Three children presented to a hospital emergency department with seizures caused by camphor poisoning. The children ranged from 15 to 36 months old. Two children ingested camphor, while one was exposed through repetitive skin rubbing. All three required medical intervention to stop the seizures. Further investigation revealed that illegally imported camphor products were being widely used in certain communities as remedies, despite known risks of toxicity in young children. Public warnings were issued about the dangers of unregulated camphor use.

1. A Cluster of Children With Seizures Caused by Camphor Poisoning
Hnin Khine, Don Weiss, Nathan Graber, Robert S. Hoffman, Nora Esteban-Cruciani
and Jeffrey R. Avner
Pediatrics 2009;123;1269-1272
DOI: 10.1542/peds.2008-2097
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/123/5/1269
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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2. ARTICLE
A Cluster of Children With Seizures Caused by
Camphor Poisoning
Hnin Khine, MDa, Don Weiss, MD, MPHb, Nathan Graber, MD, MPHc, Robert S. Hoffman, MDc, Nora Esteban-Cruciani, MDa, Jeffrey R. Avner, MDa
a Division of Pediatric Emergency Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, New York; Bureaus of
b Communicable Diseases and cEnvironmental and Occupational Disease Epidemiology, Department of Health and Mental Hygiene, New York, New York
The authors have indicated they have no financial relationships relevant to this article to disclose.
What’s Known on This Subject What This Study Adds
It is known that camphor causes seizures. Prior case reports of seizures caused by cam- We discovered that in certain communities, a wide spread use of illegally imported
phor containing products had led the FDA to restrict the contents of camphor in over- unregulated camphor in many varied ways and parental unawareness of its toxicity had
the-counter products to less than 11%. led to seizures in young children, and under-recognized cause of seizure.
ABSTRACT
BACKGROUND. Isolated cases of camphor-induced seizures have been reported in young
children after gastrointestinal, dermal, and inhalation exposure. In 1982, after a
series of unintentional ingestions of camphor products, the US Food and Drug www.pediatrics.org/cgi/doi/10.1542/
peds.2008-2097
Administration restricted the camphor content to 11% in some products intended
for medicinal use. Camphor products intended for use as pesticides must be regis- doi:10.1542/peds.2008-2097
tered with the US Environmental Protection Agency. Still, many imported camphor- Key Words
camphor, seizure, toxicity
containing products fail to meet Food and Drug Administration and Environmental
Abbreviations
Protection Agency requirements for labeling and content.
FDA—Food and Drug Administration
OBJECTIVE. To describe a cluster of cases of camphor-associated seizure activity resulting ED— emergency department
from the availability of imported camphor products in certain ethnic populations that Accepted for publication Aug 29, 2008
use it as a natural remedy. Address correspondence to Hnin Khine, MD,
Children’s Hospital at Montefiore, Pediatric
Emergency Medicine, 111 E 210th St, Bronx,
METHODS. We present 3 cases of seizures associated with imported, illegally sold cam-
NY 10467. E-mail: hkhine@montefiore.org
phor in young children who presented to a large, urban children’s hospital in Bronx, PEDIATRICS (ISSN Numbers: Print, 0031-4005;
New York, during a 2-week period. Online, 1098-4275). Copyright © 2009 by the
American Academy of Pediatrics
RESULTS. The children’s ages ranged from 15 to 36 months. Two children ingested
camphor, and 1 child was exposed through repetitive rubbing of camphor on her
skin. All 3 patients required pharmacologic intervention to terminate the seizures. One patient required bag-valve-
mask ventilation for transient respiratory depression. All 3 patients had leukocytosis, and 2 patients had hypergly-
cemia. Exposure occurred as a result of using camphor for spiritual purposes, cold remedy, or pest control. After
identification of these cases, the New York City Department of Health released a public health warning to keep
camphor products away from children. Similar warnings were issued later by other state health departments.
CONCLUSIONS. These cases highlight the toxicity associated with camphor usage in the community and that inappro-
priate use of illegally sold camphor products is an important public health issue. Camphor may be a common, yet
unrecognized, source of seizures in children in certain ethnic populations that use it as a natural remedy. Efforts are
needed to educate the communities about the hazards of using camphor products and to limit the illegal availability
of these products. Pediatrics 2009;123:1269–1272
S EIZURES ARE A known complication of camphor toxicity and are reported after ingestion, inhalation, and dermal
exposure.1–6 In 1982, after the reports of several incidents of camphor toxicity in young children, often involving
camphorated oil products (20% camphor), the US Food and Drug Administration (FDA) limited the camphor content
of common cold preparations to 11% and restricted the sale of camphorated oil.7 In addition, because of its properties
as a toxic, combustible, and irritating substance, which, if ingested, can cause injury, illness, or death, camphor
products must comply with the labeling requirements of the New York City Health Code (173.05b). The FDA also
requires proper labeling if camphor products are intended for medicinal use, as does the Environmental Protection
Agency if camphor products are intended for use as an insecticide or insect repellent.
Currently, many camphor-containing products are imported from other countries and sold without proper or
complete labeling (Fig 1). Such products are widely available in the community and are being used for medicinal,
spiritual, and aromatic purposes as well as for pest control. Because of their wide usage, inadvertent exposure of
young children and infants to camphor may represent an under-recognized cause of seizures. In this report, we
PEDIATRICS Volume 123, Number 5, May 2009 1269
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3. FIGURE 1
Examples of imported camphor products.
describe a cluster of camphor-associated seizures linked intractable vomiting. Shortly after arrival in the ED, he
to imported camphor products that occurred over a developed a generalized tonic-clonic seizure that was
2-week period at a single hospital in Bronx, New York. treated with 0.1 mg/kg of lorazepam intravenously. Ini-
tial vital signs and significant laboratory findings are
CASE REPORTS shown in Table 1. Noncontrast computed tomography of
the brain was normal. Alcohol, acetaminophen, aspirin,
CASE 1. A 15-month-old Hispanic boy with no significant and iron were not detected on a serum toxicology
past medical history or recent trauma was brought to the screen. A urine toxicology screen for drugs of abuse was
emergency department (ED) for vomiting. He was in his negative. An electrocardiogram showed sinus tachycar-
usual state of health until he suddenly dropped to the dia with normal axis and intervals. The parents initially
ground and became stiff. Immediately afterward, he had denied any ingestion, however, after additional ques-
TABLE 1 Patients’ Initial Vital Signs and Significant Laboratory Findings
Case Age, mo Temperature, oF Heart Rate, Respiratory Blood Pressure, Oxygen White Blood Serum
Beats per Min Rate, Breaths mm Hg Saturation, %a Cells, 103/uL Glucose,
per Min mg/dL
1 15 98.6 160 28 85/54 100 26.6 166
2 22 97.3 218 31 80/38 100 18.6 176
3 36 100.1 169 36 94/58 95 26.5 87
a Blood oxygen saturation as measured by pulse oximetry in room air.
1270 KHINE et al
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4. tioning, the father revealed that he saw the child put a containing products extensively in various ways including
cube of “alcanfor” (Spanish for camphor) in his mouth putting “alcanfor” in the vaporizer, placing it in a bowl with
40 minutes earlier. The parents stated that they put water under the crib, hanging camphor tablets in a meshed
camphor cubes in a bowl of water just outside the door cloth on the posts of the crib, and spreading crushed tablets
to his room to ward off evil spirits. The child was admit- around the house to control roaches. The mother also
ted to the inpatient service for 1 day and had an un- reported that 2 of her other children had previously been
eventful recovery. In a telephone interview with the diagnosed with a seizure disorder. All 3 children had ex-
father 10 weeks after the incident, he stated that the tensive evaluation for seizures in the past, including nor-
child had no additional episodes of seizures. The parents mal MRI of the brain and electroencephalograms. The
removed all camphor-containing products from the mother also noted that neither of the other siblings had any
home. seizures when they lived in the grandmother’s apartment
for 1 year in the past. The grandmother would not allow
CASE 2. A 22-month-old Hispanic boy was brought to the the mother to use camphor during that time because she
ED in status epilepticus with stiffening and mild shaking couldn’t stand the smell. The eldest sibling “outgrew” his
of extremities for 1 hour. His parents initially denied seizure disorder around the age of 5 years at which point
any preceding illness, ingestion, or trauma. He had a his anticonvulsant medication was discontinued. The pa-
history of a febrile seizure 1 month before presentation. tient was discharged from the hospital with no anticonvul-
He was afebrile at the time of presentation to the ED. The sant medications. Use of camphor products in the home
child was given 2 intravenous doses of lorezapam (each was discontinued. The children’s neurologist had advised
0.1 mg/kg) followed by an intravenous loading dose of the mother to discontinue all anticonvulsant medications
20 mg/kg of fosphenytoin to control his seizures. He for all 3 children. On follow-up 10 weeks after discharge,
required bag-valve-mask ventilation secondary to tran- no additional episodes of seizures were reported in any of
sient respiratory depression. The initial vital signs and the children.
significant laboratory findings are shown in Table 1. These cases were reported to the New York City Poison
Liver function tests were normal. A urine toxicology Control Center. In response, the New York City Depart-
ment of Health and Mental Hygiene initiated an investiga-
screen for drugs of abuse was negative. MRI of the brain
tion of the availability of camphor products in local stores
was normal except for prominent perivascular spaces of
where the products implicated in these cases were pur-
unknown significance. After stabilization, the child was
chased, surveillance of calls to the Poison Control Center,
admitted to the inpatient service for observation. On
and notification of other health departments across the
direct questioning, the father reported that the patient
county. Unlabeled and mislabeled products were embar-
ate a small piece of “alcanfor” 1 hour before onset of
goed and distributors were identified and ordered to recall
the symptoms. The product was placed around the
any product that was sold. Health alerts, press releases, and
apartment to control roaches. The child remained very
educational material warned health care providers and the
restless and irritable for 12 hours after the reported
public to keep all camphor products out of the reach of
ingestion and a lumbar puncture was performed to ex-
children.8 The New York State Department of Environ-
clude infection. Cultures of the blood and cerebrospinal mental Conservation, which enforces pesticide regulations,
fluid had no growth. The child was hospitalized for 4 was also notified. Similar warnings were issued by other
days and had a slow, but uneventful, recovery. At 10 state health departments.9
weeks after discharge, he had no additional episodes of
seizures. DISCUSSION
Sporadic cases of camphor toxicity are reported in chil-
CASE 3. A 3-year-old Hispanic girl with a history of seizures dren and result from gastrointestinal, pulmonary, and
presented after a generalized tonic-clonic seizure that dermal absorption.1–6 Despite attempts by the FDA to
lasted 9 minutes. She received rectal diazepam at home restrict and control camphor use, it remains sold over
before arrival in the ED. Initial vital signs are shown in the counter as a nonprescription natural remedy. Cam-
Table 1. On arrival, she was awake but tired. The physical phor tablets are also sold as a pesticide without proper
examination was remarkable for mild tachypnea and registration or labeling as required by the Environmental
coarse rales on lung auscultation consistent with a recent Protection Agency. In fact, most reported cases of toxic-
diagnosis of pertussis. The child’s past medical history was ity occur in the context of unintentional ingestions of
significant for a seizure disorder of unknown etiology di- rubefacients or when a parent mistakenly administers
agnosed at 3 months of age. A magnetic resonance angiog- camphorated oil instead of castor oil.10 In 2006, the
raphy/MRI of the brain and electroencephalogram per- American Association of Poison Control Centers Toxic
formed 2 years before were normal. Until 4 months before, Exposure Surveillance System reported over 7000 single
the patient had been treated for seizures with valproic acid. substance exposures because of camphor.7 Although
She was admitted to the inpatient service for observation. most exposures were not treated in a health care facility,
On direct questioning about camphor use, the mother re- there were reports of both moderate and major toxicity.
vealed that she had been rubbing a properly labeled cam- Children are particularly vulnerable to toxicity, because
phor ointment over the child’s upper chest, forehead, and camphor is highly lipophilic and is easily absorbed
back hourly for 10 hours before the onset of seizure to through the skin and mucous membranes.
relieve her cold symptoms. The mother used camphor- Although seizures are a known toxicity of camphor, our
PEDIATRICS Volume 123, Number 5, May 2009 1271
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5. TABLE 2 Parental Reports of Ways in Which Camphor-Containing of camphor toxicity when evaluating new onset seizures in
Products Are Being Used young children who otherwise have no risk factors for
seizures.
1. Camphor tablet placed in a jar containing water placed outside doors to
ward off evil spirits and keep away illness.
2. Camphor tablet in a bowl of water placed over radiator as an air CONCLUSIONS
freshener. We have described 3 children with seizures associated with
3. Camphor tablet in a bowl of water placed near a baby crib/bed to relieve toxic exposure to camphor. These cases highlight the tox-
common cold symptoms.
icity associated with extensive camphor usage in the com-
4. Camphor tablets placed in cheesecloth sacks and used as a bracelet or
munity, including treatment of common childhood ail-
anklet or placed around young children and babies to help relieve the
symptoms of common colds. ments. Our report also calls attention to the use of
5. Camphor tablets placed in mesh bags and hung on each pole of a baby imported camphor products for medicinal purposes and
crib to keep baby safe. pest control with potentially high-camphor content and
6. Camphor tablet placed in a vaporizer for a child with upper respiratory the need for restricting the availability of these products. In
symptoms to inhale to relieve them of symptoms. certain communities, camphor-containing products have
7. Repetitive rubbing of camphor ointments on babies and children over been used in varied ways for many generations.3,4 The
their chest, head, and back to relieve them of common ailments. inappropriate use of camphor and the availability of im-
8. Ingestion of water that had camphor dissolved in it (1 tablet of camphor ported, illegally sold camphor products are important pub-
in 1 gallon of water) to relieve gastrointestinal symptoms.
lic health issues. Furthermore, although manufacturers
9. Crushed camphor cubes spread around the home to keep away roaches.
and distributors are required to register and properly label
10. Camphor used as mothballs in the closets and boxes of stored clothing.
11. Camphor cubes that are burned as part of religious rituals. any product that may be harmful, this was not the case
with many of the camphor products cited in our report.
Continued efforts are needed to educate communities
about the hazards of using camphor products and to limit
cases raise the possibility that camphor toxicity in children
the availability of illegal products. Finally, we highlight
occurs more commonly than recognized, especially in
how a healthy partnership between primary care providers
communities where cultural practices support its wide-
and the Department of Health can function to improve
spread use. Young children and infants are particularly at
community health.
risk based on the misperception that camphor has medic-
inal properties. Illegally sold camphor products are widely
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6. A Cluster of Children With Seizures Caused by Camphor Poisoning
Hnin Khine, Don Weiss, Nathan Graber, Robert S. Hoffman, Nora Esteban-Cruciani
and Jeffrey R. Avner
Pediatrics 2009;123;1269-1272
DOI: 10.1542/peds.2008-2097
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/123/5/1269
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