On Saturday, the FDA released a recall of Hyland’s teething tablets. The recall stems from concerns for increased and varying amounts of belladonna, a toxic substance that could cause serious systemic effects to babies. It’s unclear how much belladonna is found in these tablets normally although it is well known it’s in them. Recently, infants have developed symptoms consistent with belladonna toxicity after using the tablets (change in consciousness, constipation, skin flushing, dry mouth). Homeopathic supplements and medications are unregulated and therefore it’s hard to know what is in them, how consistent one bottle is from the next, and how different brands of the same products compare. Local and national poison control previously deemed teething tablets safe even though it is known that they have trace amounts of belladonna (and possible caffeine). The FDA states it is “unaware of any proven clinical benefit from the product.” Because of safety concerns and no known benefit, I’ve always recommended against using teething tablets. If it were my child, I didn’t, and would not use teething tablets. If you have these at home, throw them out. Here’s some FDA tips of safe disposal of unwanted medications. If your child has had these tablets in the past, there is no reason to worry. Ill effects would have been seen soon after using them.
Some Teething Truths:
- Teething commences around 4-12 months of age and continues until around 24 months, although variability is the norm. Late teethers are very common (first tooth after 9 months) and not worrisome. I recommend you see a dentist after 12 mo of age for routine preventative screening. If there are no teeth by 14-15 months, that’s when a work-up (like getting x-rays) would begin.
- Drooling does not necessarily mean your child is teething. Don’t let the grandparents, neighbors and friends fool you. Drooling picks up readily after 3-4 months of age as a result of your baby’s increased exploration by mouth (gnawing and pulling hands in mouth) and to facilitate digestion. Prior to a big burst of drool, babies explore through their sense of sight and hearing; as 4 months hits, they start to explore through taste. Although there can be an up-spike in the volume of drool if a tooth is on its way, it’s not a perfect flag for the event.
- Teething discomfort is uncommon. Most babies are utterly unphased by teeth popping through, others may show discomfort. In my office, parents often report the experience of discomfort when their child is teething. This may be true for some babies, but don’t expect to see pain with teething. All babies are different but research does not associate teething with pain, runny nose, fever, or diarrhea. If your baby has a fever while teething, it’s likely from another source (i.e. viral infections, ear infections). If your baby has a fever over 100 and you are concerned about pain, don’t assume it’s teething; call or visit your doctor for help.
- When teething, most babies love to chew on things. I often say to parents, it looks like they have itchy teeth! I learned this while watching my boys pop teeth; it really appeared like they wanted to scratch them. But don’t misinterpret chewing behavior for pain and reach for medications. You don’t have to medicate the urge to gnaw….
- Nearly all babies pop their lower central incisors (two middle teeth) first and then the rest of the mouth fills up. Babies get about 1 tooth/month after their first incisors come in. Order and timing are extremely variable–some babies get one tooth every month while some infants pop 4-6 teeth all at once!
Medications Marketed for Teething:
- Tablets (homeopathic teething tabs like those recalled). I never recommend these. There’s no good evidence that they work. Why give your baby something that potentially can have negative effects with no proven benefit? Regarding homeopathic supplements The Medicine Guy explains today, “The terms dietary, natural, and homeopathic convey a sense of safety. Cultural beliefs, positive reviews from friends, effective selling techniques, and wishful thinking contribute to the impression that a product will be effective for its intended use. Unfortunately, it is not often that we have the clinical evidence to support the effectiveness of most of these products.” Furthermore, never rub aspirin or any other medication on your baby’s gums.
- Gels (a local anesthetic–usually benzocaine– to numb the gums) like Oragel/Baby Oragel. I don’t like these. First of all, if any of you have tried using these, they numb up your mouth leaving you with a fuzzy, funny feeling inside. They only work on superficial skin, not necessarily targeting the area of possible discomfort below the gums where teeth are moving. Lastly, I don’t like the idea that these gels can potentially numb the back of the throat as they are swallowed by infants, setting a baby up for difficulty swallowing or choking-like behavior.
- Liquid Pain Relievers. These are the safest and most effective medication for teething. The only medication I ever recommend is Tylenol (acetaminophen). I don’t recommend ibuprofen or motrin for teething (risks outweigh the benefit).
If a baby is teething, reach first for symptom relief with teething toys. Then try Tylenol if you believe your child is in pain.
How To Help Teething Symptoms (Without Medications):
- Teething Toys: find someone for your little gnawer that’s cool to touch but tough to chew on: wet washcloth chilled in the freezer for 15-30 minutes, a frozen banana or berries if you’ve introduced solids, solid (not liquid filled) teething rings chilled in the fridge or freezer (take them out before they are rock hard), a frozen bagel, your finger, or a lovie type toy. If your baby is over 6-9 months, offer a slow flow sippy cup of cool water to suck on and drink for comfort. Of note, plastic teething rings with liquids have been given a bad name in the past few years due to recalls–potential bacteria growing in liquid and the possibility of a baby cutting through the ring and into the liquid. As many parents try to avoid plastics (phalates/BPA), I suggest using the washcloth method or a cotton sock rolled up tightly to gnaw on. Silicone and latex chewy toys may be a safer bet. One of our of our boys loved loved loved the Girafe (spelling intentional) teether that is popular right now. And some babies who seem irritated by teething may enjoy having a pacifier to suck on.
- Fingers: Let your baby gnaw on your fingers (if the teeth haven’t come through) or rub their gums with your clean fingers for comfort.
- Massage: If you’re breastfeeding and your baby isn’t interested in a teething toy or more interested in chewing on your nipples (eeeeeek) or your arms, especially around the time of feeding, massage their gums with your fingers dipped in cool water prior to starting a feeding.
Clean the teething toys, washcloths, or socks after each use. And know, it’s absolutely fine to let your baby chew all day if they enjoy it. Still, nothing about gnawing means pain.
What other interventions worked for you & your baby?
The only thing that really worked for us was Motrin. We only used it when she woke up screaming in the night with her hand shoved all the way into her mouth and then flinched when we touched the swollen parts of her gums. Teething rings worked a little during the day, but she would flat out refuse them at night. And she liked comfort nursing, a LOT of comfort nursing. And biting me on the shoulder.
Wendy Sue Swanson, MD says
Here’s another post from a friend and pediatrician, Dr Kim. It’s a similar take on soothing teething discomfort:
My kiddos were quite distressed by their canine and molars. My son had all 8 erupt in the same 3 week period. He would scream, pull his hair, bang his head against the wall. Neither child responded to teethers for teething needs, though they were equal opportunity slobberers. For relief from teething pain we used the following:
* Extra chewy bagels (like Noahs)
* Wood spoon
* Chilled apple/pear slices
* Leather (like his Robeeze slipper)
* Hard plastic (like Mega Bloks)
* Wood blocks
* Velcro straps
* Frozen berry puree
* Apple sauce slushy
* Hard sippy cup spout
* Whole grain O’s (whole grain is scratch and crunchy!)
* Kashi puffs
He never took a pacifier but when I weaned him we switched to the Born Free training cups. He chewed on the spouts so intensely we went through 10 spouts. We often let him go to sleep with a cup of water so he could chew and soothe himself to sleep. Had to check the spout for tears each day (general warning about the spouts). Better the spout than me!!
I’m curious about the motrin comment. When my son’s molars erupted, the gums were bleeding and inflamed. (Like hard sobbing followed by “owie mouf!” Breaks my heart still.) Motrin seemed to help more than Tylenol in that case.
I read the comment about breastfed babies who aren’t on solids…
My kids were fussy and lost some sleep when their incisors erupted but the techniques you mentioned helped.
Wish I’d found these wood teethers before I parted with my best spoons:
thanks for this post…we used Tylenol until the recall, now generic acetaminophen, but it is really hard to find. We are able to get it at Pharmaca but they usually one have one bottle at a time.
I too am curious about why ibuprofen has more risks than is worth it. Could you please explain this more? My baby wakes up screaming when teething is particularly bad and screams during the day as well. He has trouble drinking from the bottle and flinches and cries out when gums are touched by spoon or hand. At these points, he doesn’t even want his old standby (chewing on a cool, wet washcloth) because it seems to hurt too much. It’s sometimes frustrating when doctors assume you can’t recognize certain things like discomfort vs. activity in your baby. Tylenol helps some during the day when he has distractions, but at night it doesn’t help as long or as thoroughly, and it’s hard to soothe him back to sleep until it takes effect when given again, resulting in lots of lost sleep for all of us and an even crabbier baby for daycare. I would power through it more if it weren’t for working and daycare.
All that I guess to explain why so many parents want to use ibuprofen and to explain why it helps so much and to see why it is so risky? Thanks in advance!
p.s. Mine never took a pacifier, but the soothie one given him in the hospital is PERFECT for teething/chewing
Wendy Sue Swanson, MD says
First of all, I agree, it’s frustrating when it seems like doctors don’t feel like you can recognize discomfort in your child. OF COURSE you can recognize changes and discomfort in your baby or toddler. I didn’t mean to say that. I made mention that many many parents come into clinic telling me about teething discomfort that they see in their children. I don’t doubt their experience…most research finds that teething isn’t painful but I certainly believe families. I think behavior change may not always be pain, per se, so that is why I made mention of not always experiencing drooling and gnawing as pain. But if you think your baby has had pain, you’re likely the expert on this one.
In regards to ibuprofen, I just feel the medicine carries risks greater than Tylenol and with symptomatic measures like washcloths, teething toys, and time, I wouldn’t recommend using those before a medication that has undesirable side effects. Side effects from using NSAIDs (non-steroidal anti-inflammatory medications) like ibuprofen or Motrin include stomach upset (in around 9% of patients), bleeding, platelet changes (a type of blood cell), kidney disease, and elevated liver enzymes. ALthough these are unlikely, I have seen patients with severe complications from OTC NSAIDs. Parents use these freely, but I suggest you always try Tylenol first as it doesn’t carry these risks. In this case, I meant that the risk using NSAIDS for teething outweighs the benefit gained. Using other interventions for teething is my recommendation, followed by Tylenol. I’m sure you can find a pediatrician who would rcommend using ibuprofen, but I don’t.