condition known as methemoglobinemia consult your physician. Summary The methemoglobinemia hazard from drinking water with nitrate-nitrogen occurs when bacteria in the digestive system transform nitrate to nitrite and the nitrite oxidizes iron in hemoglobin of red blood cells to form methemoglobin. Methemoglobin lacks oxygen-carrying capacity and the condition known as methemoglobinemia occurs. Because infants under six months of age have a higher concentration of the digestive system bacteria known to transform nitrate to nitrite, and a lower than normal concentration of the enzyme known to reduce methemoglobin back to hemoglobin, they are at higher risk for methemoglobinemia. Consuming water from a source containing 10 or less mg/l nitrate-nitrogen provides assurance that methemoglobinemia should not result from drinking water. Consult your physician for information on methemoglobinemia or for professional diagnosis if methemoglobinemia is suspected. Other Related Publications EC94-135, Understanding Pesticides and Water Quality in Nebraska  EC98-765, Improving Drinking Well Condition  EC98-766, Drinking Water Well Condition  EC90-2502, Perspectives on Nitrates  G89-946, Water Treatment Equipment: Water Softeners  G90-976, Water Treatment Equipment: A Buyer's Guide  G90-989, Drinking Water: Bacteria  G92-1079, Home Water Treatment Equipment: An OverviewG95-1255, Shock Chlorination of Domestic Water SuppliesG96-1274, Drinking Water: Hard Water  G96-1275, Drinking Water: Sulfates and Hydrogen Sulfide  G96-1279, Drinking Water: Nitrate-Nitrogen  G96-1280, Drinking Water: Iron and Manganese  G96-1282, Drinking Water: Man-made Chemicals  G97-1333, Drinking Water: Lead  G98-1360, Drinking Water: Copper  Adapted in part from:  Ziebarth A. (1991), NF91-49, Well Water, Nitrates and the "Blue Baby" Syndrome Methemoglobinemia; Lincoln, NE; University of Nebraska Cooperative Extension.  Davis, R. (1990), EC 90-2502, Perspectives on Nitrates, Chapter 4 - Nitrates, Nitrites and Methemoglobinemia; Lincoln, NE; University of Nebraska Cooperative Extension. File: G1369 under: WATER RESOURCE MANAGEMENT A-25, Water Quality, 5,000 printed Issued December 1998   Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Elbert C. Dickey, Director of Cooperative Extension, University of Nebraska, Institute of Agriculture and Natural Resources.  University of Nebraska Cooperative Extension educational programs abide with the non-discrimination policies of the University of Nebraska-Lincoln and the United States Department of Agriculture. 

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G98-1369 Drinking Water: Nitrate and Methemoglobinemia \u3cem\u3e( Blue Baby Syndrome)\u3c/em\u3e

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