Could a 5-month-old infant's symptoms of inflamed lower gums, feeding refusal, and excessive crying be due to teething?

Teething as the Likely Cause

Yes, the symptoms of inflamed lower gums, feeding refusal, and excessive crying in a 5-month-old infant are consistent with teething and this is the most likely diagnosis. However, you must first rule out serious illness before attributing symptoms solely to teething.

Clinical Reasoning

Timing and Presentation Support Teething

• The average age for teething onset is 6 months, with a normal range of 3-17 months, making 5 months an appropriate age for early tooth emergence 1, 2.
• The lower central incisors erupt first in 86% of infants, which explains the inflamed lower gums 2.
• Gum inflammation, irritability, and feeding difficulties are among the most commonly reported teething symptoms, occurring in up to 98.8% of teething infants 3, 1, 2.

Characteristic Teething Symptoms Present

The infant's presentation matches the temporal pattern of teething symptoms, which occur most frequently in an 8-day window: 4 days before tooth emergence, the day of emergence, and 3 days after 1. The specific symptoms align with established teething manifestations:

• Gum inflammation and sensitivity are hallmark signs of imminent tooth eruption 3, 1.
• Feeding refusal occurs because painful, sensitive gums make sucking and swallowing uncomfortable 3, 1.
• Excessive crying and irritability are statistically associated with teething, though they occur in less than 35% of teething infants 1.

Critical Exclusions Required

Before confirming teething as the diagnosis, you must actively rule out serious illness. This is the most important clinical pitfall to avoid 1, 4, 5.

Red Flags That Indicate Alternative Diagnosis

Examine specifically for these concerning features that are NOT associated with teething:

• Fever above 102°F (38.9°C) - no teething infant in prospective studies had fever ≥104°F, and mild temperature elevation (not true fever) is the only thermal change associated with teething 1.
• Vomiting - not statistically associated with tooth emergence 1.
• Severe diarrhea or persistent loose stools - not associated with teething despite common cultural beliefs 1, 4.
• Respiratory distress or difficulty breathing - indicates serious illness requiring immediate evaluation 4.
• Signs of dehydration - suggests gastroenteritis or other serious pathology 4.
• Lethargy or decreased responsiveness - never a teething symptom 1, 5.

Why This Distinction Matters

Cultural beliefs and parental expectations often lead to dangerous delays in seeking care for serious infections that coincidentally occur during the teething period 4, 5. In one study, 6.1% mortality occurred when serious illnesses were initially attributed to teething, with delayed medical attention contributing to poor outcomes 4.

Management Approach

Supportive Care Measures

Once serious illness is excluded, provide these evidence-based interventions:

• Cold teething rings applied to inflamed gums provide effective symptomatic relief 3.
• Increased biting opportunities on safe teething toys, as increased biting behavior is the most common teething symptom (occurring in the highest percentage of affected infants) 1.
• Gentle gum massage with clean fingers may provide comfort 3.
• Analgesic gels containing appropriate ingredients can be applied directly to inflamed gums for pain relief 3.

Feeding Modifications

• Offer cooled foods or liquids if the infant has started solids, as cold temperatures soothe inflamed gums 3.
• Shorter, more frequent feedings may be better tolerated than prolonged feeding sessions when gums are painful 3.
• Expect decreased appetite for solid foods during active teething, which is statistically associated with tooth emergence 1.

Common Pitfalls to Avoid

• Do not dismiss fever, vomiting, or diarrhea as "just teething" - these symptoms require evaluation for infectious or other serious causes 1, 4, 5.
• Do not delay medical evaluation when symptoms seem disproportionate to expected teething discomfort 4, 5.
• Recognize that no symptom cluster reliably predicts imminent tooth emergence - even when teething is occurring, symptoms are mild and variable 1.
• Understand that teething symptoms occur in less than 35% of teething infants and are never severe or life-threatening 1.