Melamine contamination: the short- and long-term impacts

on infants and childrenJessi Peretti

January 18, 2012

Oregon Health & Science University

Presentation Outline

During this presentation we will:• Discuss the history of melamine, its chemical

properties, and current uses• Review the melamine poisoning scandal from

2008• Evaluate the research surrounding the

implications for infants and children poisoned with melamine, as well as the mechanism behind the illnesses associated with the toxicity

• Discuss our role as dietitians

Think about the recent food safety issues over the last few years in the United

States….

On a scale of 1 to 5, 1 being not at all confident and 5 being extremely confident -

How confident are you that what you purchase at the grocery store is safe?

How confident are you that our government is doing all they can to ensure that the products we consume are safe?

Melamine• Organic base• Trimer of cyanide• Typically formed from

the dehydration of urea• In industry is combined

with formaldehyde to form a heat resistant, scratch resistant plastic

sciencebuzz.org

3rd1000.com

tutorvista.com

Current Uses of Melamine

•Dry erase boards

•Counter tops

•Dishes

•Fertilizers

AND . . .

professorshouse.com

marlerblog.com

As a protein supplement in dog food and infant formula?

Why melamine?

• Melamine is composed of 66% nitrogen

• Can be added to products to falsely increase the protein content

Chinese Melamine Scandal

• September 11, 2008 Sanlu, the largest milk producer in China, recalled 10,000 tons of infant formula tainted with melamine

• 21 other companies found to have contaminated milk

• Speculated that companies first reported contamination in early July

1. Garcia Lopez FJ, Quereda C. Melamine toxicity: one more culprit in calcium kidney lithiasis. Kidney Int 2011;80:694-6.

Sanlu Milk Powder and Upper Limits

Sanlu’s milk powder contained:• 2.56 g/kg of melamine

Other brands contained:• .090 - 619 mg/kg

Upper limit set by WHO in 2007• .2 mg/kg/day

– FDA• .63 mg/kg/day

Press conference on testing melamine in baby milk formul, the ministry of health of the People’s Repubilc of china, September 17, 2008. http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohbgt/s3582/200809/37917

Something to keep in perspective…

This was not the first time infant formula had been tampered with!

Exactly how big of an impact can this have?

• Use rate of infant formula is 98%• Fewer than 5% met Chinese and WHO target ranges for exclusive breastfeeding

until 6 months.

1. Qiu L, Binns CW, Zhao Y, Lee AH, Xie X. Breastfeeding practice in Zhejiang province, PR China, in the context of melamine-contaminated formula milk. J Health Popul Nutr 2010;28:189-98.

Chinese Melamine Scandal

• ~300,000 infants and children were ill

• ~ 52,000 infants and children were hospitalized

• 6 children died

Symptoms of melamine toxicity in children

• Restlessness• Diarrhea• Hematuria• Hx of stone

passage*• Renal Colic*

• Acute kidney injury*• Oliguria• Anuria• Edema

NO SYMPTOMS AT ALL!Hau AK, Kwan TH, Li PK. Melamine toxicity and the kidney. J Am Soc Nephrol

2009;20:245-50.

Shang P, Chang H, Yue ZJ, et al. Acute kidney injury caused by consumption of melamine-contaminated infant formula in 47 children: a multi-institutional experience in diagnosis, treatment and follow-up. Urol Res 2011;

Panfeng S, Hong C, Zhongjin Y, et al. Management of Pediatric Urolithiasis Induced by Melamine-contaminated Powdered Formula (Report of 619 Cases). Urology 2011;78:411-6.

Variable Conservative Group

Intervention Group

Gender Male 303 (66) 105(65.6)

Female 156 (33) 55 (34.4) Medical History

Stone Passage 19 (4.1) 10 (6.3) No presenting symptoms 422 (91.9) 98 (61.3)

Calculi location

Bilateral kidney 159 (34.6) 55 (34.4) Bilateral ureter 19 (4.1) 42 (26.3)

Bladder 7 (1.5) 20 (12.5)

Contaminated formula consumption

11.31 ± 8.55 10.73 ± 5.34

Kobayashi T, Okada A, Fujii Y, et al. The mechanism of renal stone formation and renal failure induced by administration of melamine and cyanuric acid. Urol Res 2010;38:117-25.

Human StudiesKidney failure due to melamine toxicity

Sun et al 2009

• 25 children with urinary tract caliculi and acute renal failure

• Ages 6-36 months

• Mean exposure of 9.5 months

Results

Results

• Renal functions impaired in all patients• 44% of patients needed cystoscopy and

catherization• 28% were dialysed• 28% received fluids for 4-20 days• At follow up at 3 months, 68% were

found to be free from stones

Conclusion

• Melamine tainted formula can cause calculi

• Stones found in infants contain uric acid and melamine rather than cyanuric acid

• All types of treatment were successful

Mechanism of Action • Melamine is alkalescent

• When introduced to acid can form cyanuric acid

www.sciencemadness.org/talk/files.php?pid=185660&aid=11296

Sun et al

• Cyanuric acid can decrease the body fluid pH

• If pH is less than 5.5, uric acid can accumulate leading to formation of crystals

• Crystals block urine flow and increased renal pressure AKI

Sun et al

Concluded that:

• It is an obstruction of the renal tubules, rather than a toxicity to the kidney itself, that causes renal damage

We have clearly identified the short-term impacts of this disaster, but what about long-term?

Too soon to tell.

How did this happen?

• No one knows!

• Olympics

• No law indicating that you had to reported chemicals used in dairy products!

• Multiply government agencies at the local and national level responsible

What was China’s response?

• 2 people received the death penalty

• 1 person on suspended death penalty

• 3 people sentenced to life in jail

• 3 people received 15 years in jail

• 7 government officials were fired or resigned

• 13 people varied sentences.

http://www.chinadaily.com.cn/china/2009-01/23/content_7422983.htm

China’s Response

• In 2009, updated food safety laws

• Developed the National Food Safety Commission

• Stricter penalties for intentional tampering of food

• Laws related to pesticide use for farmers

Impacts of the law

• Pork labeled as organic and being sold at a higher price – Closed 13 Walmarts for two weeks– Fines of nearly $600,000

• China International Food Safety and Quality Conference

Impacts of the law…

• “Gutter oil”

• Pork contaminated with clenbuterol

http://www.economist.com/node/21534812

Now how confident are you?

What can we do as dietitians?

• Educate the public

• Encourage the purchase of local foods

• Help other countries incorporate effective policy

• Acts as advocates and educators for the importance of breastfeeding

DISCUSSION and QUESTIONS