Key Milestones & Sleep: Teething

As we continue our posts on developmental milestones and impacts to sleep we must cover teething! Typing teething into google yields over 20 million hits. It’s a big topic in parenting. The normal eruption of teeth seems to be fraught with bad information, legends, horror stories and urban myths. Teething is also often blamed for a multitude of sleep problems. Is this accurate?

In this article, Lyndsey Hookway demystifies the process of teething. As you can see on her website, Lyndsey is a Paediatric Nurse and Early Childhood Health Nurse and IBCLC. Lyndsey has recently published a book Holisitc Sleep Coaching available on Amazon UK.


Tooth development starts just a few weeks after conception, and all teeth are present within the jaw bone at birth, but most babies won’t show any signs of those undercover teeth for several months. Ultimately, as adults, we have 32 teeth, but children have 20.

There are 3 stages of tooth development:

1. The primary dentition stage: When the first ‘baby’ teeth erupt

2. Mixed dentition stage: When the child, usually after the age of 5 years, begins to lose teeth, and some permanent teeth erupt, so that there is a mixture of baby and permanent teeth

3. Permanent dentition stage: When the last baby tooth is lost (usually around 11-12 years) and lasts for the rest of the person’s life.

The actual mechanisms of teething are not well understood, but it is thought that hormones are responsible for skin cell death in the gum. This cellular death causes the gums to break apart and allows space for the erupting tooth below the gum-line. The words people use for teething are often unhelpful, and lead us to attribute more pain to teething than is probably the reality. We talk about ‘cutting’ teeth, for example, but the teeth do not physically slice the gums.

The cellular death that occurs in the gums does cause inflammation, which is why the gums often appear swollen or hard. Babies instinctively want to bite and chew hard objects, as this helps the dying cells to break down faster and allow the emerging tooth through.


Of course, there is huge variability with the eruption of teeth. Some babies get their first tooth at just a few weeks, or they are even present from birth, while other baby’s first birthday comes and goes long before the first pearly white. Teeth usually erupt in pairs, and on average, the tooth eruption process is as follows:

· The 2 lower central incisors – around 6 months · The 2 upper central incisors – around 8 months · The 2 lateral upper and lower incisors – around 10 months · The first 4 molars – around 14 months · The 4 canines – around 18 months · The second 4 molars – between 2-3 years

Many people think a baby is teething at around 3 months. This is usually due to the fact that a baby will typically start to drool, and also be able to start getting their hand accurately to their mouth and chew it. Often people put these two signs together and assume that teeth are to blame. They almost never are.

The other thing that happens frequently is that the actual process of teething is often felt to be long, arduous and protracted. Unsettled behaviour, fussing and unexplained sleep disturbances are often seen as symptoms of teething, when in actual fact it is more likely to be caused by something else.


Over the centuries, teething has been blamed for all manner of evils, from diarrhoea and nappy/diaper rash, to intractable pain and even death! In fact, in 1842, records show that in nearly 5% of all infant deaths, teething was named as the cause, and it apparently caused 7% of all deaths in 1-3 year olds. Of course, nowadays, we know that infant and child mortality rates sadly used to be a lot higher, and teething just happened to coincide with a whole load of other infant and child illnesses that we are now better at treating. But it is an important part of our history.

Nowadays, it is more likely that people will blame teething for any unexplained period of fussing or sleep disturbance. The common symptoms that teething is blamed for include:

· Gas and wind · Fever · Coughs, runny nose and colds · Diarrhoea · Nappy/diaper rash · Pain · Sleep problems

We will examine these one by one in a moment, but first of all, it is important to state that the actual process of dentition usually takes about 3-6 days. That’s it. This is really important, because unexplained cranky behavior, fussing, sleep disturbance and illness that is longer than this is very likely to be caused by something else.

The truth is, babies are nearly always going through one developmental stage or another. If it’s not a gross or fine motor developmental learning curve, it’s social awareness. If it’s not learning to babble, it’s learning to sit up, or crawl. If it’s not separation anxiety, it’s probably mastering some complex hand-eye coordination task! So, if a baby always seems to be cranky or fussy for a few weeks on end, it’s more likely to be caused by back-to-back developmental phases, rather than a tooth – which is usually quite a distinct, short phase of obvious fuss.

This is important to know, for many reasons, but one is: unnecessary medication. You see, if parents attribute long drawn-out phases of fussing to teething, their very reasonable assumption is that teething is a long, protracted, painful process. What parent wants their child to be in pain for days or weeks on end? But the problem is that a) pain relief won’t help if it’s a developmental phase, b) unnecessary pain relief can be harmful, and c) it leads parents to believe that their child is really suffering from teething pain which is intractable and not resolvable with simple analgesia. This serves to reinforce the belief that teething is a very painful process. It also potentially means that a child will be given pain relief at the first onset of fussy behavior – which could be around 4 months, only for the first tooth to not arrive until 8 or 9 months. That’s 5 months of unnecessary medication, and a reinforced belief that teeth take months to emerge and it is a very painful and slow process.

Gas/wind: There is no evidence that teething causes this. It is more likely to be due to something the baby ate. Don’t forget, babies are often getting teeth around the same time they are trying lots of new foods. It could just be that one of them has caused their system to react with more gas than usual.

Fever: While teething is an inflammatory process, it will not cause a significant fever. A very low grade fever of up to about 38°C may be caused by teething, if there are other obvious signs as well, but a fever higher than this is almost certainly caused by an illness, such as a virus.

Coughs, runny nose and cold: There is no evidence that teething causes a viral illness such as a cold or cough. It doesn’t really make a lot of physiological sense. Teething is an inflammatory process, so it is plausible that the immune system is under more strain than usual, but even that is a stretch. What is more likely is that babies of the age to start teething are more exposed to new environments, germs and new people who are spreading coughs and colds. Approximately 10 colds per year is entirely normal for young children – which can feel almost endless during the winter months. Babies often start daycare or nursery around the time they start teething so it is likely that this is a coincidence.

Diarrhoea: It is highly improbable that teething causes diarrhoea. Lots of parents anecdotally report that their baby has a ‘vinegar’ smelling nappy around the time of teething, but true diarrhoea (very loose, runny, watery, foul-smelling stool) is not likely to be caused by teething. It is far more likely that the baby has touched something or been exposed to a bug that has upset their tummy. Don’t forget, around the time babies start teething, they are also crawling around, putting everything in their mouth, touching the dog’s rear end, putting other children’s chewed toys in their mouths – you get the picture!

Nappy/diaper rash: Again, this is a common young childhood complaint. While lots of parents report some nappy rash around the time of teething, it is just as likely to be caused by something their little one ate that has caused a particularly offensive stool. If the baby has had a ‘vinegar poo’ then it is possible that the skin may be more irritated than usual, but a significant nappy/diaper rash should not just be attributed to teething, in case it is a fungal or bacterial rash that needs medical attention.


So, now you know what teething probably doesn’t cause, you’ll most likely want to know what it does cause. Here we go:

Pain: Ok, now we get to the crux of it! Teething causes the gums to break down, inflammation and swelling. This can be painful, no denying it. Nobody wants their little one to be in pain. Actually, some babies don’t seem to be bothered by teething at all. And others will really let you know about it. It is not uncommon for parents to experience a totally different reaction from different children. We can only put this down to differences in pain perception, different inflammatory responses, and different anatomy. We will come back to what you can do to relieve teething pain later on.

Sleep problems: Do teeth cause sleep issues? Well, probably, if they cause pain. See above! It is important to note that teething does not always seem to cause a baby any trouble. But other babies seem to have trouble with teething for a few possible reasons:

1. There are fewer distractions in the night time: In the day, a baby may be more easily pacified with a toy, a change of scene, or a cuddle. At night, it is dark, quiet, and there is less stimulation. As distraction is a well-known form of pain relief, it makes total sense that nights would be worse than days.

2. Babies usually lie down to sleep: In the daytime, when they are upright, there is less blood flow to the head. Lying down may increase the pressure in the head. This is also true of any sinus-related pain – it is always better once you are standing upright, due to gravity.

3. Overtired babies release more cortisol to cope with fatigue: If babies are struggling with sleep anyway, they may have higher circulating cortisol, which increases the pain response, and also slows down wound healing, suppresses the immune system, and leads to more anxiety and stress.

So the link between tiredness, poor sleep and teething may be closely related, though more complex than it might first appear. You may find your child has:

- More frequent breastfeeding in the night (the action of breastfeeding soothes the pressure in the jaw and mouth) - More frequent wakings - Is struggling to fall asleep or get back to sleep

Other General Symptoms:

· Drooling · Wanting to chew on objects · Reluctance to eat · Pulling at their ears · Bright red cheeks

Teething symptoms are actually quite specific, and focused around the jaw and mouth itself. It should be fairly obvious when a child is teething – it will be 3-5 days of gnawing and chewing, and possible fussing.


Pharmalogical Remedies:

Any pharmaceutical shelf will have a wide array of gels, powders, and granules to rub on the gums to ease teething pain. Some good general advice is that if you are not sure if your baby is unwell, or teething, you should get them seen by a doctor.

For example: a baby with a fever, who is reluctant to feed, and pulling their ears may have an ear infection, rather than about to get a new tooth. Rubbing teething gel on their gums will do nothing to address the underlying condition.

If you are certain that this is new behaviour, specific to teething, then you could certainly try a teething gel or homeopathic remedy. But we would urge you not use these for more than a few days. If your baby is still upset after this, it is more likely to be something else.

Non-Pharmalogical Remedies:

There are many parents who feel more comfortable trying non-pharmacological remedies. Some good simple options include:

• Try teething chew toys that are specifically designed for teething babies. Some can be chilled first

• Putting a clean flannel/washcloth in a plastic bag and freezing it. Let it thaw a little before giving it to the baby – frozen flannels can stick painfully to lips!

• Offer cold, hard, watery foods to chew – such as cucumber, melon and frozen banana (again – thaw a little first)

• Make a ‘mumsickle’ or ‘booby lolly’ – use expressed breast milk (or formula) to make a milk popsicle that the baby can suck

You will note we have not included Amber teething necklaces or bracelets. The theory with these is that the amber is warmed against the skin and slowly releases pain relieving and anti-inflammatory properties to ease teething pain. There is no evidence to back this up. The problems with the strategy of Amber necklaces and bracelets are:

a) It feeds into the idea that teething is a long drawn out process b) They pose a choking risk c) They are a strangulation hazard

Sleep Considerations:

• Try to prioritise sleep as much as possible - it will prevent overtiredness which can make the experience of teething more painful

• Promote a stress-free environment. Since stress can cause inflammation, try to optimize a calming atmosphere. This is also good for bonding and is more conducive to sleep!

• Consider naps in a baby carrier if needed to have the baby upright


So, despite millions of hits on Google, thousands of blog posts on how to help with teething, hopefully it’s a little clearer that teething is both simpler, and more complex than you might think!

Here’s a summary:

• Teeth are present from birth, and usually begin to emerge around 6 months

• Teething is often blamed for many other problems. It is important to rule out illness, tiredness and developmental stages before you assume that teeth are to blame

• Try to avoid prolonged use of pain relieving gels and medications

• Try to keep the atmosphere calm and relaxed, and minimise stress and overtiredness – these things will make teething worse.

Any questions just let us know in the comments.

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