Skin discoloration with blue food coloring

OBJECTIVE: To describe a pediatric patient who developed a clinical cyanotic appearance after receiving an excessive amount of blue food coloring. CASE SUMMARY: An 11-year-old white girl with cerebral palsy was admitted for unresolving aspiration pneumonia and dehydration. Antibiotics and intravenous fluids were administered. During the hospital course, enteral nutrition containing blue food coloring was also administered. Twelve hours after the start of enteral nutrition, the patient appeared cyanotic despite a regular respiratory rate and normal oxygen saturation. The pediatric code response team was called. Enteral nutrition was stopped and then restarted without blue food coloring. Over the next 24 hours, the cyanotic appearance resolved and no further complications developed. DISCUSSION: At our institution, blue food coloring is used with enteral nutrition for detecting aspiration of stomach contents. The dietary department supplies food coloring to each nursing unit in pint-sized medicine bottles. Nurses place an unstandardized amount of blue food coloring into each enteral nutrition bag. This child received an unspecified amount of FD&C Blue No. 1 food coloring. No toxicity studies exist for acute or human ingestion, but the National Academy of Sciences lists 363 mg/d of FD&C Blue No. 1 as a safe level for humans. We estimated this child ingested 780–3940 mg of dye over a 12-hour period. CONCLUSIONS: This is the first known report of an adverse effect from blue food coloring. To prevent similar occurrences within our institution, the blue food coloring for tube feedings will be dispensed by the pharmacy department in standardized units.