Is it safe to use a topical anesthetic (e.g., benzocaine or lidocaine) for a teething infant under two years old?

Topical Numbing Agents for Baby Teething: Safety Recommendations

Do Not Use Topical Anesthetics for Teething in Infants

Topical anesthetic agents containing benzocaine or lidocaine should NOT be used for teething in infants under 2 years of age due to serious safety risks including methemoglobinemia, seizures, respiratory arrest, and death. 1, 2, 3

Why These Products Are Dangerous

Benzocaine-Specific Risks

• Benzocaine products are only approved for children 2 years and older according to FDA labeling, yet teething products containing benzocaine remain available over-the-counter 1
• The FDA issued warnings in 2011 against benzocaine use for infant teething due to methemoglobinemia risk—a potentially fatal condition where oxygen-carrying capacity of blood is severely reduced 4
• Case reports document severe methemoglobinemia (levels 20-55%) requiring methylene blue treatment and ICU admission from benzocaine teething gel exposure 2, 5
• Despite FDA warnings, 63% of pharmacists still inappropriately recommend benzocaine products for infant teething 4

Lidocaine-Specific Risks

• Lidocaine teething gels have caused seizures, respiratory arrest, and death in infants and young children 3
• Toxicity can occur from therapeutic application by parents, not just accidental overdose 6, 5
• Infants under 6 months have 30% reduced hepatic metabolism of lidocaine, increasing toxicity risk 7
• As little as one teaspoon can be toxic in children under 6 years old 6

General Topical Anesthetic Concerns in This Age Group

• The American Academy of Pediatrics notes concerns about methemoglobinemia, prolonged application times needed for effectiveness, local skin irritation, and toxicity—especially in young infants 8
• EMLA cream (lidocaine/prilocaine combination) should NOT be used in infants <12 months who are receiving methemoglobin-inducing agents due to additive methemoglobinemia risk 7

Lack of Evidence for Efficacy

• Literature supporting lidocaine efficacy for teething is scant and difficult to interpret due to flawed trial design 3
• The Australian and New Zealand Society of Paediatric Dentistry and the American Academy of Pediatrics do not recommend topical agents for teething 3
• The US FDA does not recommend topical lidocaine for teething due to toxicity concerns 3

Safe Alternatives for Teething Pain

Recommended Non-Pharmacologic Approaches

While the provided guidelines focus on procedural pain in neonates rather than teething specifically, safe alternatives for teething discomfort include:

• Cold teething rings (not frozen, which can damage gums)
• Gentle gum massage with clean finger
• Age-appropriate teething toys
• Comfort measures including holding and soothing the infant

When to Consider Systemic Analgesics

• For significant discomfort, oral acetaminophen or ibuprofen (age-appropriate dosing) is safer than topical anesthetics
• Consult pediatrician for appropriate dosing and frequency

Critical Safety Pitfall

The most dangerous pitfall is that these products remain readily available over-the-counter despite serious safety warnings, and many healthcare providers continue to recommend them. 4 Parents may assume products marketed for babies are safe, but this is not the case for topical anesthetics in this age group 2, 5