Camphor Revisited: Focus on Toxicity

Committee on Drugs

This commentary updates a previous AAP state- TABLE. List of Camphor-Containing Products ment developed by the Committee on Drugs con- Product % of Camphor cerning camphor.1 The original commentary re- Absorbine Arthritic Pain Lotion 10 flected the level of concern among pediatric Act-On Rub Lotion 1.5 practitioners and poison centers about the toxicity of Anabaim Lotion 3 camphor. Since the original statement, the Food and Aveeno Anti-Itch Conc. Lotion 0.3 t Drug Administration (FDA) has recognized camphor Avalgesic Banaig Muscle Pain Reliever 2 as a safe and effective topical antitussive, analgesic, Bangesic t anesthetic, and antipruritic agent.2 Following the ap- Ben Gay Children’s Vaporizing Rub 5 proval process in 1983, the FDA required that the Betuline Lotion t concentration of camphor in products not exceed Campho-phemque First Aid Gel 10.8 Campho-phenique Uquid 10.85 11%.2 Fligher concentrations were not more effective Campho-phemque Powder 4.375 and could cause more serious adverse reactions if Counterpain Rub t accidentally ingested. Most reported camphor-re- Deep Down Rub 0.5 lated fatalities involved agents containing a concen- Dencorub Cream Dermal Rub t tration greater than 11%. Dermolin Liniment t Ingestion of potentially toxic substances by chil- Emul-O-Balm 1.1 dren is related to the availabffity of a product in their Heet Lotion 3 3.6 environment. Camphor remains widely available Heat Spray Minit-Rub 3.5 (Table). The toxicity of camphor when inappropri- Mollifene Ear Drops t ately used is well documented.6 Ingestion is the Musterole Regular 4 most common route of potentially toxic exposure, Panalgesic 3 with rapid onset of toxic effects. The risk of toxicity Pronto Gel Save the Baby 6 relates to both the concentration of camphor in the Sloan’s Liniment 3.35 ingested product and the rate of absorption of cam- Soltice Quick Rub 5 phor into the body. Suring Ointment 0.475 From 1985 through 1989, 32 362 human exposures ThermoRub Lotion t Vicks VapoRub 4.75 to camphor were reported to the American Associa- Vicks Vaposteam 6.2 tion of Poison Control Centers.71’ From 1985 through Vicks Throat Drops <0.5 1989, life-threatening toxicity occurred in 33 children Yager’s Liniment t

as the result of camphor ingestion. During this pe- * TI’ list is not meant to be all indusive. The list of products and riod, there were no ChildhOOd deaths as the result of their concentrations were gleaned from several sources including camphor ingestion. In 5 cases, the products ingested product labels, Poisindex (an electronic data base of Micromedix mc), Medical Toxicology,3 and Toxicologic Emergencies.4 contained more than 11% camphor even though they t These agents list camphor as an ingredient, but the concentra- had been discontinued in 1983. In 14 cases, the prod- tions are not specified. ucts contained between 10% and 11% camphor. In 4 cases, the products contained between 6% and 10% camphor. Major toxic events occurred in 7 cases Initial symptoms of camphor toxicity have oc- where products containing less than 5% camphor curred within 5 to 15 minutes of ingestion. With mild were ingested. In 3 cases, the concentration of cam- poisoning, gastrointestinal tract effects such as burn- phor was unknown (oral communication, Toby Lito- ing of the mouth, nausea, vomiting, and epigastric vitz, MD, president, American Association of Poison distress are more frequently reported than neuro- Control Centers and Chairmen of the Data Collection logic effects. Committee, Nov 2, 1992). Children continue to suffer Severe poisonings are characterized by central ner- toxic reactions from the unintentional ingestion of vous system signs of restlessness, excitement, delir- camphor at all concentrations. ium, and seizures. Seizures may be associated with apnea and asystole. Although as much as 42 g of camphor has been ingested by adults who have re- The recommendations in this statement do not indicate an exdusive course covered, the ingestion of 2 g generally produces dan- of treatment or procedure to be followed. Variations, taking into account gerous effects. In children, ingestions of 0.7 to 1.0 g of individual circumstances, may be appropriate. PEDIATRK3 (ISSN 0031 4005). Copyright C 1994 by the American Aced- camphor have proven fatal. If a product containing emy of Pediatrics. 5% camphor is ingested, 20 mL, or 4 teaspoons, is a Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Vol. 94 No. I July 1994 127 potentially lethal dose. Death results from respira- Jeffrey L. Blumer, PhD, MD tory depression (apnea) or complications of status Richard L Gorman, MD epilepticus. George H. Lambert, MD Every pharmacologically active agent has risks Geraldine S. Wilson, MD and benefits, and most can potentially cause severe LIAISON REPRESENTATIVES toxic reactions if an inappropriate dose or route of Donald R. Bennett MD, PhD, American Medical administration is used. The risks of a known toxin Assodation Joseph Mulinare, MD, MSPH, Centers for Disease such as camphor, however, must be weighed against Control & Prevention the potential benefits. Alternative agents exist for all Paul Kaufman, MD, Pharmaceutical Manufacturers’ the approved uses of camphor-for topical analgesia Assodation and anesthesia, benzocaine and tetracaine agents; for Sam A. Ucata, MD, Health Protection Branch, Canada topical antipruritic action, hydrocortisone; and for Paul Tomich, MD, American College of OB/GYN antitussive effects, multiple oral agents that contain Gloria Troendle, MD, Food and Drug Administration dextromethorphan. Sumner J. Yaffe, MD, National institutes of Health

In the recommendation of any therapeutic agent, AAP SECTION LIAISON the following considerations should be entertained: Charles J. Cot#{233},MD,Section on Anesthesiology the risks and benefits, the safest agent in the smallest CONSULTANT effective dose, and a delivery medium that has the Anthony R Temple, MD lowest potential for misuse. The potential medical benefits from the use of camphor-containing prod- REFERENCES ucts pale in comparison to their well-documented 1. Committee on Drugs. Camphor. Who needs it? Pediatrics. 1978;62: toxicity. In 1978, the Committee on Drugs asked in 404-406 the title of the original statement, “Camphor: Who 2. Food Drug Administration. Proposed rules: external analgesic drug Needs It?” In 1993, the Committee on Drugs has the products for over-the-counter human use; tentative final monograph. Federal Register. 1983;48:5852-5869 same answer as before: no one. 3. Ellenhorn MJ, Barceloux DG. Medical Toxicology. Diagnosis and Treatment of Human Poisoning. New York, NY: Elsevier; 1988: chap 22 RECOMMENDATIONS 4. Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman ES, Howland MA. Goldfrank’s Toxicologic Emergencies. 4th ed. East Norwalk, Conn: Appleton and Lange; 1990: chap 67 I . In accordance with FDA regulations, over-the- counter drug products may not contain concen- 5. Gibson DE, Moore GP, Pfaif JA. Camphor ingestion. Am I Emerg Med. 1989;7:41-43 trations of camphor which exceed 11%. Despite 6. Siegel E, Wason S. Camphor toxicity. Pediatr Clin North Am. 1986;33: this ruling, the toxicity of camphor-containing 375-379 products continues. As part of anticipatory guid- 7. Litovitz U, Normann SA, VeltriJC. 1985 annual report of the American ance and poison prevention measures, parents Association of Poison Control Centers national data collection system. Am J Emerg Med. 1986;4:427-458 should be made aware of common camphor-con- 8. Utovitz U, Martin TG, SC1UnitZ BF. 1986 annual report of the American taming products and the potential dangers of Association of Poison Control Centers national data collection system. these products. Am J Emerg Med. 19875:405-445 2. Since alternative therapies exist for all indications 9. Utovitz ii, Schmitz BF, Matyunas N, Martin TG. 1987 annual report of for camphor therapy, other therapeutic agents that the American Association of Poison Control Centers national data col- lection systems. Am I Emerg Med. 1988;6:479-515 do not contain camphor should be considered. 10. Utovitz U, Sclunitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers national data collection system. COMM1TFEE ON DRUGS, 1992-1993 Am J Emerg Med. 1989;7:495-545 Ralph E. Kauffman, MD, Chairperson 11. Litovitz ii, Schmitz BF, Bailey KM. 1989 annual report of the American William Banner, Jr. MD, PhD Association of Poison Control Centers national data collection system. Cheston M. Berlin, Jr. MD Am J Emerg Med. 19908:394-442

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1994 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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