Is teething in infants associated with fever or other symptoms?

Journal of Family Practice, March, 2001 by Jeremiah Frank, Jonathan Drezner

Wake M, Hesketh K, Lucas J. Teething and tooth eruption in infants: a cohort study. Pediatrics 2000; 106-1374-79.

* BACKGROUND Parents and clinicians have traditionally attributed to teething many symptoms, such as fever, pain, irritability, diarrhea, drooling, and sleep disturbance. However, little evidence exists to support this claim. The authors investigated the relationship between tooth eruption, fever, and teething symptoms.

* POPULATION STUDIED All children aged 6 months to 2 years from 3 Australian daycare centers were eligible for the study if they attended at least 3 days a week. Twenty-one children (78% of eligible children) participated (mean age=14.4 months), and all completed the study.

* STUDY DESIGN AND VALIDITY This was a prospective cohort study. Data on symptoms for each child were collected using questionnaires completed by parents each morning and by daycare center staff each afternoon over a 7-month period. A dental therapist examined each of the children daily over the same time period for signs of tooth eruption and measured each child's temperature using an infrared tympanic thermometer. Tooth eruptions were defined as the first day a tooth edge emerged from the oral mucosa and remained consistently visible. Toothdays were defined as the 5 days leading up to a tooth eruption. Non-toothdays were defined as days more than 28 days clear of an eruption. Data were compared by logistic regression analysis.

The study was limited in several ways. The small sample size may have affected the power of the study to detect small but clinically significant differences. There was an attempt at blinding the participants and their parents to the purpose of the study, but this blinding was incomplete and was lost over time. Parents and daycare staff might have been inclined to over-report symptoms if a child was having a tooth eruption. There was no mention made in the study of parental administration of antipyretic or analgesic medication that may have been used to treat symptoms. Use of such medications might have affected temperature readings or the results of daycare staff questionnaires. Also, tympanic temperature readings have been found inaccurate for detecting fever compared with core temperature readings. Finally, a substantial portion of data was missing from the report (6% of dental therapist data, 13% of staff member data, and 17% of parent data) without adequate explanation.

* OUTCOMES MEASURED Tympanic temperature and symptom questionnaires (mood, wellness/illness, drooling, sleep, diarrhea/constipation, strong diapers, rashes, and flushing) were compared on toothdays and non-toothdays. A questionnaire was also given to parents at the end of the study that assessed their beliefs about which symptoms their child experienced.

* RESULTS Over the 7 months of the study, 2067 days of data were collected. There were 90 tooth eruptions, 236 toothdays, and 895 non-toothdays recorded. There was no statistically significant difference found in tympanic temperature when comparing toothdays to non-toothdays. Of the 32 separate analyses of symptoms that were performed, only parent-reported diarrhea was associated with tooth eruption (odds ratio=1.86; 95% confidence interval, 1,26-2.73). However, this association disappeared when looking at the 10 days leading up to an eruption or the 5 days on either side of an eruption and did not exist as reported by child-care staff.

Children with fever or most other symptoms tended to be younger, suggesting that age could potentially confound any observed relationship between tooth eruptions and symptoms. In the final questionnaire, all parents retrospectively reported that their child suffered a variety of teething symptoms.

RECOMMENDATION FOR CLINICAL PRACTICE

Many parents believe that teething causes a range of symptoms (fever, irritability, sleep disturbance, drooling, and so forth). This study provided no conclusive evidence that a relationship exists between the eruption of teeth and the experience of symptoms. Temperature greater than 38 [degrees] C or other serious symptoms in an infant should not be regarded by clinicians as due to teething and should be evaluated appropriately.

Jeremiah Frank, MD
Jonathan Drezner, MD
University of Washington Medical Center
Seattle
E-mail: jdfrank@u.washington.edu