Use of Camphor and Essential Oil Balms for Infants in Cambodia

Abstract

Balms and oils containing terpenic compounds, such as camphor, menthol and eucalyptus, are potentially toxic, and numerous reports of adverse events stemming from their use in infants and young children have been published. During qualitative research on newborn practices in rural Cambodia, these products were found to be commonly applied to the skin of newborns and infants and available in most households. Parents and caregivers of infants in Cambodia and other settings where use of camphor- and menthol-containing products are common should be educated on the risks of these to prevent child morbidity and potential mortality.

INTRODUCTION

Application of balms containing camphor and other terpenic oils to children’s skin is a common traditional practice in many parts of the world, particularly in Asian countries such as Cambodia [1]. Camphor is known to be toxic, and caution is recommended for use in children [2, 3]; symptoms of moderate to severe toxicity include the following: convulsions, lethargy, ataxia, severe nausea and vomiting [4]. These substances have been recognized for decades as potentially dangerous to young children [5] and, according to the Annual Report of the American Association of Poison Control Centers’ National Poison Data System, 11 521 cases of camphor exposures in children aged <5 years were reported to United States poison control centers in 2013 alone [6]. Other terpenic compounds used in balms and ointments, such as menthol [7], are also potentially toxic, though fewer cases of poisoning have been recorded [8, 9]. Numerous case reports describe infant morbidity, and even mortality, resulting from exposure to camphor and terpenic oil products [10–18]. Despite significant potential for toxicity in children, these products remain widely available and popular, especially in the region where such products as Tiger Balm^TM originated [19].

In preparation for an intervention study, we conducted formative research in Cambodia on newborn health practices and found the application of camphor and terpenic derivative containing liniments and balms to infant skin to be commonplace. This report describes data collected on the use of terpenic derivative containing products in the study population and provides a recommendation for education of parents and caregivers on the potential dangers of these products.

METHODS

Qualitative data collection consisted of four observations of newborn care in the home setting with photographs and video (obtained strictly with permission for distribution), along with 27 semi-structured interviews conducted with mothers. Data were collected during February to March 2014 in Takeo, Cambodia. The area is located in the south of the country and in a rural, agricultural setting. Participants were identified through purposive sampling in the catchment areas of 10 Health Centers. Village Health Group volunteers assisted the research team in identifying women who had delivered a baby within the past 2 years. All participants provided written informed consent. Following data collection, transcripts of interviews, photos and field notes from observation were entered into a study database and subsequently coded and analyzed using a Grounded Theory approach [20].

Ethical approval and consent

The study was reviewed and approved by the Tulane University and the Cambodian National Ethics Committee Health Research institutional review boards.

RESULTS

Mothers interviewed on newborn care practices reported applying balm to the skin on the abdomen and anterior fontanel, especially after bathing a young infant. Balms containing camphor and terpenic compounds were available in most households. All families visited for observation of newborn care, and most interviewed about newborn care practices, had such products on hand. Table 1 illustrates descriptions taken from interview transcripts.

Table 1.

Mother’s descriptions of use of balms for their infants

After he was 15 days old, I rubbed the balm on his tummy after bath. My mother-in-law told me to do so, so that the baby doesn’t have stomach problems. After 1 month I also applied the balm on the baby’s [fontanel]…to avoid colds and to help him breathe easily. (31 year old mother of a 2 month old)

After the umbilical cord drops off, I apply balm around the stomach area. (23 year old mother of an 18 month old)

They believe if the baby is just born the body of the baby is green, not mature enough so then we apply this balm to make the body more resistant. The body is not cooked. If you don’t apply on the stomach, when the baby is older they might get diarrhea… After take the bath… we apply the powder 1st and then put the balm. [We] apply balm every time after bath. (27 year old mother of a 5 month old)

I apply tiger balm on the baby’s stomach area, I was told by my mum [it was] to cook the baby’s stomach. (27 year old mother of an 8 month old)

I put Tiffy Rub on the [fontanel] and Vicks Baby Rub on the chest. Another balm also is used on the baby’s head. He couldn’t breathe as it is cold season. (29 year old mother of a 4 month old)

Mothers reported using balms for various reasons. For use in the abdominal area, many mothers described application as a way to prevent gastrointestinal problems such as diarrhea. The perception of heat generated by the balm was reported to mature the skin and stomach of the newborn. Reasons given by mothers for use of balm on the head were related to cough and cold relief or to assist in easier breathing. Participants described applying balms after bathing, and multiple baths were often given per day.

A range of different brands of balms and oils was observed during interviews and observation of newborn care. Figures 1–3 present photographs of some of the balms and oils used by study participants on their infants. The term ‘tiger balm’ was frequently used as a generic reference to camphor-containing and terpenic products. Some balms were made in China and ingredients could not be ascertained, though they were scented with camphor, menthol or eucalyptus oil. Participants used both liquid oil preparations and thicker, ointment-type balms with similar smell and ingredients. These were observed to be applied in small amounts. Researchers observed application to a newborn following the bath where the newborn’s grandmother placed a drop of medicated oil to her finger and applied this gently to the infant’s anterior fontanel. Participants similarly described that a drop of oil or small dollop of ointment only was applied. For all the products we inspected first-hand, there were no instructions, warnings or ingredients lists in Khmer language, but rather these were all in Chinese, Thai or English.

Fig. 1.

Tiffy rub/baby rub balm for infants.

Fig. 2.

Double dragon medicated oil.

Fig. 3.

Siang pure balm.

DISCUSSION AND CONCLUSION

During qualitative data collection on newborn care practices, we found that a majority of participant families applied oils and balms containing camphor, menthol and eucalyptus (terpenic derivatives) to their infants’ skin for health purposes. These products are not currently recommended for use in children <2 years of age because of the potential for accidental ingestion and the danger of over-absorption through vulnerable skin [3, 21]. Camphor is particularly dangerous for young children [22, 23] given its hepatoneurotoxicity [24, 25] and the possibility of higher than recommended concentrations of camphor in products sold internationally [26, 27]. Labeling of products in foreign languages further complicates the ability of parents to safely use these for children.

There is little scientific evidence supporting topical products containing terpenic compounds for use in adults [28] and a single study in children, funded by Proctor and Gamble (the manufacturer of Vicks Vapo Rub^TM), the results of which found that parents reported symptom relief for their children aged 2–11 years [29]. While many parents use balms to help infants breathe more easily, there is some evidence from animal models that they may have the opposite effect [30]. This is especially of concern for young infants who may have a propensity toward respiratory distress, such as small or preterm newborns.

Though these products are widely used and available in Cambodian communities, they can be harmful when used for infants and young children. To reduce the risk of illness and death, further education and the potential introduction of alternative practices are recommended for populations who use these products.