Safe and Effective Teething Remedies for Infants
Avoid all topical anesthetic gels containing benzocaine or lidocaine in infants due to serious safety risks, and instead use nonpharmacologic measures as first-line treatment, with acetaminophen or ibuprofen (≥6 months) reserved for significant discomfort. 1, 2
Critical Safety Warning: Avoid Topical Anesthetics
Never use benzocaine-containing teething gels in infants due to life-threatening methemoglobinemia risk. 1
- Infants have only 50-60% of adult levels of cytochrome b5 reductase, making them highly vulnerable to methemoglobin formation from benzocaine exposure 1
- Fetal hemoglobin is more easily oxidized to methemoglobin than adult hemoglobin, further increasing risk 1
- Even therapeutic application of benzocaine teething gels has resulted in methemoglobin levels of 20-69.9%, with levels >70% being potentially lethal 1, 3, 4
- Despite FDA warnings, 63% of pharmacists still inappropriately recommend benzocaine products for infant teething 5
Lidocaine-based teething gels also pose serious risks including seizures, respiratory arrest, and death, and are not recommended by the American Academy of Pediatrics or the American and New Zealand Society of Paediatric Dentistry. 6
First-Line: Nonpharmacologic Approaches
These should be your initial management strategy for all teething infants: 2
Comfort Measures (Use in Combination for Best Effect)
- Breastfeeding during teething episodes effectively decreases pain responses and provides comfort through both nutritional and non-nutritional sucking 7, 2
- Nonnutritive sucking on a pacifier has analgesic effects and calms the infant during discomfort 7, 2
- Skin-to-skin contact (kangaroo care) between infant and parent decreases pain behaviors 7, 1, 2
- Cold teething rings can provide relief when applied to sensitive gums 8
These nonpharmacologic measures are more effective when used in combination than when used alone. 7
Second-Line: Pharmacologic Options
Reserve these for significant teething pain that interferes with feeding, sleeping, or normal activity: 2
Acetaminophen (Paracetamol)
- Safe and effective for teething discomfort when nonpharmacologic measures are insufficient 1, 2
- Use appropriate weight-based dosing according to package instructions 1, 2
- Avoid prolonged use without medical supervision 2
Ibuprofen
- Safe and effective option for infants ≥6 months of age 1
- Use appropriate weight-based dosing 1
- Provides anti-inflammatory effects in addition to analgesia
Alternative Pain Relief for Minor Procedures (Not Specifically for Teething)
If considering oral sucrose for procedural pain in neonates:
- Dosage range: 0.012 to 0.12 g (0.05-0.5 mL of 24% solution) 7
- Give 2 minutes before anticipated discomfort 1
- More effective when combined with other nonpharmacologic measures 7
- Long-term safety of repeated doses has not been established 7
Clinical Pearls and Common Pitfalls
Timing and Expectations
- Teething typically begins around 6 months of age, with lower central incisors usually erupting first 2
- Monitor for signs of relief after implementing management strategies 2
When to Escalate Care
- If gingival swelling or discoloration develops, dental evaluation may be required 2
- Recognize methemoglobinemia: slate-gray or dusky blue cyanosis that does not improve with oxygen administration requires immediate treatment with methylene blue 1-2 mg/kg IV over 3-5 minutes 1
What NOT to Do
- Do not use any benzocaine-containing products regardless of concentration (7.5-20%) 1, 4
- Do not use lidocaine-based teething gels due to seizure and respiratory arrest risk 6
- Do not rely on topical anesthetics despite their FDA-approved labeling for "mouth and gum irritations" in children ≥2 years, as the risks outweigh benefits in young infants 9