As a pediatrician I have an opportunity to observe a wide variety of unusual and sometimes alarming parental efforts meant to help children through illness or keep them well. I have recently noticed one particular intervention that seems to be becoming more prevalent, at least in my practice. I’ve begun to see more and more infants sporting Baltic amber teething necklaces. These consist of multiple small beads of amber on a string that is worn around a baby’s neck, and are supposed to relieve the discomfort of teething. Before I had any idea what these necklaces were for or how they were supposed to work, my first reaction was to inform these parents of the dangers of necklaces or anything placed around an infant’s or young child’s neck. Strangulation is a known cause of accidental injury and death in children, and pediatricians are trained to discuss this as part of the routine anticipatory guidance we give to parents. In addition, we strongly advise against giving infants or young children any small items that could be accidentally aspirated, such as the beads found in a necklace of this sort. But I was equally surprised to learn that these necklaces are not intended for babies to chew or gum. Instead, they are supposed to ease a baby’s teething discomfort simply by lying against the skin.
I will not discuss teething here, or the many myths that surround it; that was well covered in a previous post. I will reiterate that there is little-to-no evidence that the majority of concerns parents have about teething are actually due to teething, including fever and diarrhea. The irritability associated with teething also tends to wax and wane for only several days before and after the emergence of a tooth. But let’s assume for the moment that these necklaces actually work to ease the discomfort of teething, and whatever other problems parents tend to associate with the long period of time during which infants and young children develop their teeth. Assuming these necklaces work as recounted in the glowing testimonials on countless websites and parent blogs, how do they produce their dramatic results?
Implausible mechanisms of action
The alleged mechanism of action of wearing Baltic amber against your skin varies considerably based on whom you speak to, and which snake oil salesman you are buying from. They range from the hilarious to the just barely plausible. On the absurd end of the spectrum we have:
- Activates the solar plexus and root chakra
- Bactericidal and electrostatic properties
- A powerful antioxidant that helps fight toxic free radicals
- Slight sedative effect
- Amber is electromagnetic and produces large amounts of organic, natural energy
- Ionization helps protect the human body from various magnetic fields (amber absorbs some waves, including radioactive ones)
But the most commonly cited mechanism of action (and the most plausible, with that term being used very liberally here) is that the amber beads, when warmed by body heat, release tiny amounts of succinic acid which passes trans-dermally into the blood stream where it acts as an analgesic. I refer to this mechanism as plausible for the following reasons only:
- Baltic (Class Ia) amber does indeed contain succinic acid
- Some molecules, including some drugs used in science-based medicine, are absorbed through the skin to produce physiologic effects
- Succinic acid (also known as 1,4-butanedioic acid) is found naturally in the body as an intermediate in the all-important Krebs cycle; altering the levels in the body could therefore have potential physiologic effects
The plausibility for this mechanism ends there, however, and then quickly begins to break down. First, though Baltic amber does contain succinic acid, there is no evidence that it has analgesic effects at any dose, let alone the miniscule amounts that might conceivably enter the body through this route (more on that in a moment). As mentioned above, succinic acid is an important intermediate in a very important biochemical pathway. It resembles many other similar molecules found in our body and is considered safe. Toxicity studies have shown that even large doses produce no adverse effects. The FDA even allows it to be used as a food additive and to be sold as a dietary supplement. Ironically, it is classified as a skin irritant.
The next step in the plausibility break down is the notion that succinic acid in the amber beads gets released at body temperature, and is then absorbed through the skin. There is no evidence that succinic acid is released from amber on contact, or that warming it to body temperature would facilitate this. If it was released, there is similarly no evidence for transdermal absorption. Many factors contribute to the ability of a molecule to enter the body through the skin. In addition to the physical and chemical properties of the molecule, clearly the dose is an important factor. Generally speaking, the larger the concentration the easier it is for a molecule to get through the skin. The amount of surface contact is important as well, and this would have to be considered pretty small in the case of a string of beads worn around the neck. As for the amount of succinic acid likely to be found in one of these necklaces, let’s assume the following:
- Baltic amber contains 50-400 ppm of succinic acid
- 1 mg/kg = 1 ppm
- Necklace weighs 1 oz = 0.028 kg
- Necklace contains 1.4-11.2 mg succinic acid
Even if you were to assume that succinic acid is released from the necklace onto the skin, the amount released would have to be an extraordinarily miniscule fraction of the total 1.4-11.2 mg contained in the entire necklace. For a therapeutic effect at this sort of dose one would need to invoke homeopathy, but that is an entirely different subject altogether. Interestingly, corrosive formic and acetic acids were found to off-gas as volatile degradation products from Baltic amber. Acetic acid is vinegar, and formic acid is found in fire ant venom and can cause blindness.
Multiple extraordinary claims
Putting aside the mechanism of action, do these necklaces actually work? Perusing many of the websites that either sell or discuss them, I came across a multitude of purported benefits to wearing a Baltic amber necklace:
- Provides natural pain relief for babies, toddlers, and children
- Helps to ease teething pains in children as well as colic and gas and other ailments
- Reduces inflammation of the throat, ear and stomach
- Fights irritation, infections, and respiratory disease
- Dramatically improves the body’s immunity
- Breaks the cycle of chronic inflammation
- A completely non-invasive remedy for side effects associated with teething (lack of appetite, upset tummies, ear ache, fevers and colds)
- Antispasmodic and anti-fever
- Improvement of arthritis
- Improves blood circulation
- Eases muscle pains
- Transmutes negative into positive energy
- Promotes positive thinking and attitude
- Revitalizes mind, body and soul
- Helps to relieve depression
- Supports physical healing and detoxification
- Alleviates disorders of the adrenals, liver and spleen
A major red flag for fraud if ever there was one, the making of multiple, extraordinary claims should raise our skeptical radar, and of course demands extraordinary evidence.
A search of PubMed and MEDLINE reveals not a single study of any kind or quality exploring the efficacy or safety of amber teething necklaces for infant teething. In fact, I could find only two studies that were related in any way to the therapeutic use of amber. These were published by a single research team from India, and examined the effects of an amber-containing “polyherbal” compound on chemically induced gastric ulcers in rats. The authors exposed rats to either aspirin or ethanol, and in both cases found that rats pre-treated with the compound demonstrated lower ulcer scores than controls.The authors exposed rats to either ethanol or aspirin, and in both cases found that rats pre-treated with the compound demonstrated lower ulcer scores than controls.
As for succinic acid, the most commonly-cited mechanism of action for amber necklaces, I did find a study whose abstract, at least, claims to have demonstrated promising anti-inflammatory activity in 44 succinic acid derivatives. The article was published in 1987 in the Russian language journal Farmakologiia i toksikologiia, which I was unable to obtain for review. There does not appear to be any other evidence for the therapeutic effect of succinic acid.
So why do people believe such an implausible treatment will work for teething? First, we need to understand that teething has an odd place in the folklore and mythology of parenting. Parents clearly never want to see their children suffer, and teething can be uncomfortable, albeit for very brief intervals. One contributing factor to the overblown concern about teething is the historical fact that in previous centuries, infants and young children once routinely died during the age range when the primary teeth typically come in, and teething was often erroneously implicated as the culprit. Treatments used for teething in those times were often dangerous or even lethal themselves. Thanks to modern science, parents are no longer in constant fear that their children will succumb to disease. Still, some common illnesses and even normal developmental stages and behaviors are to this day erroneously attributed to teething. Combine this historical baggage with our tendency to fall into the logical fallacy trap, and you have the perfect set-up for this myth to take hold.
The logical fallacies rear their ugly heads
Appeal to ancient wisdom –Websites touting the healing and restorative properties of Baltic amber teething necklaces abound with references to the centuries of use of medicinal amber, and to its ancient record of success. The scientific revolution is a very recent accomplishment, and most of our recorded past took place in an age when our understanding of the world was laughably inaccurate. To use the age of those beliefs as a way to validate them is akin to claiming that the Earth is flat because we thought it was so for most of human history.
Appeal to nature – Parents who swear by amber teething necklaces usually mention that it’s natural and therefore safe. Or that it’s natural, so it’s preferable to using drugs such as acetaminophen or topical anesthetic gels. First of all, the use of drugs to treat teething is not recommended. Teething pain tends to be transient and intermittent, and chasing it with serum levels of medication doesn’t make much sense. And topical anesthetics are potentially quite dangerous in infants, as they can lead to a serious condition called methemoglobinemia. They can also be easily overdosed. I recently took care of an infant who had been given around the clock Baby Orajel and nearly stopped breathing. In any case, assuming something is safe simply because it is natural defies logic when the most deadly toxins known to man are entirely natural. It is also extremely contradictory to make the assertion that drugs and man-made chemicals are somehow bad, but a naturally occurring chemical must be assumed to be perfectly safe. Let’s again assume that succinic acid gets released from the Baltic amber necklace, and that it does actually cross into the baby’s blood stream in a concentration sufficient to effect a real physiologic change in her body. Why, I wonder, are the parents who put these things on their children okay with that? It’s astounding that the same parents who shy away from man-made “chemicals”, buy organic produce, steer clear of GMOs, and are afraid of vaccine ingredients have no problem with the leeching of natural chemicals into their child’s bloodstream.
A survey exploring the perceptions and beliefs of parents in southwestern France about the use of teething necklaces illustrated the significant concern these parents had about teething symptoms, and the difficulty many have accurately assessing true risks and benefits. Even when informed of the real potential danger to their children by wearing the necklaces, many parents preferred to take that risk for the potential perceived benefits. This is no different than the parent who is fearful of giving a vaccine, and prefers taking the risk of their child getting a preventable infectious disease, or a parent who will risk giving their child an unregulated dietary supplement for perceived, unfounded benefits. This profound inability to accurately assess risks and benefits and correctly set priorities to maximize outcomes is what keeps the door open for pseudoscience, and allows belief to obscure our understanding of the world.