An 8-month-old white male came to the emergency room with his mother visibly upset. She had been in the grocery store, when a well-meaning person asked her if she knew that her son was very yellow-colored. The mother recognizing this for the first time panicked, grabbed him from the cart and came immediately to the emergency room located a few blocks away. The past medical history revealed a previously full-term, healthy infant who had been gaining weight and developmental milestones appropriately. After his 6-month health supervision visit, she had started giving him sweet potatoes, carrots and squash as part of his diet. The family history and review of systems was negative.
The pertinent physical exam showed a smiling infant with growth parameters in the 50-75% and normal developmental milestones. HEENT showed no scleral icterus or yellowing of the mucous membranes. He was obviously yellow-colored generally with increased coloring around the nose and palms and soles. His abdominal examination was negative along with the rest of the examination. The diagnosis of carotenemia was made. The mother was calmed down and was educated about carotenemia. The infant already had a follow-up appointment with his primary care provider within the following month.
Carotenemia is a common problem in infants as carotene containing foods are often the first solid foods for infants. This is a benign problem and families can be reassured. It resolves in weeks to months depending on the diet. Carotenes are not synthesized by humans and are obtained through the diet. Carotenes are ingested as amorphous solids and crystals and breakdown of cellular membranes increases the bioavailability of the carotenes. Breakdown of the walls is often mechanical (e.g. grinding up of the food), but absorption is also affected through pancreatic lipases, thyroid hormone, bile acids, dietary fiber and dietary fat.
Carotene occurs in different forms with the most common being α, β, and γ. β-carotene is converted to Vitamin A but the conversion is so slow that even with large amounts of β-carotene Vitamin A toxicity does not occur. Carotenemia is also seen in anorexia nervosa, diabetes, hypothyroidism, liver disease and kidney disease. Some familial forms have been noted. It has also been described in large scale populations when food shortages changed diets significantly to plant-based diets such as in Europe during World War I and II.
Carotenes are deposited in the stratum corneum of the skin because it is fat-soluble giving the skin a yellow color. It is most easily seen in the nasolabial folds, palms and soles and takes about 2 weeks to equilibrate with the blood level. As they do not have a stratum corneum, the yellow discoloration is not seen in the conjunctiva or mucous membranes making it distinguishable from hyperbilirubinemia. Also patients with carotenemia are well and do not have other symptoms of hyperbilirubinemia. To see differential diagnoses for different types of hyperbilirubinemia, click on the following: Direct Hyperbilirubinemia, Indirect Hyperbilirubinemia in Older Children, or Indirect Hyperbilirubinemia in Neonates.
Most people know that carotenes are found in yellow and orange vegetables and fruits, but they often do not appreciate the green vegetables can contain significant amounts. The underlying yellow color is masked by the presence of chlorophyll within the plants.
Common foods that contain carotene include:
- Brassica – broccoli, brussel sprouts, kale
- Green beans
- Greens – beet, collard, spinach, swiss chard, many other plant leaves
- Sweet potatoes
- Squash including pumpkin
- Egg yolks
- Palm oil
- Coloring additives
There are many other foods depending on the region in the world.
Questions for Further Discussion
1. What other foods contain beta-carotene that are indigenous to your location?
2. What else can be included in a differential diagnoses of yellowed skin?
- Symptom/Presentation: Jaundice
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Sale TA, Stratman E. Carotenemia associated with green bean ingestion. Pediatr Dermatol. 2004 Nov-Dec;21(6):657-9.
Serrano J, Goni I, Saura-Calixto F. Determination of beta-carotene and lutein available from green leafy vegetables by an in vitro digestion and colonic fermentation method. J Agric Food Chem. 2005 Apr 20;53(8):2936-40.
Karthik SV, Campbell-Davidson D, Isherwood D. Carotenemia in infancy and its association with prevalent feeding practices. Pediatr Dermatol. 2006 Nov-Dec;23(6):571-3.
Djuikwo1 VN, Ejoh RA, Gouado I, Mbofung CM, Tanumihardjo SA. Determination of Major Carotenoids in Processed Tropical Leafy Vegetables Indigenous to Africa. Food and Nutrition Sciences, 2011, 2, 793-802 793.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital