No, Infants Should Not Be Given Orajel (Benzocaine) for Teething Pain
Benzocaine-containing products like Orajel are contraindicated in infants and young children due to the serious risk of life-threatening methemoglobinemia. The FDA issued warnings against using any benzocaine-containing products for infant teething treatment in 2011 1.
Why Benzocaine is Dangerous in Infants
Risk of Methemoglobinemia
Infants are at particularly high risk for developing methemoglobinemia from benzocaine exposure because they have lower levels of the enzyme (cytochrome b5 reductase) needed to reduce methemoglobin back to normal hemoglobin—approximately 50-60% of adult values 2.
Fetal hemoglobin is more easily oxidized to methemoglobin than adult hemoglobin, further increasing vulnerability in young infants 2, 3.
Methemoglobin levels >70% are potentially lethal, and even therapeutic application of benzocaine teething gels has resulted in methemoglobin levels of 20-69.9% in documented cases 2, 4, 5.
Documented Cases of Harm
A 6-year-old child developed a methemoglobin level of 69.9% (considered lethal) after using 7.5% benzocaine gel (Baby Orajel) for a toothache, requiring emergency treatment with methylene blue 4.
Multiple cases of severe methemoglobinemia requiring methylene blue treatment and critical care admission have been reported from benzocaine teething gel exposure in young children 5.
Even topical application to intact skin (such as for diaper rash) has caused methemoglobinemia with levels of 35% in a 6-day-old neonate 3.
Safe Alternatives for Infant Teething Pain
First-Line Non-Pharmacologic Approaches
Breastfeeding during discomfort has been shown to effectively reduce pain in infants 6.
Oral sucrose (0.1-1 mL of 24% solution or 0.2-0.5 mL/kg) given 2 minutes before anticipated discomfort 2, 6.
Skin-to-skin contact (kangaroo care) provides comfort and pain relief 2, 6.
Cold teething rings or clean, cold washcloths for the infant to chew on (general medical practice).
Pharmacologic Options if Needed
Acetaminophen (paracetamol) at appropriate weight-based dosing is safe and effective for teething discomfort 2.
Ibuprofen (for infants ≥6 months) at appropriate weight-based dosing 2.
Critical Clinical Pitfall
Despite FDA warnings, 63% of pharmacists surveyed in 2016 would still inappropriately recommend benzocaine-containing products for infant teething 1. This highlights the ongoing need for healthcare provider education and parent counseling about the dangers of these readily available over-the-counter products.
Recognition and Treatment of Methemoglobinemia
If benzocaine exposure has occurred, watch for:
Slate-gray or dusky blue cyanosis that does not improve with oxygen administration 2, 4.
Low oxygen saturation (typically 77-85%) despite 100% oxygen 4, 5.
"Chocolate brown" appearance of arterial blood 4.
Treatment requires immediate methylene blue 1-2 mg/kg IV over 3-5 minutes, which should reduce methemoglobin levels within 30-60 minutes 2, 4, 3.