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Nitrate/Nitrite Toxicity
What Instructions Should Be Given to Patients to Prevent Overexposure to Nitrates and Nitrites?

Course: WB 2342
CE Original Date: December 5, 2013
CE Expiration Date: December 5, 2015
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Learning Objective

Upon completion of this section, you will be able to

  • Describe care advice the clinician can provide to patients to prevent overexposure to nitrates and nitrites.

Introduction

By utilizing effective risk communication techniques, the clinician can promote patient behaviors that may reduce risk of nitrate/nitrite overexposure and exposure related adverse health effects. The clinician can provide advice on

  • Self-care, so that patients can minimize risk of nitrate/nitrite overexposure and
  • When to follow-up with a health care provider.

There are potential health benefits and risks from dietary sources of nitrates and nitrites. Most health risks from overexposure to nitrates and nitrites occur in susceptible populations. Preventive messages targeted to at risk populations are the key in preventing adverse health effects from overexposures.

Self Care Advice

Self-care advice creates awareness and suggests actionable behaviors that may reduce the risk of nitrate/nitrite overexposure and exposure related adverse health effects.

Sample Message Rationale
  • Have private wells used as the household water source tested for nitrates/nitrites.
  • Do not use untested private well water to dilute infant formula.
  • Contact local or state health department for private well water testing recommendations.

The American Academy of Pediatrics (AAP) consensus panel recommends that all prenatal and well-infant visits need to include questions about the home water supply.

If a private well is the water source, the water should be tested for nitrates [Greer and Shannon 2005].

State and local health or environmental departments often test for nitrates, total coliforms, fecal coliform, volatile organic compounds, pH as well as any other substances that may be of concern locally. In addition, health departments or county governments should have a list of the state-certified (licensed) laboratories that test for a variety of substances.

  • In addition to local or state health departments, there are many informational sources available on drinking water and private well water testing.

The local or state health department can provide recommendations for private well water testing. Other online resources regarding private wells and private well water are available.

CDC's online resources on well water include:
http://www.cdc.gov/healthywater/drinking/private/wells/testing.html
http://www.cdc.gov/healthywater/drinking/private/index.html

Another informational resource is the EPA Safe Drinking Water Hotline at (800) 426-4791

  • Use of a non-contaminated water source is recommended until test results are available.

Bottled water is less likely to have high levels of nitrates. The standards for bottled water are set by the United States Food and Drug Administration (FDA). The FDA bases its standards on the EPA standards for tap water. If you have questions about bottled water, make sure you are informed about where your bottled water comes from and how it has been treated. http://www.cdc.gov/healthywater/drinking/bottled/index.html

  • Don't feed infants less than 3 months of age home-prepared infant food from certain vegetables.
  • It is okay to feed infants commercially prepared infant foods.

The American Academy of Pediatrics (AAP) consensus panel concluded that

  • Home-prepared infant foods from vegetables (e.g., spinach, beets, green beans, squash and carrots) should be avoided until infants are 3 months of age or older.
  • Infants fed commercially prepared infant food are general not at risk of nitrate poisoning [Greer and Shannon 2005].

  • Breastfeeding should continue.

Breastfed infants are not at risk of excessive nitrate exposure from mothers who ingest water with a high nitrate content (up to 100 ppm nitrate nitrogen) because the nitrate concentration does not increase significantly in breast milk [Greer and Shannon 2005].

  • Reduce the amount of cured and processed meats in diet.

Nitrates and nitrites are used in meat products including

  • Bacon,
  • Bologna,
  • Corned beef,
  • Hot dogs,
  • Luncheon meats,
  • Sausages and canned and cured meat, and
  • Hams.

Levels of nitrates and nitrites used in meat production and packaging are regulated by the FDA and USDA.

An Expert Panel representing the American Institute for Cancer Research recommends reducing the consumption of cured and processed meats to avoid adverse health effects. However a safe consumption level is not specified [WCRF 2007].

  • Eat a variety of colors and types of vegetables (4-5 servings/day) and fruits (4-5 servings/day).

Vegetable and fruit consumption has health benefits and studies have indicated that plant-based nitrates and nitrites play essential physiologic roles in supporting cardiovascular health and gastrointestinal immune function [Hord 2011].

The American Heart Association and other private health agencies recommend adherence to the public dietary health recommendations in the United States [Appel et al. 2006].

A dietary chart can be accessed at: http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Suggested-Servings-from-Each-Food-Group_UCM_318186_Article.jsp

Advice On When to Follow-up With a Health Care Provider

Patients should be advised to consult their physician if they or their child develop signs or symptoms to include

  • Changes in skin or mucous membrane color (particularly blue color or cyanosis),
  • Difficulty breathing,
  • Gastrointestinal disturbances such as nausea, severe diarrhea, vomiting,
  • Dehydration,
  • Rapid pulse, or
  • Decreased level of consciousness.

ATSDR Patient Education Care Instruction Sheet

ATSDR has developed a patient education care instruction sheet on nitrates/nitrites toxicity that you might find useful. It can be found at http://www.atsdr.cdc.gov/csem/nitrate_2013/docs/nitrate_patient-education.pdf [PDF - 98 KB].

Key Points

  • Patients should be instructed on ways to protect themselves from over exposure to nitrates and nitrites that might increase their risk of exposure related adverse health effects.
  • All prenatal and well-infant visits should include questions about the home water supply. If the water source is a private well, the water should be tested for nitrates in addition to other substances depending on area conditions. For more information on well water testing and maintenance, individuals should contact their local or state health department.
  • Home-prepared infant foods from vegetables (e.g., spinach, beets, green beans, squash and carrots) should be avoided until infants are 3 months of age or older.
  • Limiting the consumption of processed or cured meats may decrease the risk of adverse health effects from overexposure to nitrates/nitrates.
  • US public dietary health recommendations for consumption of fruits and vegetables should be promoted for their health benefits.
   

Progress Check

24. Which of the following instructions regarding exposure to nitrates and nitrites is/are true?

A. Limit the consumption of processed or cured meats.
B. Infants under 3 months of age should not be fed home prepared foods containing vegetables.
C. Infants fed commercially prepared infant food are general not at risk of nitrate poisoning.
D. Households using private wells for drinking water should have the well tested for nitrates.
E. All of the above.
F. A, B, and D only.

Answer:

To review relevant content, see "Introduction" and "Self Care Advice" in this section.

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