Food Dye Use in Enteral Feedings: A Review and a Call for a Moratorium

Quality and safety of South African hand sanitisers during the COVID-19 pandemic

Health agencies recommend using hand sanitisers as protection against the coronavirus. Thus far, the emphasis on hand sanitiser studies is limited to an analysis of disinfectant content only. This study aims to provide an extended analysis of 60 off-the-shelf alcohol-based hand sanitisers by using gas chromatography to report on alcohol content and the presence of impurities, a recombinant yeast estrogen screen to assess estrogenic activity, and an investigation into labelling compliance with the South African National Standard. Fifty hand sanitisers had an alcohol content of ≥60% v/v alcohol; however, most contained skin irritants and substances that could harm human and environmental health. Estrogenic activity was detected in 29 hand sanitisers and none of the products complied with all the labelling requirements. Since off-the-shelf hand sanitisers in South Africa are not regulated and monitored, evidence-based public awareness programmes on hand sanitiser quality and safety should become a priority.

In-situ hydrothermal synthesis of CNT decorated by nano ZnS/CuO for simultaneous removal of acid food dyes from binary water samples

The zinc sulfide/copper oxide–carbon nanotube nanocomposite (ZnS/CuO-CNT) was fabricated by using an in-situ hydrothermal synthesis method and was used for simultaneous ultrasound-assisted adsorptive removal of a binary mixture of ponceau 4R (P4R) and tartrazine (TA) acid food dyes from contaminated water. The as-synthesized ZnS/CuO-CNT was described by FESEM, XRD, FTIR, BET, and zeta potential analysis. The results included nested network morphology, high purity with the crystalline structure, oxygen-containing functional groups, mesoporous/micropores texture with cumulate interspace, specific surface area of 106.54 m² g^-1, and zero-point charge (pH_zpc) of 5.3. In adsorption experiments, the simultaneous effect of main independent variables, including solution pH, adsorbent dosage, concentration of each dye, temperature, and sonication time on the removal efficiency of dyes was studied systematically using the central composite design (CCD) method based on response surface methodology (RSM). Also, the second-order multivariate equation was presented to determine the relationship between the removal efficiencies of P4R and AT dyes and six independent effective variables. The high correlation coefficient (R² ≥ 0.99), significant p-value (P < 0.0001), and non-significant lack-of-fit (P > 0.05) showed the high accuracy, and validity of the proposed model to predict the removal efficiency of P4R and TA acid food dyes. The experimental removal efficiency for P4R and TA dyes was found to be 98.45 ± 2.54, and 99.21 ± 2.23, respectively. Also, the Langmuir maximum adsorption capacity for P4R and TA dyes was determined to be 190.1 mg g^-1 and 183.5 mg g^-1, respectively. Finally, the adsorbent's reusability was tested for six periods and could be reused repeatedly without significant reduction in adsorption performance.

Evaluating the safety of oral methylene blue during swallowing assessment: a systematic review

OBJECTIVE

Methylene blue (MB) is frequently administered during fiberoptic endoscopic evaluation of swallowing (FEES) to enhance visualization of pharyngeal bolus transit. However, the safety of MB is being questioned since serious adverse events (AEs) such as hemodynamic instability, hemolysis, and serotonin syndrome were reported. The aim of this study is a systematic analysis of the literature to obtain an evidence-based overview of AEs due to oral administration of MB and to determine its safety as a food dye during swallowing assessment.

METHODS

A systematic literature search was carried out in PubMed, Embase, and Cochrane Library. Two reviewers independently selected articles describing oral administration of MB as a main diagnostic/therapeutic intervention, dosage, and AEs. Expert opinions, conference papers, sample size < 10, and animal studies were excluded. Level of evidence of the included studies was determined.

RESULTS

A total of 2264 unduplicated articles were obtained. Seventeen studies met the inclusion criteria with 100% agreement between the two reviewers. Among these, twelve studies were randomized controlled trials. In a pooled population of 1902 patients receiving oral MB, three serious AEs were reported related to MB. Non-serious AEs showed a dose-related trend and were usually mild and self-limiting. A meta-analysis could not be performed as studies were methodologically too heterogeneous.

CONCLUSION

Serious AEs due to oral administration of MB are rare (n = 3, 0.16%). MB-related non-serious AEs are mild, self-limiting, and show a dose-related trend. These findings indicate that it is safe to use small amounts of MB as a food dye during swallowing examinations.

The color of skin: blue diseases of the skin, nails, and mucosa

Diseases of the skin, hair, nails and mucosa can appear as flesh-colored lesions or may present as any of the colors of the visual spectrum. Diseases associated with blue (or shades of blue) discoloration represent a unique group of conditions that occur de novo or as a reaction to either a topical or a systemic agent to which the individual has been exposed. Blue diseases can affect the skin, the nails or the mucosal membranes of the mouth (buccal mucosa, gingiva, lips, palate or tongue) or eyes (sclera). In addition to appearing blue, they can also appear as blue-black, blue-brown, blue-gray, blue-green, blue-purple, blue-red, and blue-silver. The conditions range from those secondary to exogenous agents (systemic or tattoo or topical) to syndromes to systemic diseases to tumors (adnexal, melanocytic, vascular, or miscellaneous). A comprehensive attempt to include all conditions that have been described as blue (or a shade of blue) has been performed by evaluating the following terms using the medical search engine PubMed: blue and either gingiva, lips, lunula, mucosa, nails, oral, palate, sclera, skin, or tongue. Subsequently, the conditions were organized by color (blue and shades of blue) and within each color by location (skin, nails, oral mucosa and sclera). The results are presented in organized tables; in addition, there is discussion of some of the conditions that are unique to one or more specific locations. In conclusion, 'preserve and cherish the pale blue dot' and remember that a big red rock eater with chrysiasis is the answer to the riddle, "What is big and blue and eats rocks?"

Nasojejunal tube feeding in children: knowledge and practice

Nasojejunal tubes (NJ) are used in small numbers of children outside of neonatal and paediatric intensive care units. There is limited evidence on which to base practice aside from insertion techniques. Ongoing care and management is largely based on historical practice and extrapolation from nasogastric tube practice. This paper presents the historical caseload data for 36 babies and children over a five year period. The children ranged from 0 to 13 years of age, and 95% were less than 2 years old. They had a median of 4 tubes each (range 1 - 46). The paper presents data from two surveys of health professionals that demonstrate a lack of consistency in practice. There are concerns about ongoing position checks and about the radiation burden in these children. Local practice is described that aims to reduce dependence on x-ray procedures and to stimulate debate. Finally, an argument is made for a better evidence base for future practice.

Brilliant Blue Dyes in Daily Food: How Could Purinergic System Be Affected?

Dyes were first obtained from the extraction of plant sources in the Neolithic period to produce dyed clothes. At the beginning of the 19th century, synthetic dyes were produced to color clothes on a large scale. Other applications for synthetic dyes include the pharmaceutical and food industries, which are important interference factors in our lives and health. Herein, we analyzed the possible implications of some dyes that are already described as antagonists of purinergic receptors, including special Brilliant Blue G and its derivative FD&C Blue No. 1. Purinergic receptor family is widely expressed in the body and is critical to relate to much cellular homeostasis maintenance as well as inflammation and cell death. In this review, we discuss previous studies and show purinergic signaling as an important issue to be aware of in food additives development and their correlations with the physiological functions.

Preparation, Characterization and Application of Silver Chloride-Eosin Y Inclusion Material

From the adsorptive precipitation of Cl–, eosin Y (EY) and Ag+, we developed in-situ inclusion of EY into growing silver chloride particles to form ternary electronegative micro-conductors. The composition of the particles was determined by inductively coupled plasma atomic emission spectrometry (ICP-OES), ion chromatography (IC) and spectrophotometry and the size and pattern of the particles characterized by the particle size analysis, X-ray diffractometer (XRD), scanning electron microscopy (SEM), and thermogravimetry. The results showed that the in-situ inclusion of EY into AgCl crystal particles in layer-by-layer and the supermolecular complex {[(AgCl)50EY]n}2n– was formed in cubic and globe-like shape. The ternary inclusion particles adsorbed cationic dyes selectively, rapidly and with high efficiency. A representative cationic dye, victoria blue B (VBB), was used to investigate the performance of the ternary particles as adsorbents and the mechanism involved. The equilibrium adsorption capacity of the ternary particles is 353 mg/g VBB, over 10 times higher than absorption to the silver chloride–only particles and over 3 times to activated carbon. Moreover, the adsorption approached the equilibrium in 10 min, which is much less than that with activated carbon in about 2 h. This work advanced a sample method for preparation of the supramolecular inclusion materials as dye adsorbent and it provided a simple, efficient and practical approach for the recovery or removal of organic substances from aqueous.

Complications related to feeding tube placement

PURPOSE OF REVIEW

Blind placement of a feeding tube can result in serious complications. Given the widespread use of tube feedings, even a small percentage of such problems can affect a significant number of people. The purpose of this review is to describe recent reports of feeding tube placement problems and to examine possible solutions.

RECENT FINDINGS

Multiple case reports of complications of malpositioned feeding tubes continue to surface; most are due to inadvertent placement in the respiratory tract. A tube with feeding ports in the esophagus significantly increases risk for aspiration, as does the displacement of a small bowel tube into the stomach of a patient with significantly slowed gastric motility. Isolated reports of a nasally placed tube entering the brain following head injury continue to occur, as do reports of esophageal and gastric perforation in neonates. A recent study showed that malpositioned tubes are not routinely recorded in risk management databases; it further demonstrated that a comprehensive intervention to reduce complications from small-bore nasogastric feeding tubes was effective.

SUMMARY

Complications related to malpositioned feeding tubes are usually preventable. Poor reporting of feeding tube placement errors hinders the adoption of effective protocols to prevent such errors.

Preliminary Evidence for a Medical Nutrition Therapy Protocol: Enteral Feedings for Critically Ill Patients

The objective of this study was to evaluate the evidence behind specific but common patient care decisions in support of enteral feedings for patients admitted to intensive care units. Six specific questions were developed and refined to address clinical outcomes specific to clinical practice decisions pertinent to enteral feeding of critically ill patients. The data sources consisted of an intensive literature review from five databases, using standardized search terms. Randomized controlled clinical trials, meta-analyses, consensus statements, reviews, US Food and Drug Administration alerts, and case reports were selected for study. Research reports were abstracted in detail and evaluated for research quality using the criteria developed by the American Dietetic Association. Consensus statements regarding the influence of specific enteral feeding methods on key clinical outcomes (ie, infectious complications, cost, length of hospital stay, and mortality) were developed and graded based on the quality of the available evidence. The data support the use of enteral over parenteral nutrition to reduce infectious complications and cost, and the initiation of enteral feedings within 24 to 48 hours of injury or admission to an intensive care unit to reduce infectious complications and length of hospital stay in head injury and trauma patients. Postpyloric tube placement is associated with reduced gastric residual volume and reflux, but adequately powered trials are not available to support prevention of aspiration pneumonia. Acceptance of gastric residual volumes of up to 250 mL may increase volume of formula delivered. Promotility agents are associated with reduced gastric residual volume. Feeding patients in the semirecumbent rather than supine position is associated with reduced aspiration pneumonia and pharyngoesophageal formula reflux. Actual delivery of 14 to 18 kcal/kg/day or 60% to 70% of goal is associated with improved outcomes, whereas greater intake may not be in some populations. Blue food coloring should not be used with enteral feedings due to its limited sensitivity for aspiration and some risk of mortality. Well-designed, adequately powered, randomized controlled clinical trials are needed to evaluate any benefit of tube tip position on aspiration pneumonia or mortality, and of early enteral feedings on mortality.

Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food

The purpose of this prospective study was to determine if fiberoptic endoscopic evaluation of swallowing (FEES) maintains high intra- and interrater reliability in detecting pharyngeal dysphagia and aspiration without the addition of FD&C Blue No. 1 to food. Twenty consecutive adults referred for a swallow evaluation participated. Nine subjects received blue-dyed food and 11 subjects received regular nondyed food, i.e., yellow pudding and white skim milk. Four variables were rated: (1) the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow; (2) evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow; (3) laryngeal penetration defined as material in the laryngeal vestibule but not passing below the level of the true vocal folds either before or after the pharyngeal swallow; and (4) tracheal aspiration defined as material below the level of the true vocal folds either before or after the pharyngeal swallow. Three speech-language pathologists experienced in interpreting FEES results independently and blindly reviewed the digitized videotape three times. Intrarater agreements for the four variables with blue-dyed and non-blue-dyed food trials were 100% and monochrome trials ranged from 95% to 100%. Average kappa values for interrater reliability ranged from moderate to excellent agreement (0.61-1.00) for all viewing conditions. Kappa values for blue-dyed trials versus monochrome trials were 0.83 and for non-blue-dyed trials versus monochrome trials were 0.88, indicative of excellent reliability under both viewing conditions. FEES maintains both high intra- and interrater reliability in detecting the critical features of pharyngeal dysphagia and aspiration using either blue-dyed or non-blue-dyed foods. The endoscopist, therefore, can be assured of reliable FEES results using regular, non-dyed food trials.

Nutritional support for the burn-injured patient

The nutritional needs of the bum-injured patient are exaggerated and change constantly with the patient's stage of convalescence. Nurses working closely with other members of the health care team, specifically the nutritional specialist, can positively affect the patient's survival by optimizing the nutritional assessment,delivering enteral feedings that meet established goals,minimizing the negative consequences of hyperglycemia, and minimizing unnecessary energy expenditures by the patient. Adequate nutritional is required for wound healing, immunocompetence, and, ultimately,patient survival.

Exhaled breath condensates: a potential novel technique for detecting aspiration

There is an urgent need for diagnostic procedures that can detect aspiration of oral and gastrointestinal (GI) secretions into the respiratory tract. Current approaches are limited by poor sensitivity and specificity. These techniques include (1) adding indicators to feedings; (2) recovery of lipid-filled macrophages in respiratory secretions; (3) measurement of changes in the pH of the upper GI and respiratory tracts; (4) endoscopic visualization of reflux events; and (5) measurement of increased glucose concentrations in respiratory secretions. Ideally, specific markers from various sites in the oral and GI tracts might be discovered in respiratory secretions, but conventional bronchoalveolar lavage for sampling respiratory secretions is not practical and involves some risk. Noninvasive measurements of indicators in the exhaled breath condensates could be used to detect aspiration, but a number of theoretical and practical aspects of such studies must be considered before this approach can be applied to the problem of aspiration.

Detection of aspiration in enterally fed patients: a requiem for bedside monitors of aspiration

BACKGROUND

Pulmonary aspiration of gastric and oropharyngeal contents is common in enterally fed patients. Detection of early aspiration in these patients has relied on clinical impression, the coloring of enteral feedings with dyes, and less commonly the detection of elevated glucose in tracheal aspirates. The potential benefits, risks, and clinical use of bedside monitors of aspiration are under increasing scrutiny.

METHODS

Literature review. Although this review reflects the opinions of the authors, recommendations of an expert consensus panel (North American Summit on Aspiration, which included one author, J. P. Maloney) were also used to guide recommendations. The specific recommendations of that panel are presented elsewhere.

RESULTS

No large prospective clinical trials have been done to evaluate the use and safety of bedside monitors for aspiration. Clinical impression remains a poor "gold standard" of aspiration diagnosis in enterally fed patients. The coloring of enteral feedings with blue dyes (chiefly FD&C Blue No.1) is ubiquitous in hospitals despite evidence that it is not sensitive and potentially harmful. Cases of absorption of blue dye from enteral feedings in patients with critical illness have raised concern about the safety of the blue dye method, particularly in light of apparent toxic effects of these dyes on mitochondria. The glucose detection method has not been embraced; it too has little use and is labor intensive.

CONCLUSIONS

Use of colored dyes in enteral feedings and glucose detection methods should be abandoned. Nonrecumbent positioning is an evidenced-based method for aspiration prevention that needs to be re-emphasized. Novel bedside methods of detecting early aspiration are needed to supplement preventative strategies.