University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In healthy infants are symptoms such as fever and diarrhea associated with teething?

Clinical Bottom Lines

1. Many mild symptoms are temporally associated with teething, but no set of symptoms could predict that a tooth was about to emerge.¹  High fevers and diarrhea are not significantly associated with teething.
2. No good evidence exists that teething is associated with any severe, health threatening conditions. Thus, before attributing any signs or symptoms of a potentially serious illness to teething, other causes must be ruled out.

Summary of Key Evidence

1. A prospective study of 125 healthy infants (3 - 5.6 months old) from August 1994 and February 1996 was conducted to determine which symptoms may be attributed to teething and to attempt to predict tooth emergence from infant symptoms. To mask the purpose of the study, it was described as one of normal infant behavior.¹
2. Infants with one parent employed at the Cleveland Clinic Foundation were used because parents could be contacted regularly. 
3. Parents checked for tooth eruption daily by feeling if a new tooth had broken through the gums. Parents also kept a daily log of 18 symptoms. All concurrent illnesses, medications, and immunizations were also recorded. 
4. Parents were instructed to record daily information on each variable, using 0 in indicate normal, single arrow pointing up or down to indicate an increase or decrease, and 2 arrows up or down in indicate a large increase or decrease.
5. Any decrease in appetite for liquids or solids or sleep duration was considered abnormal. The temperature was classified as abnormal if it was higher than 1 standard deviation above that child's own mean temperature over the study. 
6. The study group consisted of 111 infants whose parents at least provided some daily symptom information. 
7. The teething period was defined as the 8-days, beginning 4 days before a tooth emergence and extending 3 days afterwards  
8. Although there were statistically significant associations between many symptoms and tooth emergence, no symptom occurred in greater than 35% of infants during their 8 day teething periods, and no symptom occurred in greater than 20% more often in the teething period. 
9. Only weak associations, not considered statistically significant, were found between teething and diarrhea. 
10. Temperature higher than 1 standard deviation above the child's mean was significantly associated with tooth emergence only on the day of emergence or 1 day earlier (P< 0.01). None of the fevers higher than 104 F and only one over 103 F that occurred during the 369 tooth eruptions were unexplained by another illness known to be associated with fever.  Temperatures over 100 F occurred on 2067 days during the study, but only 64 of these were days in which a tooth emerged.
11. Symptoms of decreased appetite for solid foods, biting, drooling, ear rubbing, gum rubbing, irritability, rash on the face, sucking, and abnormal temperature (defined as being greater than a child's own mean temperature plus one standard deviation or fevers <102 F), and wakefulness were found to have some association with the teething process. No set of symptoms could predict that a tooth was about to emerge.

Additional Comments

• Some parents provided incomplete data, which may have introduced biases into the study. 
• The study relied on parental reports of tooth eruption. There was no confirmation by investigators.
• Multiple comparisons and analyses introduce the possibility that symptoms found to be slightly associated with teething were spurious. 
• Although parents were told the study was of infant behavior, most seemed to discern from the questionnaire that it was designed to study teething.  Preconceived parental notions may have biased parental reporting. 

Citation

1. Macknin M, et al.  Symptoms associated with infant teething: A prospective study.  Pediatrics 2000;105(4):747-752.

CAT Author: Sue Lin, MD

CAT Appraisers: Robert Schumacher, MD

Date appraised: August 6, 2001