Reexamining the risks of drinking-water nitrates on public health

Nitrates in drinking water are generally considered the sole source of nitrite poisoning with methemoglobinemia in infantile methomoglobinemia (IM). However, IM, which occurs during the first 4 months of life, is actually a constellation of cyanosis and hypoxia associated with methemoglobinemia that can result from several other causes.

This review reexamines the role of nitrate levels in drinking water as a cause of IM and identifies other sources of nitrates that can affect public health and cause chronic diseases.

Causes of IM include nitrites in foods, environmental chemical exposures, commonly prescribed pharmaceuticals, and the endogenous generation of oxides of nitrogen. Infants with congenital enzyme deficiencies in glucose-6-phosphate dehydrogenase and methemoglobin reductase are at greater risk of nitrite-induced methemoglobinemia from nitrates in water and food and from exposures to hemoglobin oxidizers.

Early epidemiological studies demonstrated significant associations between high groundwater nitrate levels and elevated methemoglobin levels in infants fed drinking water-diluted formulas. However, more recent epidemiological investigations suggest other sources of nitrogenous substance exposures in infants, including protein-based formulas and foods and the production of nitrate precursors (nitric acid) by bacterial action in the infant gut in response to inflammation and infection.