Pediatric Methemoglobinemia Treatment & Management

  • Author: Michael J Verive, MD; Chief Editor: Max J Coppes, MD, PhD, MBA   more...
 
Updated: Nov 14, 2011
 

Medical Care

Once the diagnosis of methemoglobinemia has been confirmed and appropriate treatment has been initiated, the underlying etiology should be sought.

  • In acquired methemoglobinemia, the toxin or drug may be identified by obtaining blood levels, performing gastric lavage, or both. In asymptomatic patients with low levels of methemoglobin, monitoring serial serum levels is all that may be necessary. The levels normalize over time unless recurrent or chronic exposure to the offending agent occurs.
  • If the methemoglobin levels are more than 30%, methylene blue should be intravenously administered at 1-2 mg/kg (up to 50 mg/dose in adults, adolescents, and older children) as a 1% solution over 5 minutes; repeat in 1 hour, if necessary. Methylene blue is an oxidant at levels of more than 7 mg/kg and, therefore, may cause methemoglobinemia in susceptible patients; thus, care must be taken in administration of this drug. Methylene blue is contraindicated in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency because it can lead to severe hemolysis.
  • Ascorbic acid is an antioxidant that may also be administered in patients with methemoglobin levels of more than 30%.
  • N -acetylcysteine has been shown to reduce methemoglobin in recent studies but is not yet an approved treatment for methemoglobinemia.
  • No pharmaceutical treatment for hereditary forms of methemoglobinemia exists.
    • Oral ascorbic acid (200-500 mg) has been found to be partially effective, if continued on an ongoing basis; however, this therapy has the potential risk of renal stones and hyperoxaluria. Methylene blue has also been used in these patients.
    • In severe cases, exchange transfusion may be necessary.
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Consultations

  • Consultation with other specialists, such as hematologists, cardiologists, and pulmonologists, may be required to assist in the search for the cause of the methemoglobinemia.
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Diet

  • Some vegetables (eg, beets, spinach, and carrots) are high in nitrite content and may need to be avoided in susceptible patients.
  • Well water can be contaminated with nitrites, nitrates, and oxidants and could lead to methemoglobinemia, especially in small infants (< 4 mo) when well water is used to prepare formula or is given alone.
  • Curcumin, the main curcuminoid in turmeric, has been shown experimentally to reduce methemoglobinemia in rats treated with dapsone.[12]
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Activity

  • No change in activity is indicated.
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Contributor Information and Disclosures
Author

Michael J Verive, MD  Medical Director, Pediatric Intensive Care, Department of Pediatrics, St Mary's Hospital for Women and Children

Michael J Verive, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, Pediatric Sedation, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mudra Kumar, MD, MBBS, MRCP  Associate Professor, Department of Pediatrics, University of South Florida College of Medicine

Mudra Kumar, MD, MBBS, MRCP is a member of the following medical societies: American Academy of Pediatrics and American Society of Hematology

Disclosure: Nothing to disclose.

Specialty Editor Board

Sharada A Sarnaik, MBBS  Professor of Pediatrics, Wayne State University School of Medicine; Director, Sickle Cell Center, Attending Hematologist/Oncologist, Children's Hospital of Michigan

Sharada A Sarnaik, MBBS is a member of the following medical societies: American Association of Blood Banks, American Association of University Professors, American Society of Hematology, American Society of Pediatric Hematology/Oncology, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steven K Bergstrom, MD  Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland

Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology

Disclosure: Nothing to disclose.

Samuel Gross, MD  Professor Emeritus, Department of Pediatrics, University of Florida; Clinical Professor, Department of Pediatrics, University of North Carolina; Adjunct Professor, Department of Pediatrics, Duke University

Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA  Senior Vice President, Center for Cancer and Blood Disorders, Children's National Medical Center; Professor of Medicine, Oncology, and Pediatrics, Georgetown University School of Medicine; Clinical Professor of Pediatrics, George Washington University School of Medicine and Health Sciences

Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Mudra Kumar, MD, MBBS, MRCP, to the original writing and development of this article.

References

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  2. Ash-Bernal R, Wise R, Wright SM. Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. Medicine (Baltimore). Sep 2004;83(5):265-73. [Medline].

  3. Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: Etiology, Pharmacology, and Clinical Management. Annals of Emergency Medicine. 1999;34:646-656. [Medline].

  4. Yano SS, Danish EH, Hsia YE. Transient methemoglobinemia with acidosis in infants. J Pediatr. Mar 1982;100(3):415-8. [Medline].

  5. Lavezzi AM, Mohorovic L, Alfonsi G, Corna MF, Matturri L. Brain iron accumulation in unexplained fetal and infant death victims with smoker mothers--the possible involvement of maternal methemoglobinemia. BMC Pediatr. Jul 6 2011;11:62. [Medline]. [Full Text].

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  7. [Guideline] Greer FR, Shannon M. Infant methemoglobinemia: the role of dietary nitrate in food and water. Pediatrics. Sep 2005;116(3):784-6. [Medline]. [Full Text].

  8. Fung HT, Lai CH, Wong OF, Lam KK, Kam CW. Two cases of methemoglobinemia following zopiclone ingestion. Clin Toxicol (Phila). Feb 2008;46(2):167-70. [Medline].

  9. Skold A, Klein R. Symptomatic-Low Grade Methemoglobinemia Because of Dapsone: A Multiple Hit Hypothesis. Am J Ther. Jun 3 2011;[Medline].

  10. Bauters T, Mondelaers V, Robays H, De Wilde H, Benoit Y, De Moerloose B. Methemoglobinemia and hemolytic anemia after rasburicase administration in a child with leukemia. Int J Clin Pharm. Feb 2011;33(1):58-60. [Medline].

  11. Odièvre MH, Danékova N, Mesples B, Chemouny M, Couque N, Parez N, et al. Unsuspected glucose-6-phosphate dehydrogenase deficiency presenting as symptomatic methemoglobinemia with severe hemolysis after fava bean ingestion in a 6-year-old boy. Int J Hematol. May 2011;93(5):664-6. [Medline].

  12. Bergamaschi MM, Alcantara GK, Valério DA, Queiroz RH. Curcumin could prevent methemoglobinemia induced by dapsone in rats. Food Chem Toxicol. Jul 2011;49(7):1638-41. [Medline].

  13. US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when methylene blue is given to patients taking certain psychiatric medications. Available at http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm. Accessed July 27, 2011.

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  16. Geller RJ, Barthold C, Saiers JA, Hall AH. Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs. Pediatrics. Nov 2006;118(5):2146-58. [Medline].

  17. Hjelt K, Lund JT, Scherling B, et al. Methaemoglobinaemia among neonates in a neonatal intensive care unit. Acta Paediatr. Apr 1995;84(4):365-70. [Medline].

  18. Jacka MJ, Kruger M, Glick N. Methemoglobinemia after transesophageal echocardiography: a life-threatening complication. J Clin Anesth. 2006;18(1):52-54. [Medline]. [Full Text].

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  20. Lebby T, Roco JJ, Arcinue EL. Infantile methemoglobinemia associated with acute diarrheal illness. Am J Emerg Med. Sep 1993;11(5):471-2. [Medline].

  21. Lindenmann J, Matzi V, Kaufmann P, et al. Hyperbaric oxygenation in the treatment of life-threatening isobutyl nitrite-induced methemoglobinemia--a case report. Inhal Toxicol. Dec 2006;18(13):1047-9. [Medline].

  22. Mansouri A, Lurie AA. Concise review: methemoglobinemia. Am J Hematol. Jan 1993;42(1):7-12. [Medline].

  23. McMullen SE, Casanova JA, Gross LK, Schenck FJ. Ion chromatographic determination of nitrate and nitrite in vegetable and fruit baby foods. J AOAC Int. Nov-Dec 2005;88(6):1793-6. [Medline].

 
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Note the chocolate brown color of methemoglobinemia. Tube 1 and tube 2 have a methemoglobin concentration of 70%; tube 3, a concentration of 20%; and tube 4, a normal concentration.
 
 
 
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