The Journal of Emergency Medicine, Vol. 32, No. 1, pp.

63– 69, 2007

Copyright © 2007 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/07 $–see front matter

doi:10.1016/j.jemermed.2006.08.009

Selected Topics:
Toxicology

ARE ONE OR TWO DANGEROUS? METHYL SALICYLATE EXPOSURE

IN TODDLERS
Jonathan E. Davis, MD

Department of Emergency Medicine, Georgetown University Hospital and Washington Hospital Center, Washington, DC
Reprint Address: Jeffrey N. Love, MD, Department of Emergency Medicine, Georgetown University Hospital, 3800 Reservoir Road,
N.W., Washington, DC 20007

e Abstract—Serious toxicity can result from exposure to
small amounts of methyl salicylate. Methyl salicylate is
widely available as a component in many over-the-counter
brands of creams, ointments, lotions, liniments and medi-
cated oils intended for topical application to relieve mus-
culoskeletal aches and pains. Among the most potent forms
of methyl salicylate is oil of wintergreen (98% methyl sa-
licylate). Other products with varying concentrations of
methyl salicylate are ubiquitous throughout many parts of
the world, including a number of products marketed as
Asian herbal remedies. The toxic potential of all of these
formulations is often underestimated by health care pro-
viders and the general public. A comprehensive review of
the existing medical literature on methyl salicylate poison-
ing was performed, and data compiled over the past two
decades by the American Association of Poison Control
Centers (AAPCC) was examined. Methyl salicylate contin-
ues to be a relatively common source of pediatric exposures.
Persistent reports of life-threatening and fatal toxicity were
found. In children less than 6 years of age, a teaspoon
(5 mL) or less of oil of wintergreen has been implicated
in several well-documented deaths. More needs to be
done to educate both health care providers and the gen-
eral public regarding the dangers of these widely avail-
able formulations. © 2007 Elsevier Inc.
Series Editors: Jeffrey N. Love, MD, The Georgetown Uni-
versity Emergency Department, Washington, DC; Wendy
Klein-Schwartz, PHARMD, MPH, The Maryland Poison Center,
Baltimore, MD; Liesl Curtis, MD, The Georgetown University
Emergency Department, Washington, DC.
e Keywords—methyl salicylate; oil of wintergreen; pedi-
atrics; toxicity; poisoning
INTRODUCTION
Aspirin and other salicylates have a long history of use
throughout the world as analgesics, antipyretics, anti-
inflammatories, and inhibitors of platelet aggregation.
Their potential for serious, even fatal, toxicity has been
appreciated for centuries. As a result of observed toxic-
ity, the United States Food and Drug Administration
(FDA) mandated nearly four decades ago that aspirin
tablets made especially for pediatric use be produced
only in 81 mg strength, that retail packages contain no
more than 36 tablets per bottle, and that tablets stronger
than 81 mg be free of any sweeteners or flavorings (1). In
addition, the Poison Prevention and Packaging Act of 1970
stipulates that the vast majority of aspirin-containing prod-
ucts intended for oral use must be packaged in a child-
resistant fashion (2). Although these and similar mea-
sures have undoubtedly contributed to the dramatic
reduction in the incidence of death from the ingestion of
drugs by children in the past half-century, salicylates are
among the many poisons that continue to result in child-
hood morbidity and mortality (3).
Non-aspirin salicylates, such as methyl salicylate, are
found in many over-the-counter brands of creams, oint-
ments, lotions, liniments and medicated oils intended for

Selected Topics: Toxicology is coordinated by Kenneth Kulig, MD, of Denver, Colorado

RECEIVED: 22 December 2004; FINAL SUBMISSION RECEIVED: 31 August 2005;
ACCEPTED: 11 April 2006
63
64
topical application to relieve musculoskeletal aches and
pains. Owing to its potential for serious toxicity, al-
though paling in comparison to the restrictions imposed
on aspirin, FDA regulations mandate that the label of any
drug containing more than 5% methyl salicylate bear a
conspicuous warning against its use other than as di-
rected (i.e., for topical use only), and a warning to keep
the product safely out of the reach of children (1).
Among the most potentially devastating forms of
methyl salicylate is oil of wintergreen, which is approx-
imately 98% methyl salicylate. It is a highly potent
liquid, as just 1 mL of oil of wintergreen is equivalent to
1400 mg of aspirin (4). In other terms, one teaspoon
(5 mL) of oil of wintergreen contains the equivalent of
approximately 7000 mg of aspirin. Given that a routine
adult tablet contains 325 mg of aspirin, a mere teaspoon
of this potent toxin is toxicologically similar to ingesting
nearly 22 adult aspirin tablets (5). To place this in con-
text, the potentially acute toxic ingested dose of aspirin is
150 mg/kg, with serious toxicity possible in the 300 to
500 mg/kg range (or roughly one adult aspirin tablet per
kilogram) (6). Thus, a teaspoon of oil of wintergreen
(equivalent to 7000 mg of aspirin) can be inferred to
possibly result in serious toxicity in children weighing
less than about 23 kg (7000 mg divided by 23 kg equals
approximately 300 mg/kg), the weight of an average
6-year-old.
Numerous commercially available methyl-salicylate-
containing compounds are available on the market (Table
1). In addition, many readily available Asian herbal reme-
dies, sold as topical self-treatments for musculoskeletal
Table 1. Examples of Some Non-prescription Methyl-
Salicylate-Containing Medications and Remedies
Product % Methyl Salicylate
Oil of wintergreen 98
Topical creams*
Icy Hot® Extra Strength Cream 30
Bayer® Muscle Joint Pain Relief Cream 30
Muscle Rub® Extra Strength Cream 30
Ben-Gay® Extra Strength Cream 30
Tiger Balm® Liniment 28
Ben-Gay® Original Cream 18.3
Pain Bust-R II® Ointment 17
Thera-Gesic® Cream 15
Banalg® Hospital Strength Lotion 4.9
Asian herbal remedies†
Hung Far Oil (Red Flower Oil) 67
Pak Far Oil (White Flower Medicine Oil) 40
Tiger Oil 38
Kwan Loong Medicated Oil 15
* From information found online (www.americanrx.com; www.
vitaminshoppe.com).
† From (14): Chan TY. Potential dangers from topical prepara-
tions containing methyl salicylate. Hum Exp Toxicol 1996;
15:748.
J. E. Davis
aches, pains or the common cold, contain potentially
dangerous concentrations of methyl salicylate, the most
potent of which is Koong Yick Hung Far Oil (KYHFO,
or Red Flower Oil), which contains about 67% methyl
salicylate (Table 1) (7–10). Use of these methyl-
salicylate-containing formulations is widespread, and
many patients and parents erroneously assume that they
must be safe, simply by virtue of their ubiquitous over-
the-counter availability (11). As a result, patients may
not even think to report a history of their use, or think to
report them as a potential source of home pediatric
ingestion. In Hong Kong, medicated oils containing
methyl salicylate account for nearly 50% of acute salic-
ylate poisonings treated at a major teaching hospital
(8,10). In Africa, both topical and orally administered
methyl salicylate have been used as home remedies for
the treatment of acute respiratory infections in children
(12). Salicylate poisoning has also been reported after
ingestion of oil of wintergreen sold as a flavoring for
homemade candy (13). In addition, salicylate toxicity has
been observed through percutaneous absorption after use
of salicylate-containing topical preparations (14 –17).
The widespread over-the-counter availability,
pleasant odor, and palatability of methyl salicylate
often lead to a gross underestimation of its potential
for serious, even fatal, toxicity. The purpose of this
article is to evaluate the existing medical literature as
well as data from the American Association of Poison
Control Centers Toxic Exposure Surveillance System
(AAPCC-TESS) to determine the current risk of tox-
icity when children under 6 years of age are exposed
to small amounts of methyl salicylate.
CLINICAL MANIFESTATIONS
After oral ingestion, methyl salicylate is readily metab-
olized to salicylic acid. As such, the clinical features of
methyl salicylate poisoning are identical to those ob-
served after poisoning with other salicylates (18). Salic-
ylate toxicity is dependent upon the ingested formulation
and dosage, patient age, and the acuity of ingestion, with
those at the extremes of age and with chronic intoxica-
tions at greatest risk.
The pathophysiology of salicylate toxicity relates both
to the direct stimulation of the central nervous system
(CNS) respiratory center, resulting in hyperventilation
and respiratory alkalosis, and the uncoupling of mito-
chondrial oxidative phosphorylation, resulting in an in-
creased anion gap metabolic acidosis. These effects lead
to the classic mixed acid-base disturbance characteristic
of salicylate toxicity: a primary respiratory alkalosis and
a primary metabolic acidosis. In children, metabolic ac-
idosis with acidemia may predominate (19,20).
Methyl Salicylate
Effects of salicylate toxicity include nausea and vom-
iting (by stimulation of the CNS chemoreceptor trigger
zone), fever (paradoxical effect of an antipyretic pro-
duced by uncoupling of oxidative phosphorylation, with
excessive heat generation resulting from a heightened
rate of anaerobic metabolism), dehydration and electro-
lyte disturbances (fluid losses from hyperpnea, emesis
and renal wasting), tinnitus (vasoconstriction of the au-
ditory microvasculature), hematologic disturbances (ef-
fects on platelets and, rarely, on hepatic synthetic func-
tion), and in severe cases, non-cardiogenic pulmonary
edema (increased permeability of pulmonary vasculature)
(21,22). The earliest manifestations of acute toxicity include
mild gastrointestinal (GI) symptoms, diaphoresis, fever and
tinnitus. As toxicity progresses, multisystem organ dysfunc-
tion, including seizures, coma, non-cardiogenic pulmonary
edema, and cardiovascular collapse may ensue.
Movement of salicylic acid into tissues is facilitated
by the increased volume of distribution seen in overdose,
and with a pKa of 3.5, by the increased fraction of
non-ionized (lipophilic) drug yielded as progressive
acidemia ensues. This allows access to the crucial
tissues of the brain (resulting in encephalopathy, sei-
zures and coma), lung (resulting in noncardiogenic pul-
monary edema) and heart (resulting in cardiovascular
collapse) (23–25). The target of the lethal effects of
salicylates is most often the CNS. Patients who die as a
result of salicylate toxicity often die a brain death (26). In
addition, dysrhythmia resulting from hypokalemia (pri-
marily through vomiting and renal losses) and hypoxia
resulting from pulmonary edema may also contribute to
mortality.
Laboratory evaluation for salicylate toxicity, includ-
ing methyl salicylate, includes the qualitative ferric chlo-
ride test and the quantitative serum salicylate concentra-
tion (27). The advantages of the ferric chloride test
include the ability to perform it rapidly and at the bed-
side, potentially averting a needlestick in low-risk chil-
dren, especially where it is not clear that ingestion has
even occurred. A positive result is indicated by a purple
or brown color change when adding a few drops of ferric
chloride solution to urine. The disadvantages include
qualitative information only, and an appreciable false-
positive rate (28). Overall, this test is rarely used these
days, as serum quantitative tests are so rapidly available
and reliable. Quantitative serum salicylate concentrations
are obtained both on presentation as a baseline and at
least every 2 h until clearly decreasing (29). Given a
number of limitations, the Done nomogram is no longer
advocated to predict the severity of salicylate toxicity
(30). The clinical severity of single-dose acute salicylate
ingestion correlates better with the highest overall serum
concentration attained during the patient’s course, as
opposed to the measured serum salicylate concentration
65
at any given point in time (31). That is to say that a
patient’s serum salicylate concentration may be declin-
ing, however, their clinical condition may continue to
deteriorate due to the ongoing cascade of events at the
cellular level in the target organs, despite falsely reas-
suring blood laboratory results. Indeed, plasma salicylate
concentration is not the sole indicator of morbidity or
fatal outcome (32).
TREATMENT
The first priorities in the treatment of any poisoned
patient are fundamental, beginning with attention to a
secure airway, maintenance of oxygenation, ventilation
and adequate perfusion of vital organs. Once these pri-
orities have been achieved, attention then focuses on the
specific toxins involved. In the majority of poisoned
patients, treatment is largely supportive in nature. How-
ever, certain toxins have specific antidotes and other treat-
ment modalities that have been shown to reduce their harm-
ful effects. Such is the case with salicylate toxicity, where
treatments such as gastrointestinal decontamination, hy-
dration, urinary alkalinization, and hemodialysis have
been successfully employed.
Initial therapy for salicylate toxicity includes early GI
decontamination with activated charcoal. Fluid resusci-
tation should be early and aggressive, ensuring adequate
tissue perfusion and urinary output. In addition, alkalin-
ization by intravenous sodium bicarbonate administra-
tion is advocated to correct acidemia, tempering the shift
of non-ionized salicylate into target tissues, and hasten-
ing urinary elimination by trapping ionized salicylate in
the proximal tubule. In fact, urine alkalinization is con-
sidered the first line treatment for patients with moder-
ately severe salicylate poisoning who do not meet criteria
for extracorporeal elimination (33). Potassium supple-
mentation is also an important aspect of management, as
patients may become severely depleted. Extracorporeal
methods of elimination are indicated if a patient has very
high serum salicylate concentrations, exhibits progres-
sive clinical deterioration despite adequate hydration and
alkalinization, or is otherwise unable to eliminate salicy-
lates, as in the case of renal failure (34). Hemodialysis,
hemoperfusion, and peritoneal dialysis have been em-
ployed, with hemodialysis having the added advantage of
correcting acid-base and electrolyte disturbances in ad-
dition to clearing salicylate from plasma (35). Exchange
transfusion also has been reported as a viable alternative
to hemodialysis in infants with severe salicylate toxicity,
given the challenges in obtaining suitable vascular access
in this population and the need for specialized dialysis
equipment and highly experienced personnel (36). Prep-
aration for hemodialysis may be initiated in the Emer-
66 J. E. Davis

gency Department in certain circumstances, including the
presence of coma, seizures, pulmonary edema, severe acid-
base disturbances, or rapidly deteriorating clinical condition
despite initiation of more conservative treatments.
LITERATURE REVIEW
Although it has been reported and referenced that mini-
mal doses of oil of wintergreen can be fatal to a child, we
reviewed the existing medical literature on this topic to
see what evidence exists to support this widely purported
claim (37–39). Literature on methyl salicylate exposure
was identified by a Medline search using the key words
“methyl salicylate” or “oil of wintergreen,” focusing on
articles pertinent to the pediatric population. Textbooks
in Emergency Medicine, Toxicology, Pediatrics and
other disciplines were also reviewed in search of perti-
nent publications. References from all of the articles and
chapters were reviewed to extend the search. Further-
more, data from the AAPCC-TESS yearly reports from
1983 to the present time were reviewed to identify epi-
demiologic information and current trends.
The available information on serious aspirin toxicity
in children is more frequently encountered in the medical
literature as compared with non-aspirin salicylates, ow-
ing to the comparatively increased incidence of aspirin
poisonings (40). As a result, many of the references to
the fatal effects of methyl salicylate are extrapolated
from a calculated “aspirin-equivalency.” Methyl salicy-
late, however, is a relatively common pediatric exposure
in its own right. The 2003 annual AAPCC-TESS data
reports nearly 10,000 exposures to methyl salicylate, of
which the majority (77%) occurred in children under 6
years of age (41). These numbers have been relatively
stable over the past several years (40,42– 47). Likewise,
children under the age of 6 years have made up the
majority of methyl salicylate exposures reported in the
last two decades.
A medical literature search found many case reports
and a few case series involving methyl salicylate intox-
ication, yet failed to reveal any clinical studies. Table 2
summarizes the lowest doses of methyl salicylate that
resulted in life-threatening toxicity (48 – 61). As avail-
able treatment regimens have been refined with a grow-
ing knowledge of the underlying mechanisms of toxicity
in salicylate poisoning in general, we have focused on
methyl salicylate cases reported in the past half-century.
However, several cases from antiquity are included in
addition to the more contemporary cases, as they are
illustrative of the potential dangers of methyl salicylate.
The seminal case series that defined methyl salicylate
as a poison was published in 1937 by Stevenson (48). Of
the 43 exposures tabulated in this case series, Stevenson
reported on 20 pediatric exposures (ages 1 month to 4
years), of which only 5 patients survived (75% fatality
rate). The lowest reported doses producing fatalities in
this series were 4 mL in two cases (17 months old and 2
years old) and 5 mL in two additional cases (1 month old
and 2 years old). Also of note is that the smallest lethal

Table 2. Lowest Doses of Oil of Wintergreen (Methyl Salicylate) Found to Cause Life-Threatening Toxicity and Death in
Children: Summary of Notable Cases

Estimated Death (D)/

Source (reference) Age* Exposure† Treatment CNS Toxicity Recovery (R)

Stevenson (48) 17 M 4 Induced emesis Yes D

Stevenson (48) 2Y 4 Unspecified Yes D
Cann (49) 2.5 Y 5 Unspecified Yes D
Adams (50) 20 M 5 Exchange transfusion Yes R
Eimas (51) 22 M 5 i.v. Fluids Yes D
Stevenson (48) 1M 5 Home remedies Yes D
Stevenson (48) 2Y 5 GI decontamination Yes D
Litovitz (52) 2Y 10 Hemodialysis Yes D
Litovitz (53) 2Y 15 GI decontamination Yes D
Cann (49) 2.5 Y 15 Unspecified Yes D
Cann (49) 2Y 15 Unspecified Yes D
Martin (54) 2.5 Y 15 i.v. Fluids Yes D
Stevenson (48) 2Y 15 Blood transfusion Yes R
Done (55) 2Y 20 Exchange transfusion Yes R
Jacobziner (56) 18 M 22.5 Gastric lavage Yes D
Feldman (57) 20 M 30 Exchange transfusion Yes D
Kloss (58) 3Y 30 Peritoneal dialysis Yes R
Millar (59) 3Y 30 Exchange transfusion Yes R
Halle (60) 3.5 Y 60 Peritoneal dialysis Yes R
Diamond (61) 2Y 60 Exchange transfusion Yes R

* Age in months (M) or years (Y).

† Milliliters (mL) of oil of wintergreen (98% methyl salicylate).
Methyl Salicylate
dose reported among adults occurred in a 21-year-old
man who died after consuming only 6 mL of oil of
wintergreen, giving further credence to the lethality of
this agent (62). The author concludes that because only 4
to 5 mL of methyl salicylate had been lethal in four
toddlers, and only 6 mL lethal in an adult, the drug
should be labeled “poisonous if used internally.” Another
pediatric fatality caused by ingestion of a minimal
amount of methyl salicylate was reported by Eimas in
1938 (51). He reported on the clinical and post-mortem
findings observed in a 22-month-old boy who ingested
5 mL (one teaspoonful) of oil of wintergreen.
Since the AAPCC started publishing its annual reports
in 1983, only five fatalities have been reported in chil-
dren younger than 6 years as a result of methyl salicylate
poisoning (52,63– 66). For cases where specific ingested
doses of oil of wintergreen were included in the AAPCC
data, the fatal doses were up to 10 mL in a 2-year-old,
and 15 mL in another 2-year-old. Although such fatali-
ties are sparsely reported in the literature, methyl salic-
ylate toxicity seems to be an ongoing risk to the pediatric
patient given the number of annual exposures reported to
the AAPCC and the outcomes observed. For instance, a
published comparison of pediatric poisoning hazards
from examination of the AAPCC data during an 8-year
period from 1983–1990 revealed four deaths from methyl
salicylate, compared with only two deaths reported from
aspirin during the same period (67).
The cases in Table 2 all document serious toxicity
from doses of 2 ounces (60 mL) or less. These doses are
largely based on parental estimates of volumes ingested.
At least some signs of serious CNS toxicity, including
some degree of alteration in level of consciousness with
or without seizures, were noted in all, and 13 children
died. On initial review of our data, it paradoxically seems
as though the majority of patients who recovered from
methyl salicylate intoxication ingested comparatively
larger volumes of the liquid. However, on close exami-
nation it becomes apparent that the vast majority of those
who survived were evaluated in more recent times (last
half century), and were rescued with treatment modali-
ties that are now appreciated as effective, such as ex-
change transfusion, dialysis, or intravenous bicarbonate
administration. Stevenson, on the other hand, reported a
2-year-old who in 1927 fully recovered after ingestion of
15 mL of oil of wintergreen after treatment with blood
transfusions, among other modalities (48).
The cases of life-threatening toxicity or death found
on our review of the literature all involved oil of win-
tergreen or Asian herbal oils. To our knowledge, there
are no modern reports of significant toxicity resulting
from the oral ingestion of methyl-salicylate-containing
creams, ointments, lotions or liniments (such as Ben-
Gay® and others; Table 1). There are several reports of
67
significant toxicity resulting from percutaneous or trans-
mucosal absorption after topical or intraoral application,
respectively, of salicylate-containing compounds, but
none specifically involving methyl salicylate in children
(16,17,68,69). In 1959, Burt referenced a fatality pro-
duced by a topically applied methyl salicylate product;
however, he failed to provide any specifics regarding the
case, including the decedent’s age or the source of the
information (70).
EVALUATION RECOMMENDATIONS
Over a half century of clinical experience suggests that
small doses of oil of wintergreen are toxic, especially in
a child under 6 years of age. Several well-documented
cases suggest that doses of 5 to 15 mL (or less) may
cause serious toxicity and even death. This, coupled with
the difficulty in accurately assessing the amount of liquid
that has been ingested by a toddler, supports the recom-
mendation that any child who ingests any amount of oil
of wintergreen should be immediately assessed by an
experienced pediatric provider skilled in acute care, with
input from a toxicologist or poison control specialist.
This recommendation also holds true for liquid Asian
herbal preparations containing a high concentration of
methyl salicylate (Red Flower Oil, for example).
However, the more frequently encountered situation
involves ingestion of methyl salicylate in a cream, oint-
ment, lotion or liniment formulation, which necessitates
different recommendations. The consistency of these
formulations makes ingestion of a large volume of the
product difficult. This, combined with their relatively
low methyl salicylate concentration, makes significant
toxicity unlikely. These patients should be managed by
calculating an “aspirin equivalent ingested dose” by use
of the methyl salicylate conversion factor of 1.4, and
then applying the aspirin guidelines to determine the
potential severity of the ingestion (71). For example, a
15-kg child who ingests 5 mL of 18.3% Ben-Gay® Orig-
inal Cream: 18.3% is equivalent to 183 mg/mL, therefore, 5
mL ingested volume multiplied by 183 mg/mL results in
915 mg of methyl salicylate ingested. With use of the
methyl salicylate conversion factor, 915 mg multiplied
by 1.4 is equivalent to 1281 mg of aspirin. The aspirin
equivalent dose of 1281 mg divided by the child’s weight
of 15 kg yields a weight-based ingested dose of 85
mg/kg. Applying the guidelines used for aspirin inges-
tion, 85 mg/kg falls well below 150 mg/kg, the poten-
tially toxic dose from acute aspirin ingestion (6).
Because patients who progressed to life-threatening
toxicity nearly uniformly experienced emesis within sev-
eral minutes to a few hours of ingestion, followed by
signs of at least some degree of CNS toxicity (drowsi-
68
ness, lethargy, seizures), observation for clinical symp-
toms should occur for a minimum of several hours post
ingestion. We recommend at least 6 h of observation in
a facility fully equipped with advanced pediatric airway
and critical care capabilities. Treatment should be initi-
ated without delay when indicated by clinical or labora-
tory findings. In the presence of clinically evident methyl
salicylate poisoning, the most important determinant in
further decision-making always remains in the continual
reassessment of a patient’s global clinical picture, with
special attention to findings of CNS toxicity. On the
other hand, patients who remain entirely asymptomatic
throughout the observation period can be discharged
home with a reliable caretaker, with specific instructions
regarding when to return for repeat evaluation. Serum
salicylate concentrations may also be beneficial in as-
sessing the degree of toxicity, particularly in oil of win-
tergreen ingestion. At least two determinations are rec-
ommended, one on patient arrival and the second a few
hours later to ensure that the concentration is not rising.
CONCLUSIONS
This series of articles asks the question: Are one or two
[pills] dangerous? In the case of liquid preparations, such
as oil of wintergreen, the question is better phrased: Is a
sip or a mouthful dangerous? A prior study defined a
mouthful in a toddler as 9.3 mL (approximately 2 tea-
spoons) (72). This review shows that this amount of oil
of wintergreen is clearly dangerous to small children.
Although methyl salicylate is found in a multitude of
commercially available varieties, ingestion of oils
(such as oil of wintergreen and Asian herbal oils)
seems to pose the greatest threat, given their propen-
sity for easy ingestion of relatively large quantities
when compared to the higher viscosity creams, oint-
ments, lotions and liniments.
Oil of wintergreen and other high concentration methyl-
salicylate-containing products remain a source of serious
toxicity in the pediatric patient. It is clear from the
available literature that as little as a single teaspoonful
(or less) of oil of wintergreen has the potential to cause
life-threatening toxicity and death. More needs to be
done to educate both health care providers and the gen-
eral public regarding the great risks of these widely
available formulations.
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