Orajel (Benzocaine) Should Not Be Used in Infants Under Two Years
Do not use Orajel or any benzocaine-containing products in infants under 2 years of age for teething pain. The FDA explicitly states that benzocaine products should only be used in "children 2 years of age and older," and children under 2 years should "consult a dentist or doctor" 1. This restriction exists because benzocaine can cause life-threatening methemoglobinemia in young children.
Why Benzocaine Is Dangerous in Infants
Risk of Methemoglobinemia
- Benzocaine causes methemoglobinemia, a potentially fatal condition where hemoglobin cannot carry oxygen effectively, resulting in tissue hypoxia 2, 3.
- Case reports document methemoglobin levels reaching 20.2%-69.9% in young children exposed to benzocaine concentrations of 7.5-20%, with the 69.9% level considered lethal 2, 3.
- Clinical manifestations include cyanosis, anemia, hypoxia, vomiting, and lethargy that can progress rapidly 3.
- Treatment requires immediate administration of methylene blue and potential admission to critical care 2, 3.
Lack of Efficacy
- Benzocaine provides no meaningful pain relief for teething—a study showed infants treated with topical benzocaine actually cried longer (21.6 seconds) than controls (13.1 seconds) after a procedure 4.
- The American Academy of Pediatrics does not recommend topical agents for teething due to lack of efficacy data 5.
Safe Alternatives for Teething Pain in Infants
Non-Pharmacological First-Line Options
- Breastfeeding during painful episodes has demonstrated effectiveness in reducing pain responses in term neonates 6.
- Non-nutritive sucking, facilitated tucking, and skin-to-skin contact are recommended by the American Academy of Pediatrics to decrease pain during minor procedures 6.
- Oral sucrose (0.1-1 mL of 24% solution) administered 2 minutes before painful procedures is effective for mild to moderate procedural pain in neonates 6.
- Glucose solutions (20-30%) can be used as an alternative to sucrose 6.
When Pharmacological Treatment Is Necessary
- Acetaminophen is the preferred systemic analgesic for infants when non-pharmacological measures are insufficient 6.
- Topical anesthetics like EMLA (lidocaine/prilocaine) may provide pain relief for specific procedures, but require careful dosing—infants under 6 months need a 30% dose reduction due to delayed metabolism 7, 6.
Critical Pitfalls to Avoid
- Never assume over-the-counter means safe for infants—benzocaine products are readily available but contraindicated in this age group 1, 2.
- Therapeutic application by parents or caregivers has led to methemoglobinemia requiring methylene blue treatment and ICU admission 2.
- Even "baby" formulations like Baby Orajel (7.5% benzocaine) have caused lethal methemoglobin levels 3.
- Failing to recognize chocolate-brown blood as a sign of methemoglobinemia can delay life-saving treatment 3.