Management of Teething Pain in Infants
For an otherwise healthy infant experiencing teething pain, start with nonpharmacologic interventions—specifically breastfeeding, nonnutritive sucking, and skin-to-skin contact—and reserve acetaminophen for situations where pain significantly interferes with feeding, sleeping, or normal activity. 1
First-Line: Nonpharmacologic Strategies
These interventions are safe, effective, and should be attempted before any medication:
Breastfeeding during teething episodes is highly effective at decreasing pain responses and provides both nutritional and comfort benefits 2, 1, 3
Nonnutritive sucking on a pacifier or clean finger provides analgesic effects through endogenous pain-modulating pathways 2, 1
Skin-to-skin contact (kangaroo care) between infant and parent decreases pain behaviors and cortisol levels 2, 1, 3
Cold teething rings can provide local relief when the infant chews on them, though evidence is limited 4
Gentle gingival massage may provide comfort, though this should be done with clean hands 4
Second-Line: Pharmacologic Management
Reserve medications for significant pain that disrupts normal infant function:
Acetaminophen is the preferred pharmacologic option when teething pain interferes with feeding, sleeping, or normal activity 1, 3
Use appropriate weight-based dosing following package instructions carefully 1, 3
Avoid prolonged use without medical supervision—do not use for more than a few days consecutively 1, 5
Ibuprofen is an alternative for infants ≥6 months at appropriate weight-based dosing 3
Critical Safety Warnings
Absolutely avoid benzocaine-containing teething gels—these products carry serious risk of methemoglobinemia in infants:
Infants have only 50-60% of adult levels of the protective enzyme cytochrome b5 reductase, making them highly vulnerable 3
Fetal hemoglobin is more easily oxidized to methemoglobin than adult hemoglobin 3
Even therapeutic application has resulted in methemoglobin levels of 20-69.9%, with levels >70% being potentially lethal 3
Signs of methemoglobinemia include slate-gray or dusky blue cyanosis that does not improve with oxygen—this requires immediate emergency treatment with methylene blue 3
When to Seek Medical Evaluation
Parents should contact their healthcare provider if:
The infant becomes systemically unwell with fever, diarrhea, or other concerning symptoms that may be mistakenly attributed to teething 6
Severe distress persists despite appropriate management 6
Gingival swelling, discoloration, or other dental complications develop 1
Pain interferes significantly with feeding or sleep for more than a few days 1
Common Pitfalls to Avoid
The evidence base for teething management is surprisingly limited, and many traditional approaches lack rigorous validation 7. The most important clinical consideration is not to dismiss systemic illness as "just teething"—fever, irritability, and other symptoms often attributed to teething may represent serious illness requiring urgent medical attention 6. Teething is a normal physiological process that typically begins around 6 months of age and should not cause high fever, severe systemic symptoms, or prolonged distress 1, 4.