Pediatric Practitioner Knowledge of Arsenic in Baby Food

Abstract

OBJECTIVE

Rice, one of the first solid foods introduced to infants, is 10 times more absorbent of inorganic arsenic than any other grain. An evaluation has not been performed about practitioner knowledge of arsenic content in infant foods. The purpose of this survey was to determine pediatric practitioners' knowledge of current US Food and Drug Administration (FDA) recommendations to limit exposure to arsenic-containing foods in infants.

METHODS

This was a convenience sample of pediatric practitioners conducted as an online survey. The survey contained 19 questions related to knowledge of arsenic-containing foods, FDA recommendations, practitioner recommendations on feeding infants, and demographic information. Participants were recruited using organization list servs. Participants were reminded to complete the survey 2 months after the initial email. An infographic on arsenic was provided at the end of the survey.

RESULTS

One hundred thirty-seven individuals completed the survey. The majority of respondents were physicians or pharmacists and have been in practice less than 6 years. Nine percent of respondents (11/123) stated the FDA arsenic limit of 100 ppb. Sixteen percent (20/123) identified white rice as having a lower inorganic arsenic content than brown rice and 27% (36/132) identified that there is no difference in inorganic arsenic content between organic infant rice cereal and conventional infant rice cereal.

CONCLUSIONS

The vast majority of participants were not aware of the FDA's proposed limit on arsenic consumption or the concern of heavy metals in baby foods. More education is needed to increase knowledge regarding arsenic in baby foods.

Introduction

Rice is one of the first solid foods introduced to infants and is the most common grain used to thicken infant formula due to its tolerability in infants and young children.^1,2 Compared with other cereal grains, rice is 10 times more absorbent of inorganic arsenic than any other grain, making heavy metal buildup a concern.^1,2 Arsenic is a natural element that exists in both organic and inorganic forms. Inorganic arsenic is the primary toxic form and can be found in food, soil, water, and air. Specifically, inorganic arsenic can be found in metal machinery and manufacturing and farming practices, such as pesticides, wood preservatives, burning wood, oil, and gasoline.^1,2 One of the main reasons rice contains a higher content of inorganic arsenic compared with other cereal grains is because rice is grown under flood-like conditions. These conditions allow for more inorganic arsenic uptake into the rice plants.^2,3

When comparing organically with inorganically grown rice, both contain the same amount of inorganic arsenic.¹ Although organically grown rice products avoid the use of pesticides, which often contain lead and arsenic, heavy metals contaminate the soil and are therefore still present in organically grown rice.¹ In addition, when comparing brown rice with white rice, brown rice is found to contain higher amounts of inorganic arsenic.^2,4 Inorganic arsenic is concentrated in both the inner layer of the grain and in the outer layer of rice, the latter of which is removed to make white rice.⁴

Infant consumption of inorganic arsenic can have detrimental effects on health such as poor cognitive development, cancer, and may be linked to autism and attention-deficit/hyperactivity disorder.^1,2 Unfortunately, there are currently no mandated regulations to limit the amount of inorganic arsenic in baby foods.^4,5 Consumer Reports and the US Food and Drug Administration (FDA) report that most products of common infant foods containing rice, such as Gerber and Beech-Nut, contained heavy metals that should be of concern to individuals feeding their infants just 1 serving per day.^1,2 Unfortunately, arsenic content is not listed on consumer packaging. Information on arsenic content can be found based on product category, not brand name, in a document published by the FDA titled, “Analytical Results from Inorganic Arsenic in Rice Cereals for Infants—Non-rice Infant Cereal and Other Foods Commonly Eaten by Infants and Toddlers.”²

The FDA published a draft guidance about arsenic content in rice and rice products in March 2016 and an update in 2020 with additional information for apple juice and water.³ The FDA recommended a maximum limit of inorganic arsenic to be 100 ppb or 100 μg/kg.³

As there is no published information about practitioner knowledge of arsenic in foods, the purpose of this survey was to determine if pediatric practitioners were aware of current FDA recommendations to limit exposure to arsenic-containing foods in infants and differences in types of rice related to arsenic content. Additionally, we determined which foods and the number of servings pediatric practitioners recommend for infant feeding and for thickening of formula.

Materials and Methods

A convenience sample survey of pediatric practitioners was conducted online and included participants aged 18 years and older. Participants were recruited using organization list servs. Emails were sent to the General Pediatrics, Ambulatory Care, and Gastroenterology Pediatric Pharmacy Association (PPA) list servs to recruit pharmacists and University of Maryland Department of Pediatrics list serv to recruit physicians, pharmacists, nurse practitioners, nurses, and dietitians. Participants were reminded to complete the survey 2 months after the initial email.

Our survey was conducted in Qualtrics, an online survey software, and included questions that were multiple choice as well as fill-in-the-blank. Participants were not required to answer every question to proceed. The survey contained a total of 19 questions with 4 questions on knowledge of arsenic-containing foods, 1 question on FDA recommendations, 5 questions on practitioner recommendations related to infant feeding, and 9 questions on demographic information. This survey was piloted for clarity prior to distribution and a copy of the survey questions can be found in the Supplemental Material. An infographic was provided at the end of the survey to provide all survey participants with more information about arsenic and the FDA recommendations (Figure 1).

Figure 1.

Infographic.

Results

The survey was sent to 1200 email addresses with an undefined amount of overlap in the PPA list servs. The survey was completed by 137 participants, a response rate of 11.4%. Professions included 36% (49/137) physicians, 26% (36/137) pharmacists, 8% (11/137) nurse/nurse practitioners, and 30% (41/137) other/did not specify. Fifty-two percent (46/88) of participants reported having less than 6 years in practice. Eighty-one percent (79/98) were between the ages of 25 to 44 years, 86% (82/95) were female, and 71% (68/96) identified as white. A majority (73%) currently practice in Maryland. Sixty-three percent (62/99) report working in an inpatient area and 13% (13/98) of participants have current or past gastrointestinal experience. Demographic data can be found in the Table in supplemental material.

Forty-four percent (60/136) of respondents were aware that baby foods contain arsenic and other heavy metals. Sixteen percent (20/123) correctly identified white rice as having a lower inorganic arsenic content than brown rice and 27% (36/132) correctly identified that there is no difference in inorganic arsenic content between organic infant rice cereal and conventional infant rice cereal. Nine percent (11/123) correctly stated the FDA arsenic limit of 100 ppb and 34% (32/93) correctly identified the maximum amount of rice cereal recommended per day for a 6-month-old infant to remain below the recommended FDA limit. Seventeen percent (15/90) correctly identified the amount of rice cereal to be used for thickening 1 ounce of baby formula. In addition, 78% recommended too little rice cereal for thickening (Figure 2).¹⁰ Sixty percent (60/100) ranked a grain (rice, multigrain, oats, or barley) as the first solid food recommended to add to infant patients' diets (Figure 3) and 37% (37/100) ranked rice specifically, as the first solid food they recommend for infant patients. About half (49%) of the respondents would not recommend a specific brand of rice cereal.

Figure 2.

Survey results of pediatric practitioner recommendations for amount of rice cereal to be added to 1 ounce of baby formula (for thickening) for a 6-month-old. Number of responses = 90.

Figure 3.

Survey results of pediatric practitioner recommendations of first solid food to add to infant patients' diets. Number of responses = 100.

Discussion

Despite the FDA guidance on limiting arsenic to 100 ppb, the vast majority of participants were not aware of the FDA's proposed limit on arsenic consumption or the concern of heavy metals in infant foods. This is the first study to examine practitioner knowledge on this topic. Education on the topic of heavy metals in baby foods would benefit all pediatric health care professions. Evaluations of health professionals' curriculum related to heavy metals and best practices for current practitioners to receive FDA's updated guidance are needed.

Since we have completed this study, the FDA has published an action plan in April 2021, “Closer to Zero.”⁶ The plan includes specific timelines and phases to reduce infant exposure to arsenic and other heavy metals.⁶ In June 2021, Beech-Nut announced they would stop selling baby rice cereal due to their inability to meet the FDA's limit.⁷ This topic has garnered the attention of politicians in Congress as they attempt to pass the Baby Food Safety Act of 2021.^8,9 The Baby Food Safety Act was referred to the Committee on Health, Education, Labor, and Pensions in March of 2021 and has not made it out of committee for a vote.

Thickened formulas are often used in infants who are formula fed and have consistent vomiting and poor weight gain or who exhibit irritability when vomiting.¹⁰ It was interesting to see just a small percentage of practitioners were aware of how to appropriately thicken infant formula to reduce vomiting. The recommended ratio of rice cereal to formula is 1 tablespoon of rice cereal to 1 ounce of formula.¹⁰ This appears to be the first data looking at practitioner knowledge related to thickening of infant formula to reduce vomiting.

Limitations associated with this study include the majority of respondents being located in 1 state and half of respondents reported having 6 years or less experience in practice. Additionally, the question asking the number of recommended servings of rice cereal per day could have influenced respondents since the serving size information was provided. Also, the number of respondents in professions other than pharmacists and physicians was limited and therefore may not be representative of other professions.

Conclusion

Pediatric practitioners surveyed were generally not aware of current FDA recommendations to limit exposure to arsenic-containing foods in infants. Further education on arsenic content in infant foods for pediatric practitioners is needed. The authors recommend infants receive less than 1 serving of infant rice cereal per day or consider other grains such as oat.

ABBREVIATIONS

FDA

US Food and Drug Administration

PPA

Pediatric Pharmacy Association

Funding Statement

Disclosures. The authors declare no financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. The authors had full access to all the data and take responsibility for the integrity and accuracy of the data analysis.