How Should Fruits and Vegetables Be Washed?

Patient Presentation
A 6-month-old male came to clinic for his health supervision visit. He was doing well overall and his mother said that she was making her own baby food which he was taking well. She had already given him 3 different types of vegetables. “I want to give him the best food, and I am using a commercial food wash to clean the vegetables. But I’m worried that they still may not be getting clean, what do you recommend?” she asked.

The pertinent physical exam showed a healthy appearing male with normal vital signs and growth parameters in the 10-50%. The neurological examination was normal and developmentally the child was sitting without assistance and had no head lag when pulled to a seated position. The diagnosis of a healthy male was made. “I don’t really have an opinion about using one of the commercial food washes, but I would recommend that if you use it, you follow the manufacturer’s recommendations especially. If it says to soak or rinse the food in a certain way or length of time, that is how it is supposed to be use and how it was tested,” he replied. “Usually washing foods thoroughly with a large amount of clean water is a good idea. Keeping the kitchen surfaces clean and separating how you prepare protein and raw foods such as fruits and vegetables is important. Most importantly, infants and young children should not be given foods that could be choking hazards and there are a few foods that aren’t recommended for home preparation for baby foods. We can go over those,” he said.

Discussion
Fruits and vegetables are great sources of nutrition and often are eaten raw. However, they can become contaminated during harvest, transportation, production, preparation and storage. Produce accounts for about half of all foodborne illness and about 20% of foodborne deaths. Outbreaks have been associated with all food sources including home gardens, local farms and large scale commercial food operations. Vegetables most associated with illness are leafy green vegetables, herbs and sprouts.

Learning Point
What are the best ways to keep raw fruits and vegetables safe?

  • “Wash your hands with hot soapy water before and after preparing food.
  • Clean your counter top, cutting boards, and utensils after peeling produce and before cutting and chopping. Bacteria from the outside of raw produce can be transferred to the inside when it is cut or peeled. Wash kitchen surfaces and utensils with hot, soapy water after preparing each food item.
  • Do not wash produce with soaps or detergents. [They are not designed for this and residual product may be retained on the food. Fruits and vegetables are also porous and may absorb the detergent.]
  • Use clean potable cold water to wash items. [Some people recommend distilled water as it has been purified and filtered to remove contaminants.]
  • For produce with thick skin, use a vegetable brush to help wash away hard-to-remove microbes.
  • Produce with a lot of nooks and crannies like cauliflower, broccoli or lettuce should be soaked for 1 to 2 minutes in cold clean water.
  • Some produce such as raspberries should not be soaked in water. Put fragile produce in a colander and spray it with distilled water.
  • After washing, dry with clean paper towel. This can remove more bacteria.
  • Eating on the run? Fill a spray bottle with distilled water and use it to wash apples and other fruits.
  • Don’t forget that homegrown, farmers market, and grocery store fruits and vegetables should also be well washed.
  • Do not rewash packaged products labeled “ready-to-eat,” “washed” or “triple washed.” [It could actually become contaminated from your home food preparation area.]
  • Once cut or peeled, refrigerate as soon as possible at 40ºF or below.
  • Do not purchase cut produce that is not refrigerated.”

Washing just before the food is eaten is a common recommendation.

Leafy green vegetables should be stored within 2 hours of harvesting or purchasing at 35-45°F. They can be soaked in cold water for a few minutes, then change the water and repeat. Dry in a colander, strainer or salad spinner. Another option is to soak the greens in 1/2 cup of vinegar and 2 cups of water followed by a clean water rinse.

In a study that tested blueberries soaked in distilled water for 1-2 minutes against 3 different commercial fruit and vegetable washes (that followed the manufacturers instructions) it was found that 1 commercial product was the same as the distilled water wash for removing pesticides, and distilled water was better than the 2 other washes tested. The University of Maine which conducted the study recommends to “[s]oak all produce for one to two minutes to reduce the risk of food-borne illness.” They also state that “You can also use… very clean cold tap water to clean produce instead of distilled water.”

The Iowa State University Extension offered a home recipe for a fruit and vegetable wash: “1 quart water, 2T. baking soda, 2 T. grapefruit or other acidic juice and 1 tsp cream of tartar. This mixture can be refrigerated for up to 2-3 weeks and is safe for human consumption.”

Overall properly washing or soaking in cold water will significantly reduce bacterial and other contaminants, and drying also aids this reduction.

Questions for Further Discussion
1. What foods should not be used for homemade baby food? Click here to review.
2. What are developmental milestones for solid food readiness? Click here to review.
3. What are the recommendations for starting peanut containing foods for children at risk for food allergies? Click here to review.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Food Safety and Foodborne Illness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

The University of Maine Extension. Bulletin #4336, Best Ways to Wash Fruits and Vegetables.
Available from the Internet at https://extension.umaine.edu/publications/4336e/ (rev. 2013, cited 4/13/18).

Marrs, Beth. Iowa State University Extension. Washing Fruits and Vegetables.
Available from the Internet at https://blogs.extension.iastate.edu/answerline/2014/01/13/washing-fruits-and-vegetables/ (rev. 1/13/14, cited 4/13/18).

University of Connecticut Extension. Wash Your Veggies (and Fruits)
Available from the Internet at https://blog.extension.uconn.edu/2014/03/12/wash-your-veggies-and-fruits/ (rev. 3/12/14, cited 4/13/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Is Considered a Minor Automobile Crash?

Patient Presentation
A 3-month-old female came to clinic about 2 hours after being a restrained passenger in a low-speed car accident. The patient was inrear-facing car seat in the back seat of a 2-year-old, sedan-style car. The mother was driving in a parking lot and had been rear-ended by another car. The mother stated that the left rear light area had been damaged but the bumper was intact. The other car had right front light damage and was otherwise okay. Both drivers had no injuries, no airbags deployed in either car, and both cars were drivable. The infant had seemed slightly fussy after the incident and did not feed as well as usual so the mother wanted the child examined. The mother denied any other problems such as loss of consciousness. The past medical history showed a full-term infant who had received appropriate preventative care.

The pertinent physical exam revealed a smiling infant with normal growth parameters and vital signs. HEENT showed that the anterior fontanelle was patent and not bulging. Skin showed no bruising. Her neurological examination was normal. The diagnosis of a healthy 3 month old who had been in a low-speed car accident was made. The mother was counseled that the infant appeared well at this time and that this seemed to be a low-speed accident, therefore watchful monitoring was called for. “I’m not sure why the baby didn’t eat as well but she appears well now and I think you can just watch her as this sounds like a low-speed accident. Let’s look at the car seat you have here and see if it has any information about when to replace it after an accident too,” the pediatrician counseled. The car seat did not have any noticeable damage but did have a notice that it should be replaced if it was in a crash when examined by the pediatrician. “You should always follow the manufacturer’s recommendations and in this case, I would replace the car seat even though this seemed to be a low-speed collision,” she remarked. Later she was reviewing the encounter with the medical student who had accompanied her during the visit. The medical student asked at what speeds airbags deploy. “I’m not entirely sure but it is lower than you think. We should try to find the answer,” and they went to a computer to check the Internet for more information.

Discussion
Airbags are supplemental (not primary) safety devices in motor vehicles that are intended to prevent injuries mainly to the head, neck, and torso. They are designed to provide the greatest protection when the occupant is seated properly and wearing a seat belt properly. Front airbags are designed to inflate within 50 milliseconds of impact in a moderate to severe crash. They usually will deploy for belted occupants at speeds of 16 miles/hour (mph) or more, but with newer sensors and algorithms will deploy at lower speeds if they detect unbelted occupants (i.e. 10-12 mph). Forward airbags will also deploy for impacts in other vehicle locations if there is sufficient forward motion of the occupant detected. In the US front airbags have been required since the 1999 model year.

Side airbags are designed to inflate for side impacts or if parts of the vehicle begin to intrude in the passenger compartment. Head protection is considered of primary importance, but other airbags offer more pelvis or torso protection. As there is a smaller space between the vehicle’s side and the occupant, the airbags need to deploy quicker usually within 10-20 milliseconds of impact. Side airbags are not necessarily required in the US but are often used to meet the standards for head and torso protection required for all occupants.

Airbags may deploy from a variety of locations depending on the model. Steering wheel, passenger front panel, ceiling, doors, and seat backs are common locations for airbags which may be marked with “SRS” or “Airbag”. Airbags should be replaced with “OEM” or original equipment manufacturer replacement parts after they have been deployed. Recalled airbags should be replaced as soon as replacement parts are available by a qualified repair shop associated with a new-car dealership.

Other airbags include knee airbags, inflatable seat belt airbags, between seat airbags, and external hood airbags. In some countries airbags integrated into motorcycles are available. There is also a bicycle helmet that has an integrated airbag too.

National Highway Transportation Safety Administration (NHTSA) estimates that 44,869 lives have been saved by frontal airbags and 2252 saved because of side airbags up to 2015. Airbags can cause injury because they must inflate quickly. Therefore, drivers and front passengers should be as far back from the steering wheel and passenger instrument panel as they can: at least 10 inches from the occupant’s chest. Pregnant women, especially in their last trimester of pregnancy, if they cannot be positioned correctly are recommended to not drive. Shorter drivers may be able to slightly recline the seat or may need pedal extenders. A rear-facing car seat should never be put into a front passenger seat with an airbag as it positions the head to close to the airbag. All children should be placed in the rear seat. Children over 13 may sit in the front seat, properly belted in and positioned, but still the safest location is the middle or rear of the vehicle. Young children who must routinely be transported in the front seat can seek help from their car manufacturer or NHTSA regarding airbag options.

Learning Point
The National Highway Transportation Safety Administration (NHTSA) defined a minor motor vehicle crash and all criteria must apply as:

  • “The vehicle was able to be driven away from the crash site.
  • The vehicle door nearest the car seat was not damaged.
  • None of the passengers in the vehicle sustained any injuries in the crash.
  • If the vehicle has air bags, the air bags did not deploy during the crash; and
  • There is no visible damage to the car seat.”

Always follow the manufacturer’s instructions. A car seat should never be used that has been involved in a moderate to severe crash.

A moderate to severe crash is defined as the “equivalent to hitting a solid, fixed barrier at 8-14 mph or higher. (This would be the equivalent of striking a parked car of similar size at about 16-28 mph or higher.)

Questions for Further Discussion
1. What are the recommendations for use of car seats for various ages and sizes of children?
2. What are the recommendation for bike helmet use and bicycling safety for children?
3. What summer and winter safety guidance should be offered to families? For summer safety click here; for winter safety click here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Motor Vehicle Safety.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

NHTSA. Air Bags.
Available from the Internet at https://www.nhtsa.gov/equipment/air-bags (cited. 4/13/18).

Insurance Institute for Highway Safety. Highway Loss Data Institute. Airbags.
Available from the Internet at http://www.iihs.org/iihs/topics/t/airbags/qanda (cited 4/13/18).

NHTSA. Car Seat Use After a Crash.
Available from the Internet at https://www.nhtsa.gov/car-seats-and-booster-seats/car-seat-use-after-crash (cited 4/13/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What is BACM?

Patient Presentation
A 7-year-old female came to clinic with a history of sudden onset of lower leg pain in the afternoon. She had stayed home the past few days because of an influenza-like illness and had been improving. After a short nap she woke up and complained that her calf muscles hurt and she was crying. She would walk but this also increased the pain. Her mother tried to massage her legs but this made the pain worse. The mother put her in a warm bath and used warm compresses that helped the child some. In clinic about 4 hours after the onset of the symptoms, the mother said that she thought it was very strange because as they were getting ready to come to the office, her pain had gone away. She was walking normally and now denied any pain. Both mother and daughter said that the change was quite dramatic. She had no bowel or bladder problems and her urine continued to be a normal color and amount. She denied any neurological problems including any changes in sensation or mentation. She denied any pain elsewhere in her body. The patient had not traveled and influenza was circulating in the community. The past medical history was positive for pressure equalizing ear tubes at age 3. The family history was negative for any muscle, neurological or kidney disease. The review of systems was positive for rhinorrhea and cough that were both improving. Her last fever was 2 days previous.

The physical examination showed a normal appearing female in no distress. Vital signs were normal including growth parameters of ~75%. HEENT showed clear rhinorrhea. Lungs were clear and abdomen was soft. Palpation of the lower extremities was normal. Vigorous dorsiflexion of the foot did not elicit pain. There was normal range of motion in all lower extremity joints including the toes. No warmth, redness, or swelling was noted. Strength and tone were normal. DTRs were +2/+2 with down going Babinski reflexes bilaterally. There were normal pulses and sensation in the lower extremities. The patient had a normal gait. Her back also had normal range of motion and did not elicit any pain.

The diagnosis of a transient acute myositis was made. The family was counseled that this can occur at times usually due to viruses. They were to continue to monitor her and make sure she kept hydrated. They were also to monitor her urine output and report if there were any changes in the quantity or coloring. “Usually as the virus goes away, so do the muscle pains, but you keep watching her closely and call if things change,” the pediatrician counseled.

Discussion
Leg pain in children has a broad differential diagnosis and includes more innocuous problems such as growing pains and transient synovitis but also more serious problems including neurological diseases or malignancy. Occult or self-limited trauma are also common causes. A review can be found here. Limping can be painful or painless and has its own differential diagnosis which can overlap with leg pain. A differential diagnosis for limping can be found here. Muscle weakness also has its’ own differential diagnosis which can be found here.

Learning Point
Benign acute childhood myositis (BACM) has other names including viral myositis, acute myositis, influenza-induced myositis, or myalgia cruris eidemica. It is a benign acute myositis that occurs usually during the late winter or early springtime. School age children predominate but the range is ~3-14 years, with males being more common than females. Exact incidence as well as the exact disease mechanism are unknown.

Infectious agents that have been linked to it include influenza A (including H1N1), influenza B (most common overall), adenovirus, coxsackie, dengue, parainfluenza type 1, respiratory syncytial virus and Mycoplasma pneumoniae. The clinical course is that the patient has a viral prodrome for several days and the fever resolves. The patient then has sudden onset of lower extremity (particularly calf muscles) moderate to severe pain with refusal to walk/bear weight. The onset is often after a rest period such as a nap. Patients who are walking will try to minimize the muscle movement and may toe-walk or have a wide-based, stiff-legged gait (i.e. “Frankenstein gait”).

Physical examination shows pain usually in the gastronemius-soleus muscle groups, however rarely other groups can be involved predominantly in the lower extremities and very rarely in the upper extremities. The patient has normal strength, tone, deep tendon reflexes and normal neurological examination including sensory examination of the lower extremities. Laboratory testing is usually not needed but there is an elevated serum creatinine kinase level. Creatinine kinase level does not correlate with symptoms. There may also be elevated aspartate aminotransferase and alanine aminotransferase levels as well as leukopenia.

BACM is benign but Guillain-Barré, osteomyelitis and deep vein thrombosis may present acutely too. Rhabdomyolysis is also a rare complication of BACM and can be reviewed here. Compartment syndrome should be considered in the proper context also. Other problems such as dermatomyositis and muscular dystrophy usually have more chronic symptoms. Polio has not been eradicated from the world and with the appropriate history such as travel to Pakistan, Afghanistan or Nigeria, should also be a consideration.

The natural history of BACM is self-limited with resolution in about 1 week without sequelae. Recurrences are rare. Patients should be treated symptomatically.

Questions for Further Discussion
1. What are indications for a muscle biopsy?
2. What are indications for admission for leg pain?

3. What are indications for radiological imaging for leg pain?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Myositis and Muscle Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jain S, Kolber MR. A stiff-legged gait: benign acute childhood myositis. CMAJ. 2009 Nov 10;181(10):711-3.

Terlizzi V, Improta F, Raia V. Simple diagnosis of benign acute childhood myositis: Lessons from a case report. J Pediatr Neurosci. 2014 Sep-Dec;9(3):280-2.

Rosenberg T, Heitner S, Scolnik D, Levin Ben-Adiva E, Rimon A, Glatstein M. Outcome of Benign Acute Childhood Myositis: The Experience of 2 Large Tertiary Care Pediatric Hospitals. Pediatr Emerg Care. 2016 Aug 20. pp. 1-3.

Cavagnaro S M F, Aird G A, Harwardt R I, Marambio Q CG. Benign acute childhood myositis: Clinical series and literature review. Rev Chil Pediatr. 2017 Apr;88(2):268-274.

Magee H, Goldman RD. Viral myositis in children. Can Fam Physician. 2017 May;63(5):365-368.

Szenborn L, Toczek-Kubicka K, Zaryczanski J, Marchewka-Kowalik M, Miskiewicz K, Kuchar E. Benign Acute Childhood Myositis During Influenza B Outbreak. Adv Exp Med Biol. 2018;1039:29-34.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa