Vapor Rub, Petrolatum, and No Treatment for Children with Nocturnal Cough and Cold Symptoms

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Vapor Rub, Petrolatum, and No Treatment for Children With Nocturnal Cough and Cold Symptoms

AUTHORS: Ian M. Paul, MD, MSc,a,b Jessica S. Beiler, WHAT’S KNOWN ON THIS SUBJECT: There are few evidence- MPH,a Tonya S. King, PhD,b Edelveis R. Clapp, DO,a Julie based therapies for children with cold symptoms. Topical Vallati, LPN,a and Cheston M. Berlin Jr, MDa aromatic compounds are widely used to treat cold symptoms Departments of aPediatrics and bPublic Health Sciences, Penn without contemporary evidence to support this practice. State College of Medicine, Hershey, Pennsylvania KEY WORDS WHAT THIS STUDY ADDS: A vapor rub combination of camphor, cough, congestion, rhinorrhea, camphor, menthol, eucalyptus, menthol, and eucalyptus oils provided nocturnal symptom relief placebo, upper respiratory infection for children with cold symptoms. Children treated with vapor rub ABBREVIATIONS had improved sleep, as did their parents, when compared with URI—upper respiratory infection children given placebo or no treatment. OTC—over-the-counter VR—vapor rub This trial has been registered at www.clinicaltrials.gov (identifier NCT00743990). www.pediatrics.org/cgi/doi/10.1542/peds.2010-1601 abstract doi:10.1542/peds.2010-1601 Accepted for publication Aug 13, 2010 OBJECTIVE: To determine if a single application of a vapor rub (VR) or petrolatum is superior to no treatment for nocturnal cough, conges- Address correspondence to Ian M. Paul, MD, MSc, Department of Pediatrics, Penn State College of Medicine, HS83, 500 University tion, and sleep difficulty caused by upper respiratory tract infection. Drive, Hershey, PA 17033-0850. E-mail: [email protected] METHODS: Surveys were administered to parents on 2 consecutive PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). days—on the day of presentation when no medication had been given Copyright © 2010 by the American Academy of Pediatrics the previous evening, and the next day when VR ointment, petrolatum FINANCIAL DISCLOSURE: Dr Paul has been a paid consultant for ointment, or no treatment had been applied to their child’s chest and the Consumer Products Healthcare Association, McNeil Consumer Health Inc, the Procter and Gamble Company, Reckitt neck before bedtime according to a partially double-blinded random- Benckiser Healthcare International Ltd, and Novartis Consumer ization scheme. Health Inc; the other authors have indicated they have no financial relationships relevant to this article to disclose. RESULTS: There were 138 children aged 2 to 11 years who completed Funded by the National Institutes of Health (NIH). the trial. Within each study group, symptoms were improved on the second night. Between treatment groups, significant differences in improvement were detected for outcomes related to cough, congestion, and sleep difficulty; VR consistently scored the best, and no treatment scored the worst. Pairwise comparisons demonstrated the supe- riority of VR over no treatment for all outcomes except rhinorrhea and over petrolatum for cough severity, child and parent sleep difficulty, and combined symptom score. Petrolatum was not significantly better than no treatment for any outcome. Irritant adverse effects were more common among VR-treated participants. CONCLUSIONS: In a comparison of VR, petrolatum, and no treatment, parents rated VR most favorably for symptomatic relief of their child’s nocturnal cough, congestion, and sleep difficulty caused by upper respiratory tract infection. Despite mild irritant adverse effects, VR provided symptomatic relief for children and allowed them and their parents to have a more restful night than those in the other study groups. Pediatrics 2010;126:000

PEDIATRICS Volume 126, Number 6, December 2010 1 Downloaded from www.aappublications.org/news by guest on September 24, 2021 Upper respiratory infections (URIs) termine if a single application of a va- criteria for enrollment were estab- are the most common acute illnesses por rub (VR) or petrolatum is superior lished. Only parents who answered at in the world,1 and symptoms caused by to no treatment for nocturnal cough, least “moderately often” for cough fre- these infections are disruptive for chil- congestion, and sleep difficulty caused quency and “moderately severe” for dren. The characteristic features of by URIs. We hypothesized that VR or stuffy nose (both equivalent to 4 points URIs are often adversely affected sleep petrolatum would be superior to no on the scale) on the basis of the previ- for both ill children and their parents treatment for relief of nocturnal symp- ous night’s symptoms were eligible. with an effect on subsequent daytime toms and that VR would be superior to After stratification for age (2–5 and activities. In addition to attempting to petrolatum. 6–11 years), each child was randomly improve their comfort, giving medica- assigned in a partially double-blinded tions to children before bed is often an METHODS fashion to 1 of 3 treatment groups: VR attempt by parents to improve their From October 2008 through February ointment (Vicks VapoRub, which con- own sleep and functioning during the 2010, patients were recruited from a tains camphor [4.8%], menthol [2.6%], subsequent day. university-affiliated pediatric practice and eucalyptus oil [1.2%] [Procter and Recent studies2,3 and guidelines4–7 in Hershey, Pennsylvania. Eligible pa- Gamble, Cincinnati, OH]); petrolatum have questioned the efficacy of many tients were aged 2 to 11 years with ointment (Equate 100% pure white pe- oral over-the-counter (OTC) treat- symptoms attributed to URIs charac- troleum jelly [Wal-Mart Inc, Benton- ments for URI symptoms. Clinicians terized by cough, congestion, and rhi- ville, AR]); and no treatment. For the 2 and parents have been left with limited norrhea that lasted 7 days or longer. groups that received an ointment, the therapeutic options to administer to Patients were excluded for signs or dose volume distributed was stratified children with these disruptive symp- symptoms of a more treatable disease according to age: 5 mL (2–5 years) and toms. Alternatives to oral medications (eg, asthma, pneumonia, laryngotra- 10 mL (6–11 years). The randomization are popular topical preparations that cheobronchitis, sinusitis, allergic rhi- sequence was constructed by a statis- contain menthol, camphor, and euca- nitis). They were also ineligible with a tician not affiliated with the study and lyptus oils and have been used in history of asthma, chronic lung dis- was used to assign treatment groups. adults and children for more than a ease, or a seizure disorder. Children All study parents were instructed on century.8–12 with seizure disorders were excluded routine care for children with URI, in- Commenting on camphor-containing because of the reported association of cluding hydration measures, saline products, in 1994 the American Acad- camphor with seizures, particularly af- nose spray use, and use of acetamino- emy of Pediatrics Committee on Drugs ter ingestions of toxic amounts.13 Fi- phen or ibuprofen as needed for com- wrote, “Since alternative agents exist nally, subjects were excluded if on the fort. Because nasal saline could affect for all indications for camphor ther- night before enrollment they used OTC some outcome measures, parents apy, other therapeutic agents that do or prescription medication that con- were asked to not use it within 1 hour not contain camphor should be consid- tained VR components, pseudoephed- of bedtime or throughout the night. ered.”13 The “alternative agent” for rine, phenylephrine, dextromethor- They were instructed not to administer cough and cold symptoms cited by the phan, guaifenesin, diphenhydramine, excluded OTC medications listed above Committee in 1994, dextromethor- brompheniramine, chlorpheniramine, to their child at any time after enroll- phan, was subsequently not recom- or honey. ment and to avoid giving them caffein- mended by that committee 3 years Subjective parental assessments of ated beverages within 4 hours of later in a policy statement on dextro- their child’s symptoms on the previous bedtime. methorphan use.4 Dextromethorphan night were assessed after informed To maintain investigator blinding, all continues not to be recommended,14 and consent was obtained through a mod- study groups received an opaque pa- therefore the question of whether clini- ified version of our previously used per bag that contained a glass speci- cians can recommend topical prepara- and validated questions15 by using a men cup filled with either ointment or tions containing camphor, menthol, and 7-point Likert scale (Fig 1). Trained no treatment. Given the aromatic and eucalyptus oil for URI symptoms in chil- study coordinators were responsible characteristic smell of VR, a series of dren requires reevaluation. for survey administration, and survey steps was required to maintain paren- With no contemporary evidence that responses ranged from most severe tal blinding. First, a second glass spec- supports or refutes the efficacy in chil- symptoms (7 points) to no symptoms imen cup labeled for parents was dren with URIs, this study sought to de- (1 point). Minimum symptom-severity placed in each bag. Although the par-

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1. How OFTEN did your child COUGH last night?

□1 □2 □3 □4 □5 □6 □7 Not at all Moderately Very Often Often Often

2. How SEVERE was your child’s COUGH last night?

□1 □2 □3 □4 □5 □6 □7 Not at all Moderately Very Severe Severe Severe

3. How SEVERE was your child’s STUFFY NOSE last night?

□1 □2 □3 □4 □5 □6 □7 Not at all Moderately Very Severe Severe Severe

4. How SEVERE was your child’s RUNNY NOSE last night?

□1 □2 □3 □4 □5 □6 □7 Not at all Moderately Very Severe Severe Severe 5. How much did last night’s cough and cold symptoms affect your CHILD’S ABILITY TO SLEEP?

□1 □2 □3 □4 □5 □6 □7 Not at all A moderate Very much amount Much 6. How much did your child’s cough and cold symptoms affect your OWN ABILITY TO SLEEP last night?

□1 □2 □3 □4 □5 □6 □7 Not at all A moderate Very much amount Much FIGURE 1 Survey questions to assess nocturnal URI symptoms. ent cup for the no-treatment group ent whether the treatment had an questions about adverse effects such was empty, similar to their child’s cup, odor, and the participating parent was as hyperactivity, sleepiness, headache, the cups for parents in the VR and pet- instructed to ask other family mem- rash, and skin redness were included rolatum groups were both ﬁlled with bers also not to comment on this. as were some inquiring about symp- VR. Second, 30 minutes before their Lastly, parents agreed not to remove toms associated with VR use (burning child retired for the evening, parents the VR from under their noses until af- sensation of skin, nose, and eyes). Fi- opened their opaque bag and removed ter completing their survey the follow- nally, parents were asked what treat- the cup labeled for parent use. Parents ing morning. ment they thought their child had re- in the VR and petrolatum groups then ceived. Blinded study coordinators This second survey, in which parents applied the VR between their upper lip contacted parents during that day to were asked the same questions re- and nose before opening their child’s retrieve responses. A physician exam- lated to the child’s illness as those an- treatment. After this, for the VR- and ination was not routinely performed petrolatum-treated groups, parents swered at enrollment, was self- on the second study day. were instructed to apply the entire completed by parents within 30 contents of the specimen cup labeled minutes of waking the morning after Sample-size calculations indicated for their child to the upper chest and the above-listed procedures. Ques- that 138 subjects (46 per arm) would neck area of their child and massage tions were included to assess addi- have 80% power to detect a 1-point the ointment in for 1 minute. Children tional treatments, including analge- Likert-scale difference between any 2 were asked not to disclose to their par- sics and nasal saline. Speciﬁc treatment groups on the basis of a Wil-

PEDIATRICS Volume 126, Number 6, December 2010 3 Downloaded from www.aappublications.org/news by guest on September 24, 2021 coxon rank-sum test with Bonferroni- TABLE 1 Baseline Characteristics (N ϭ 138) corrected ␣ ϭ .0167 to allow for 3 pair- Characteristic VR Petrolatum No Treatment wise comparisons for outcomes (N ϭ 44) (N ϭ 47) (N ϭ 47) related to cough, congestion, rhinor- Age, mean Ϯ SD, y 5.8 Ϯ 2.9 5.8 Ϯ 2.7 5.8 Ϯ 2.9 Gender, n (%) rhea, and sleep difficulty. Female 21 (47.7) 23 (48.9) 27 (57.4) Between-study-group baseline and de- Male 23 (52.3) 24 (51.1) 20 (42.6) Race/ethnicity, n (%) mographic features were compared White 41 (93.2) 40 (85.1) 35 (74.5) by using a ␹2 and Fisher’s exact test Black 0 (0.0) 1 (2.1) 4 (8.5) where appropriate for gender and Hispanic 3 (6.8) 2 (4.3) 1 (2.1) race and Fisher’s exact tests for Asian 0 (0.0) 2 (4.3) 3 (6.4) Ͼ1 race/ethnicity 0 (0.0) 2 (4.3) 2 (4.3) weight and age. Within-treatment- Other 0 (0.0) 0 (0.0) 2 (4.3) group comparisons for the 2 nights Duration of cough, mean Ϯ SD, d 4.3 Ϯ 1.6 4.1 Ϯ 1.4 4.4 Ϯ 1.5 were conducted using paired t tests. Duration of congestion, mean Ϯ SD, d 4.1 Ϯ 1.5 4.2 Ϯ 1.6 4.2 Ϯ 1.6 Cough frequency score, mean Ϯ SD 5.6 Ϯ 1.3 5.1 Ϯ 1.2 5.3 Ϯ 1.2 Treatment group comparisons were Cough severity score, mean Ϯ SD 5.1 Ϯ 1.3 5.0 Ϯ 1.4 5.0 Ϯ 1.2 conducted by analysis of covariance, Congestion severity score, mean Ϯ SD 5.0 Ϯ 1.3 4.9 Ϯ 1.0 4.9 Ϯ 1.1 which was deemed appropriate after Rhinorrhea severity score, mean Ϯ SD 3.6 Ϯ 1.8 3.4 Ϯ 1.8 3.4 Ϯ 1.6 Effect on child ability to sleep score, mean Ϯ SD 5.1 Ϯ 1.6 5.3 Ϯ 1.5 5.2 Ϯ 1.5 assessment outcome variable distri- Effect on parent ability to sleep score, mean Ϯ SD 4.9 Ϯ 1.9 4.9 Ϯ 1.7 5.0 Ϯ 2.1 bution. For the primary analysis of Combined symptom score, mean Ϯ SD 29.1 Ϯ 6.4 28.5 Ϯ 5.9 28.8 Ϯ 5.7 treatment effect, the outcome of No significant difference between treatment groups exists for any baseline characteristic. between-night change included baseline scores as a covariate. Fisher’s exact tests were used to compare groups. There were no demographic For both cough severity and cough fre- adverse reaction rates between or baseline symptom-severity differ- quency, VR was significantly better treatments. ences between groups. than no treatment (P Ͻ .01), but only The study was approved by Penn State The baseline symptom scores that de- marginally better than petrolatum for College of Medicine’s Human Subjects scribed the night before enrollment frequency (P ϭ .07) and severity (P ϭ Protection Office and was registered at when no participants received treat- .06). Petrolatum was marginally better www.clinicaltrials.gov before the first ment were compared with scores than no treatment for cough frequency subject’s enrollment. Informed con- from the subsequent night when VR, (P ϭ .09), but not better than no treat- sent was obtained from participating petrolatum, or no treatment was given ment for cough severity. For nasal con- parents, and verbal assent was ob- before bed. Within each treatment gestion, the only significant pairwise tained from children older than 7 group, all outcomes were signifi- comparison was VR versus no treat- years. cantly improved on the subsequent ment (P ϭ .01); other comparisons be- night (P Ͻ .05 for all). When sepa- tween individual treatments were not RESULTS rated by treatment group, with the significant. There were 144 children with URIs en- exception of rhinorrhea severity, sig- The most profound effects in pairwise rolled, and 138 (95.8%) completed the nificant differences were detected in comparisons were for the outcomes single-night study. The mean age of the the amount of improvement re- related to sleep. As rated by parents, children completing the study was ported for all of the study outcomes children treated with VR were signifi- 5.8 Ϯ 2.8 years (Table 1). Of these par- in the planned 3-way comparison cantly more able to sleep than were ticipants, 51.4% were female, and (Fig 2). Again, with the exception of rhi- children randomized to receive petro- 85.5% were described by their parents norrhea, all of the outcomes found VR latum (P ϭ .006) or no treatment (P Ͻ as white and non-Hispanic. The cohort to yield the greatest improvement, fol- .001). No significant difference was de- had been coughing on average 4.3 Ϯ lowed by petrolatum, whereas no tected between petrolatum and no 1.5 days and congested 4.2 Ϯ 1.5 days treatment consistently showed the treatment. Similarly, parents of chil- before enrollment. Of the children who least amount of improvement (P Ͻ .05 dren treated with VR rated their own completed the study, 44 were ran- for all). ability to sleep as significantly better domly assigned to the VR study group, Because differences existed for all out- than did parents of children random- and 47 participants were randomly as- comes except rhinorrhea, pairwise ized to petrolatum (P ϭ .008) or no signed to each of the other study comparisons were then performed. treatment (P Ͻ .001).

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was significantly better than petrolatum (P ϭ .03) and no treatment (P Ͻ .001) whereas petrolatum was marginally better than no treatment (P ϭ .08). To help understand parents’ ability to judge their child’s nocturnal symptoms, parents quantified the number of times they checked on their child between the time the child went to sleep and the time they awoke. On the night before enrollment, parents reported checking their child a median of 4 times (interquartile range: 2–5); they checked their child a median of 3 times on the treatment night (interquartile range: 2–5). No significant difference was detected between treatment groups for either night. Several secondary analyses were conducted. First, there was no effect of illness duration on treatment effect. Sec- ond, parents were asked about other therapies used on the treatment night both before and after the treatment bag was opened. In the hours between enrolling in the study and opening the treatment bag, there was a significant difference between treatment groups in the use of acetaminophen (P ϭ .004), with 36% of petrolatum-treated children receiving the drug compared with 16% in the VR group and 9% in the no-treatment group. There were no significant differences between groups for any other remedy. After opening the treatment bag, 13% of children in the petrolatum group were given acetaminophen, compared with 7% in the VR-treatment and 0% in the no-treatment groups, respectively (P ϭ .03). Among children in the no- treatment group, 9% were given a cough and cold medication by their FIGURE 2 parents, whereas no child in the other Between-night treatment effects of VR, petrolatum, and no treatment on (A) cough frequency (P ϭ .003, 3-way treatment comparison), (B) cough severity (P ϭ .02), (C) severity of congestion (P ϭ .04), 2 study groups received such drugs (D) severity of rhinorrhea (P ϭ not significant), (E) child’s ability to sleep (P Ͻ .001), (F) parent’s (P ϭ .03). There were no other signifi- Ͻ Ͻ ability to sleep (P .001), and (G) combined symptom score (P .001). N/S indicates nonsignificant. cant differences between groups for A combined symptom score was calcu- rhinorrhea; child sleep; and parent other remedies. lated using all study outcomes: cough sleep. In addition to the significant 3-way Adverse effects were more common in frequency; cough severity; congestion; treatment comparison (P Ͻ .001), VR the VR group (Table 2). Twenty (46%)

PEDIATRICS Volume 126, Number 6, December 2010 5 Downloaded from www.aappublications.org/news by guest on September 24, 2021 TABLE 2 Parent-Reported Adverse Effects (N ϭ 138) effect that parents reported for their VR Petrolatum No Treatment P own sleep after VR application to their (N ϭ 44), n (%) (N ϭ 47), n (%) (N ϭ 47), n (%) child. Although improved parent sleep Skin rash 2 (5) 0 (0) 0 (0) .10 is obviously related to child’s sleep, the Skin redness 2 (5) 0 (0) 0 (0) .10 Burning sensation of the skin 12 (28) 0 (0) 0 (0) Ͻ.001 mechanism by which sleep is im- Burning sensation of the nose 6 (14) 0 (0) 0 (0) Ͻ.001 proved for children with URIs treated Burning sensation of the eyes 7 (16) 0 (0) 0 (0) Ͻ.001 with VR is unclear. It is probable that Hyperactivity 1 (2) 0 (0) 0 (0) .32 Sleepiness 1 (2) 3 (6) 1 (2) .62 some, if not all of this effect is because Headache 1 (2) 2 (4) 0 (0) .53 of relief of other symptoms. Whether an additional mechanism of aromatics is contributing is unclear. Nonethe- participants in the VR group reported strates that this therapy is indeed ef- less, the benefit on child sleep is clear at least 1 adverse event, with nearly all fective. As rated by their parents, in this study and indicates that the rel- of them being expected, mild irritant children with URIs who were treated atively common irritant adverse ef- 16,17 adverse effects. Parents of 28% of with VR had more nocturnal relief fects were generally transient. participants in the VR group reported from cough, congestion, and sleep Although the investigators were blinded a burning sensation of the skin, difficulty than did children treated to all 3 treatment groups, one-third of whereas 16% and 14% reported a with a placebo ointment, petrolatum, the cohort, those in the no-treatment burning sensation of the eyes and or with no treatment. arm, were unblinded. Also, although nose, respectively. No child in the other The benefits of aromatic compounds every attempt was made to blind par- 2 study groups had these adverse ef- that produce a cooling sensation such fects (P Ͻ .001 for all comparisons). ents to whether their child was treated as menthol seem to stem from effects Importantly, within the group of 44 VR- with VR or petrolatum, adherence to on the TRPM8 cation channel. This treated children there was no signifi- the protocol details could not be guar- channel is activated by menthol and cant differences in any study outcome, anteed. In addition, parents of partici- thermal stimuli in the cool to cold including sleep, for the 15 children pating children who experienced the range, which indicates that the cool who reported a burning sensation of sensation of skin, nose, or eye burning sensation elicited by compounds such the skin, eyes, and/or nose compared were likely to realize which treatment as menthol acts on a thermally sensi- with the 29 in that study group who did their child received even if they ad- tive receptor.18,19 Most likely through not report these symptoms, which sup- hered to the protocol as instructed. this mechanism, menthol has been ports the notion that these were of Next, it is notable that children in the shown to improve the nasal sensation mild severity. All other adverse effects petrolatum group were given acet- were rare and did not differ between of airflow in congested adults with aminophen more commonly by their 20 the 3 study groups. URIs and healthy school-aged chil- parents. Explanations could relate to dren.21 Compounds that contain men- differences in the illnesses for this As expected, all 47 (100%) parents who thol and/or camphor have also been treatment group or to differences in applied no treatment correctly shown to reduce respiratory rate and parenting practice, but symptom se- guessed their child’s study group restlessness in children with acute verity for the outcomes of interest was when surveyed the next morning. bronchitis,22,23 reduce evoked cough in not different at baseline. Related to Among VR-treating parents, 38 of 44 healthy adults,24 and improve mucocili- rescue treatment, 9% of parents in the (86%) guessed correctly, as did 42 of ary clearance in adults with chronic no-treatment group admitted to ad- 47 (89%) parents of petrolatum- bronchitis.25 treated children. ministering a cough and cold medica- The improved ability of children to tion overnight despite explicit instruc- DISCUSSION sleep with VR is noteworthy. A child’s tions not to, which indicates that some The results of this study indicate that inability to sleep during a URI can be parents have a strong desire to do an old, commonly used remedy is ef- disruptive to their daytime functioning something for URI symptoms and are fective at providing symptomatic reas well as the functioning of other fam- not content to simply observe their lief from nocturnal cold symptoms. ily members. The significant benefit children or provide “supportive care.” Combinations of aromatic oils in a seen in ability to sleep for those in the An additional study limitation is that petrolatum base have been used for VR group is an important finding for each child had a physician visit be- generations, but this study demon- families especially given the positive tween the 2 study nights, which may

6 PAUL et al Downloaded from www.aappublications.org/news by guest on September 24, 2021 ARTICLES provide some of the explanation for was associated with ingestion of ille- symptoms, and clinicians want to offer the improvement in all of the groups, gally sold camphor.28 In contrast with evidence-based therapies. Although including the no-treatment group, be- oral ingestion, dermal exposure to limited data support many commonly cause parents may have been reas- camphor, as occurs when following available and OTC remedies for cough sured that their child had a URI instead the directions for use of VR, results in cold symptoms, the current data indi- of a more severe illness. Alternatively, low systemic exposure.34 Serious ad- cate that VR helps to ﬁll the therapeu- some of the improvement in all groups verse events such as seizures associ- tic void. Despite mild irritant adverse can also be attributed to the natural ated with dermal exposure are gener- effects, VR provided symptomatic re- history of URIs, which generally im- ally limited to young infants in whom lief for children with URIs and allowed prove with time and supportive care. VR use is not recommended.30,35 Mini- them and their parents to have a more The subjective survey used for this mizing safety concerns, the Food and restful night. study may also be considered as a Drug Administration approved cam- limitation, but clinicians and parents phor as an effective antitussive, but ACKNOWLEDGMENTS often make decisions on the basis of limited the concentration in prepara- This study was supported by an unre- subjective assessment of symptom tions to 11%.36 The concentration in VR stricted research grant from Procter severity, which has been argued ointment is 4.8%. Although recom- and Gamble to Penn State University previously.3,26,27 mended only for topical use, at this and by National Institutes of Health Some clinicians may express caution concentration it is estimated that an General Clinical Research Center grant about using a product that contains ingestion of 20 mL of VR is required to M01RR10732 and GCRC construction camphor because of the association produce toxic effects and 40 mL to po- grant C06RR016499 awarded to the between toxic ingestions and adverse tentially cause a fatality in a child Pennsylvania State University College events such as seizures.28–32 Historical younger than 6.29 of Medicine. concerns over the toxicity of camphor Dr King had full access to all the data in centered on the ingestion of camphor CONCLUSIONS the study and takes responsibility for as a liquid preparation, camphorated Parents desire effective therapies for the integrity of the data and the accu- oil,13,33 and a recent report of seizures their children with cough and cold racy of the data analysis. REFERENCES

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8 PAUL et al Downloaded from www.aappublications.org/news by guest on September 24, 2021 Vapor Rub, Petrolatum, and No Treatment for Children With Nocturnal Cough and Cold Symptoms Ian M. Paul, Jessica S. Beiler, Tonya S. King, Edelveis R. Clapp, Julie Vallati and Cheston M. Berlin, Jr Pediatrics originally published online November 8, 2010;

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 Vapor Rub, Petrolatum, and No Treatment for Children With Nocturnal Cough and Cold Symptoms Ian M. Paul, Jessica S. Beiler, Tonya S. King, Edelveis R. Clapp, Julie Vallati and Cheston M. Berlin, Jr Pediatrics originally published online November 8, 2010;

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