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Separating Fact from Fiction in Pediatric Medicine: Infant Teething

Teething is one of the most common sources of parental concern in the world of pediatric medicine. All children go through it, typically starting at about 6 months of age, and the current list of signs and symptoms attributed to the eruption of teeth in infants is long and varied, with most if not all of them inaccurate if not highly suspect. And although teething as a concept may seem rather commonplace, it is an entity with an interesting history and a frequent impetus for exposing young children to ineffective and even risky treatments.

What is teething?

Simply put, teething occurs when a tooth nears completion of its journey into the oral cavity, a journey which begins early in fetal development. The tooth erupts though the gum, often preceded by a small lump. Occasionally there can be a larger eruption cyst, and the area may appear somewhat bluish and swollen from bleeding into the tissue, but this is uncommon. The most widely accepted duration of a bout of teething is a roughly 8 day period, with tooth emergence generally felt to occur on day 5. The whole process usually takes about two years, with an average of one tooth emerging each month until the full complement of 20 baby teeth are present.

Teething past

In my opinion, the history of teething is a great example of the extreme degree of absurdity that conclusions based on a prescientific approach to illness often resulted in, right up there with humors and homeopathy. Early philosophers like Hippocrates attributed a wide variety of minor symptoms, such as itching gums and loose stools, to teething, and many of these still make the current list. But because of our once-poor understanding of human physiology, infants were felt to be extremely vulnerable to any derangements in their nervous system and more serious outcomes were attributed to the eruption of teeth, including death. Yes, death.

As crazy as this sounds, it actually isn’t that hard to understand why it was believed for at least a couple thousand years that teething could result in serious illness and even death. Remember how frequently a tooth emerges? Once a month, on average, for a couple of years, in early childhood. People attributed severe illness and death to teething for the same reason that some people continue to blame autism on vaccines: Pure coincidence and a lack (or the in the case of vaccines and autism the denial of) a systematic and logical approach to documenting and evaluating natural phenomena.

Until the advancements of scientific medicine, such as vaccines for instance, children frequently died or suffered through a variety of common ailments during the same time period as teething. And of course the true cause of these afflictions was unknown. So it became widely accepted that teething was a source of fever, diarrhea, vomiting, seizures, tetanus and meningitis, to name just a few, and even death. It was not uncommon for teething to be listed as the cause of death in children prior to the late 19th century. Unfortunately, many of these children probably died as a result of the misguided attempts at treating the perceived symptoms of teething.

Teething present

Though we have come a long way in our understanding of human physiology since the 19th century, there remains widespread misunderstanding of what symptoms can reasonably be attributed to teething. Parents and other caregivers are quick to list fever, difficulty sleeping, fussiness, drooling, changes in feeding amount and frequency, nasal congestion, and diarrhea, in addition to the most frequently cited symptom of pain, but the evidence has not been very supportive of these beliefs. To put it bluntly, it does not appear that the eruption of a tooth can be successfully predicted by any collection of symptoms. I have spoken to many parents who believe that their child has been teething for weeks without a tooth revealing itself. It just doesn’t work that way.

Experts do not believe that any systemic symptoms can be caused by the teething process. This includes poor appetite, congestion, difficulty sleeping, diarrhea, vomiting, cough, rash, or fever. At most, there may be some discomfort that goes along with the teething process. As with colic, a significant factor is the variability or fit of the parent-child dyad. The same child may be perceived as being more or less symptomatic, or not symptomatic at all, depending on which caregiver is observing them. Many new parents are exposed to misinformation regarding what to expect from teething and it is likely that at least in some instances it is a self-fulfilling prophecy of sorts.

The eruption of permanent teeth, which begins around age 6 years, is not typically associated with discomfort. This may be because of differences in sensitivity to pain between infants and older children, but it also might be evidence that the process just doesn’t really hurt that much. It is a myth that the new tooth cuts its way through the bone and gum. In reality a pathway emerges because of the remodeling of the tissue. Many children felt to be teething, and in need of treatment, may in reality be feeling no discomfort whatsoever. An indirect danger in continuing to attribute systemic symptoms to teething, and perhaps even pain, is the possible delay in seeking out appropriate investigation into their true cause.

Popular (but ineffective and potentially dangerous) teething treatments

More troublesome than any indirect harm of the misattribution of systemic symptoms to teething is the potential direct harm of actively trying to manage them. Historically the risk of serious harm from teething treatments was much greater. Many therapies used in the past were extremely toxic, such as lead- and mercury-based compounds. Consistent with beliefs in homorism, vomiting and diarrhea were frequently induced in order to purge the body of excess humors. The use of opiate based preparations could cause respiratory suppression and honey was a source of infant botulism.

The belief that tension on the gums played a prominent role in teething symptomatology was widespread. As a result, surgically cutting the gums in order to open up a path for the emerging tooth was a common procedure until the late 19th and early 20th century in developed countries. In some less developed regions around the world, the gums of infants were still frequently sliced open and the teeth removed. Sadly, well-meaning but dangerous efforts such as this still exist in some areas, and children continue to die of infection or live with significant malformations of the lower jaw and remaining teeth.

Many historical remedies for teething were based on a belief in magic. This hasn’t changed appreciably considering that one of the most common treatments used today is homeopathy. The pages of SBM are filled with articles discussing the mind-boggling inanity of homeopathy, so I won’t go into great detail in this post. In a nutshell, homeopathic remedies consist of concoctions diluted to the point that there is no possible means of therapeutic efficacy, if not non-existence. The proposed hypothetical underpinnings of these remedies are irrelevant as the reality is that there is no remedy in the remedy.

Hyland’s homeopathic teething tablets is one of the most popular examples of this. Continued belief in homeopathic remedies despite our improved knowledge of the pathophysiology of human illness, and how to treat it, is based on the naturalistic fallacy and an overemphasis on personal anecdotes rather than actual quality scientific evidence. Check out their website and provided video testimonials, and count up the logical fallacies. Their disclaimers, and reassurances that the amount of belladonna in the product is completely safe, are quite telling. The reason for all the fuss on their website is because of FDA concerns about the inconsistency in the amount of belladonna in the tablets and reports of toxicity in children. Hyland’s appears to disagree with these concerns. I’d go with the guy with all those medals though. Camilia from Boiron is another popular homeopathic product marketed for teething.

Another popular but ineffective remedy for teething symptoms is amber, typically incorporated into a necklace or bracelet. The claims regarding just how wearing amber might treat teething symptoms range from complete woo, such as it being charged with reiki energy, to somewhat more reasonable claims of analgesic chemicals being absorbed by the skin. These claims are implausible and thoroughly unproven, and amber jewelry represents a worrisome choking risk in young children.

Since it is believed by many that the source of any potential pain related to teething is localized to the area around where the tooth erupts, naturally a variety of topical preparations have been developed. These products typically contain the anesthetic agent benzocaine. Even assuming that teething does cause discomfort amenable to being numbed by a local anesthetic, there is a lack of evidence to support that these products are effective. But even if they were helpful in teething infants, the risks far outweigh any possible benefit. Children, particularly those under the age of 2 years, are at risk for a potentially deadly condition called methemoglobinemia when benzocaine is ingested or absorbed through oral mucosa. Methemoglobinemia interferes with the bloods ability to transport oxygen and can occur within minutes or hours after exposure, even after the very first use.

The FDA has issued warnings about this risk, and most pediatricians discourage the use of products containing anesthetics as well as those containing aspirin-like chemicals. There are also homeopathic gels, and teething oils that commonly contain clove oil. These only appear to work via parental placebo. The manufacturers of Orajel, probably the most widely known line of products used for teething and pain from oral ulcers or hardware, has jumped on the bandwagon and now offer their own homeopathic gel.

Use of oral analgesics like acetaminophen and ibuprofen (in babies over 6 months of age) is also common. There are no studies proving their effectiveness. Instead their use, as with all other interventions, is based on personal anecdotes and likely only appear to help because of any number of placebo effects. While these medications are relatively safe, and certainly safer than historical remedies or some of the other current popular treatments, they do have risk. Acetaminophen is associated with severe liver injury when overdose occurs and ibuprofen can cause bleeding in the stomach and kidney injury with regular dosing. These adverse effects aren’t common but they do occur.

How should teething be managed?

The safest approach to teething is to return whatever “remedy” you just purchased, thus avoiding anything that may potentially be harmful. Most experts will concede that although there are no systemic symptoms caused by teething, there may be some local discomfort. But it may be very mild, or there may be no pain at all. So any risk is likely too much when it comes to treatment.

If you believe that your child is experiencing discomfort, there are teething rings which can be chilled in the refrigerator which he or she can chew on. The thought process is that cold and pressure may help relieve discomfort. Avoid anything that may serve as a choking hazard in young infants, such as teething biscuits or cold bagels. And if you do choose to give acetaminophen or ibuprofen, check your dosing very carefully and avoid other products, such as cough and cold medicines, that may also contain acetaminophen.

Conclusion

Everyone has an opinion about teething and how to treat it, and most of that advice is wrong or at least not based on any evidence. Though historically teething was seen as a life threatening malady, it does not cause systemic symptoms and may not even actually cause significant discomfort. If your child has fever, diarrhea, significant changes in behavior, or excessive irritability, talk to their doctor before blaming these symptoms on teething. If your child appears to have some minor discomfort, supportive care (i.e. TLC) is the safest and likely most effective remedy.

Posted in: Science and Medicine

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