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The Truth About Teething

By November 8, 2016 No Comments

Last month the United States Food and Drug Administration (FDA) issued an advisory about the use of homeopathic teething aids.  Many of us know these under the popular brand name of Hyland’s Teething Tablets.  So what are parents of teething babies supposed to do?

Teething gets a bad rap.

In the not-so-distant past, it was blamed for seizures, and up to 1/3 of infant deaths. It was treated with bloodletting, gum-lancing (cutting the gums with a scalpel), leeches, mercury, and cocaine. Yes, cocaine. Obviously, we’ve moved on from most of those beliefs, but teething is still a common concern for parents, and also a common reason for pediatric visits. But when we do studies to really look at the symptoms teething causes and the treatments that are effective, the results can be surprising.

Teething Basics
The teething period is generally considered to be an eight-day window, including the four days before the tooth erupts, the day it erupts, and the three days subsequent.  Babies usually cut their first tooth around six-months-old, but it can happen sooner or later.  The bottom central incisors are usually the first to pop through, followed by the upper central incisors, but there’s no need to panic if they erupt in a different order.  Generally speaking parents can expect one tooth a month until they’ve acquired all 20 teeth, but they can also erupt in pairs.  Parents can expect their child to cut their last tooth around the 24 or 30 month-mark.

The medical literature about teething symptoms is not great. There isn’t a lot of consensus about what symptoms can actually be attributed to teething and what are myths passed down from our own parents and our friends.   What the literature does agree on, is that severe symptoms like high fevers, diarrhea and vomiting are NOT associated with teething.  If your child exhibits these symptoms they are most likely caused by something other than by teething.

The best evidence we have is from a review of all the studies about this topic, and its conclusion was that gum irritation, mild irritability, and drooling were likely to be caused by teething. There is also a very minor rise in body temperature (like 0.1-0.2 degrees), but not enough to cause a true fever. If your baby has a fever (temperature greater than 100.4 F), rash, or diarrhea, or if he seems particularly irritable, it’s probably not because of teething. However, it may very well be related to a viral illness he picked up from putting his hands or other objects in his mouth.

The literature is also split on whether or not parents and caregivers can accurately predict a the eruption of a tooth, based on teething symptoms alone. What this means is that before parents shouldn’t delay seeking medical care for their child, or assume symptoms are teething related, because chances are they’re not.

But what about common treatments for teething used today? Do they work? Are they safe? That’s a bit of a loaded question as I’ll discuss below.  On the bright side it appears that the medical community has decided against gum lancing, rabbit brains, and mercury-based powders which were common centuries ago. But there are a lot of other questionable options out there. Here are some remedies I’ve seen, along with what we know about them:

  1. Hard liquor. Fortunately, this has become quite a bit less popular over the past few decades, but I’ve still seen it. Brandy, whiskey, rum…they may help you get through a night with a screaming baby, but you shouldn’t be giving them to your baby. An infant’s liver cannot process alcohol well, and it can become toxic even at very low doses.
  2. Amber necklaces. These have become quite common in recent years. They are made from beads of Baltic amber on a string, and they reportedly help teething by releasing succinic acid from within the amber to be absorbed through your child’s skin. I have a number of issues with amber necklaces. Regarding safety, they present a very real danger of strangulation or choking, both of which outweigh the (mostly imagined) symptoms of teething. And as for their effectiveness, the idea of a child’s body heat warming the amber enough to release anything doesn’t make sense; nor has succinic acid been shown to be an effective treatment for teething symptoms, especially in the minute doses that could plausibly be absorbed from these beads. (If you are interested in reading more about amber beads and teething, there are some great discussions here, here, and here.)
  3. Topical teething gels (Orajel, etc). These have a numbing effect and do provide some pain relief. They might actually help. However, most of them contain benzocaine, a medication that can cause a potentially fatal condition called methemoglobinemia in rare cases, even at the recommended dose. They are widely available, but I discourage their use due to this risk.
  4. Teething tablets (Hyland’s, etc). These homeopathic tablets are made from ingredients marketed as natural that the manufacturer claims help with symptoms of teething. There has been some controversy surrounding children that were potentially harmed by ingesting too much belladonna, one of the tablets’ active ingredients, but children have also been reportedly harmed when their parents used the tablets as directed. It’s important for parents to realize that “homeopathic” isn’t just another word for “natural”–it’s a very specific subgroup of alternative medicine that goes against everything we know about physics, chemistry, and biology. Homeopathic treatments aren’t proven to be safe or effective, and they are not tested or regulated by the FDA. They probably won’t hurt your baby if used as directed on the package, but be aware of the risks, and realize that they won’t help either.
  5. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). These are commonly used medications for pain and fever. They have been proven to be safe at the recommended dosages, but both can be toxic and even fatal in overdose amounts. Both of these medicines help with fevers and pain, and they may help to relieve some mild discomfort caused by teething (or pain/fever caused by anything else). Do not use acetaminophen under 2 months of age or ibuprofen under 6 months of age unless directed by your doctor. Do not use any medications containing aspirin in children. Keep all medications out of reach and double-check the dose for your child’s weight. (You can find a printable dosing chart here.)
  6. Cold objects. These are probably both effective and safe, as long as they are chosen wisely. Teething toys designed to be placed in the refrigerator, cold washcloths, or similar items could provide some relief with very little risk of harm. Avoid ice cubes or other small objects that could present a choking hazard.
  7. Teething toys. Similar to the cold objects above, these seem to provide a benefit with very little risk. Choose toys designed for this purpose that don’t have small parts, sharp edges, or other dangerous properties. If nothing is available, most babies seem totally fine with using their hands or feet.
  8. Patience. This is the only remedy that works every time and has no potential risks (except of course, the risk of ignoring an important symptom because it was attributed to teething). As Voltaire wrote, “The art of medicine consists in amusing the patient while Nature cures the disease.” And while I wouldn’t call teething a disease, his wisdom still applies.

Probably the most important thing parents can realize about teething is that, despite what your grandmother told you, it doesn’t cause severe symptoms. But no matter what’s causing the fever/fussiness/etc., the symptoms are real. For mild symptoms, it’s OK not to treat at all–but if you’re going to give your child a medicine, It’s important to choose one that is known to be safe and effective. And if you have any questions about your child’s health, be sure to ask your pediatrician–it’s what we do.

Categories: Newborns + Infants, Science 101 + Mythbusting, Toddlers + Preschoolers

The FDA Answers Your Questions About Hyland’s Teething Tablet Advisory

By November 8, 2016 No Comments

A little over a month ago the United States Food and Drug Administration (FDA) issued an advisory to parents to stop using and immediately dispose of any homeopathic teething aides or gels they may have in their homes or may be using.  The most popular of the brands that falls under this umbrella are Hylands Teething Tablets.

We received a number of questions from readers about the recall, and while we were able to independently find several references in the medical literature of seizures and death resulting from belladonna poisoning as a result of using the tablets as directed, the FDA’s advisory left many parents with questions.  We’ve covered the issues with products marketed as homeopathic remedies previously, but like others we needed more information about what specifically prompted the FDA’s advisory about Hyland’s Teething Tablets.  For that we reached out to the FDA directly.  We spoke with Lyndsay Meyer who works in communications at the FDA and also happens to be the mother of a four-year-old boy.

Due to the nature of the FDA’s investigation, which is ongoing, Lyndsay was limited in what information she could provide.

Can you provide a little more information about what prompted the September 30 advisory?
On Sept. 9, the FDA received a comprehensive report of a recent adverse event of a child having a seizure associated with use of a homeopathic teething product, which triggered an agency investigation.

At this time, the FDA is still conducting our investigation, and we have not yet completed the analyses of products to determine if there is an association between the adverse events and the homeopathic teething products.

It is important to note that while adverse event reports give us some information about a product and serious injuries or deaths related to use of a particular product, they often indicate situations that require additional analysis and do not constitute conclusive evidence of a problem with the product. Sometimes after further analysis, the adverse events may inform agency decisions to take regulatory action. Other times, further analysis shows that the adverse events were not attributable to a problem with the product but to other factors, such as a patient’s underlying health conditions. It also is important to note that the number of adverse events identified may fluctuate with our growing understanding of an issue, as well as through identification and elimination of duplicate reports.

The FDA’s September 30 advisory didn’t offer much information about the nature, frequency and severity of the adverse events associated with the use of the teething tablets, what symptoms should parents be aware of?
The FDA issued the warning following this report and because further examination showed more than 400 reports of adverse events associated with homeopathic teething products in the last six years. These adverse events included  seizure, death, fever, shortness of breath, lethargy, constipation, vomiting, sleepiness, tremor, agitation, and irritability.

We are also aware of reports of 10 deaths during [the time period reviewed in the report] that reference homeopathic teething products, though the relationship of these deaths to the homeopathic teething products has not yet been determined and is currently under review.

The FDA previously recalled the tablets in 2010, is the 2016 advisory related to the issues reported in 2010 or are these new issues?
Our preliminary review shows that these adverse events are similar to those observed in 2010 when the FDA warned of belladonna toxicity associated with Hyland’s Teething Tablets, when we also issued a warning to protect the public health.

What, if any products, can parents use to help manage teething discomfort?
There are more theories about teething and “treating” a baby’s sore gums than there are teeth in a child’s mouth. One thing doctors and other health care professionals agree on is that teething is a normal part of childhood that can be treated without prescription or over-the-counter (OTC) medications.

If your child’s gums are swollen and tender,

  • gently rub or massage the gums with your finger, and
  • give your child a cool teething ring or a clean, wet, cool washcloth to chew on.

Chill the teething ring or washcloth in the refrigerator for a short time, making sure it’s cool—not cold like an ice cube. If the object is too cold, it can hurt the gums and your child. The coolness soothes the gums by dulling the nerves, which transmit pain.

Parents should supervise their children so they don’t accidentally choke on the teething ring or wash cloth.

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Categories: Accidents, Injuries, + Abuse, Newborns + Infants, Toddlers + Preschoolers