A baby is suddenly inconsolable at 2 a.m. for three nights running. The natural assumption is teething. Sometimes that's right. Often it isn't — teething is one of the most over-blamed phenomena in early childhood, and the AAP and Cochrane reviews are clear that it does not cause fevers above 38°C, diarrhoea, or weeks of disrupted sleep. What it does cause, often, is mild gum tenderness and fussiness that genuinely intensifies at night. Knowing what's actually teething — and what's something else — changes how you treat it. Healthbooq covers infant health and sleep with a focus on what the evidence supports.
What Teething Actually Causes (and What It Doesn't)
The 2016 systematic review in Pediatrics and a 2017 update in Archives of Disease in Childhood — both drawing on Cochrane methodology — looked at every reasonable study on teething symptoms. The genuinely associated symptoms:
- Mild gum tenderness and irritation
- Drooling
- Mild fussiness or irritability
- Mild rise in temperature, but not over 38°C
- Slightly disrupted sleep around the day of eruption (typically the day before, day of, and day after)
- Occasionally chewing or biting on objects
What teething does not cause, despite enduring folklore:
- Fever over 38°C — that's an infection, not teeth
- Diarrhoea — drool can soften stools mildly, but loose, frequent stools are an illness
- Persistent sleep disruption beyond about three days per tooth
- Vomiting
- Cough or runny nose (these often coincide because babies between 6 and 24 months have many viral infections, but they aren't caused by teething)
If your baby has any of those "not-actually-teething" symptoms, treat the cause separately — and consider whether teething is a coincidence rather than the explanation.
Why It's Worse at Night
Three reasons, none of them imagined:
Distraction is gone. Pain perception is partly attentional. During the day a 12-month-old has constant inputs — visual novelty, motion, food, faces. At night, in a dark quiet room, the only thing the brain has to process is the gum.
Lying flat increases head and gum blood pressure marginally. This intensifies the throbbing quality of inflammation-related pain. It's the same mechanism that makes adult toothache worse at night.
Cortisol drops. Cortisol is the body's endogenous anti-inflammatory hormone, and it follows a circadian curve — highest in the morning, lowest around midnight to 2 a.m. Slightly less natural buffering against inflammatory pain at exactly the time the baby is least distracted.
This is why a baby who handled teething fine during the day melts down at 11 p.m.
How to Tell Teething from Something Else
The practical test is whether the timing fits a real tooth eruption. Look at the gum. A tooth genuinely close to coming through produces:
- A visible white or pearl-like spot under the gum
- A swollen, sometimes slightly bruised-looking patch (a small haematoma over the emerging tooth is normal)
- Tenderness if you gently press
If you can't see anything in the gum and the baby has been waking for more than three or four nights, the explanation is probably elsewhere — illness, sleep regression, separation anxiety, sleep onset association change, hunger, or environmental.
A second clue: genuine teething pain responds to paracetamol or ibuprofen at the right dose. If you've given an appropriate dose and the waking is unchanged, it isn't teething pain.
The teething calendar (rough order, individual variation is huge):
- 6–10 months: lower central incisors
- 8–12 months: upper central incisors
- 9–13 months: upper lateral incisors
- 10–16 months: lower lateral incisors
- 13–19 months: first molars (often the worst offenders)
- 16–22 months: canines
- 23–33 months: second molars (the other rough patch)
The first molars and second molars are the ones associated with the most genuinely difficult nights. The incisors are usually mild.
What Helps at Night
Weight-based paracetamol or ibuprofen 30–60 minutes before bedtime when the baby has been clearly uncomfortable during the day. Use the dosing on the bottle by weight, not age. Paracetamol is licensed from 2 months in the UK (over 4 kg, born after 37 weeks); ibuprofen from 3 months and 5 kg, with food. Don't give pain relief routinely "in case" — give it when there's evidence of pain. A single appropriately-dosed evening dose is reasonable for genuinely uncomfortable nights.
A chilled teething ring at the bedtime feed. Refrigerated, not frozen — frozen teething rings can cause cold injury to the gums. Cold provides counter-pressure and mild local anaesthetic effect.
Gum massage with a clean finger. A minute of firm rubbing along the swollen area at bedtime. Counter-pressure reduces pain perception via the gate-control mechanism.
A breastfeed at bedtime if breastfeeding. The combination of suckling, oxytocin, and the breast itself comforts genuinely teething babies and contains some natural analgesic compounds.
Don't use teething gels overnight. The MHRA in the UK and the FDA in the US both have specific warnings:
- Benzocaine gels (over-the-counter in the US): the FDA has warned since 2018 against use in under-2s due to risk of methaemoglobinaemia — a serious oxygen-transport disorder
- Lidocaine-containing gels: the MHRA advises against use in under-2s
- Choline salicylate gels (Bonjela in older formulations): not for under-16s due to Reye's syndrome risk
- Homeopathic teething tablets and gels: the FDA recalled multiple homeopathic teething products in 2016–2017 after inconsistent and sometimes dangerous belladonna concentrations were detected
Even when a gel is safely formulated, the night-time concern is repeated dosing across multiple wakings — a parent giving gel at 11 p.m., 1 a.m., and 4 a.m. can deliver a cumulative dose well above what was studied.
Don't use amber teething necklaces. No mechanism, no evidence, and a real strangulation and choking risk per AAP and the Royal College of Paediatrics. NHS England has explicitly advised against them.
What Doesn't Help (or Actively Harms)
- Putting whisky, brandy, or any alcohol on gums (yes, this still circulates as advice; no, don't)
- Sugary teething rusks (open the door to early dental decay)
- Frozen teething rings (cold injury risk)
- Routine pain relief without symptoms ("just in case")
- Teething necklaces and anklets (strangulation, choking, no evidence of benefit)
When the Habit Outlasts the Tooth
A baby who's been picked up, fed, or held repeatedly through three to five nights of genuine teething pain may keep waking after the tooth has come through. The pain is gone; the expectation isn't. This is a sleep onset association issue — see the night-waking-toddler material — and is best addressed by giving 7–10 days for things to settle, then returning to whatever the previous self-settling routine was.
When to Call the GP
Most teething does not need a GP. Book an appointment if:
- Fever above 38°C, or any fever in a baby under 3 months — this isn't teething
- Diarrhoea, vomiting, or refusal to feed
- A child who looks unwell beyond fussy
- Persistent inconsolable crying that doesn't respond to standard comfort or appropriate analgesia
- A non-blanching rash (always urgent — A&E)
- Significant facial swelling, gum infection signs (pus, hot red gums), or a fever that came with the gum changes — could be a dental abscess or eruption haematoma needing a look
- Teething pain seems severe and prolonged beyond a few days per tooth
Teething is a real source of mild pain and a few rough nights per tooth. It is not a six-month explanation for everything that goes wrong with sleep. If the symptoms don't fit the pattern, look elsewhere.
Key Takeaways
Teething is real, often mildly painful, and frequently worse at night because there are no daytime distractions to compete with the discomfort. But teething is also dramatically over-blamed: per AAP and Cochrane reviews, it does not cause fevers above 38°C, diarrhoea, or major sleep disruption beyond a few days around tooth eruption. The mainstays of management are weight-based paracetamol or ibuprofen at bedtime when the baby has been clearly uncomfortable that day, a chilled (not frozen) teething ring, and gum massage. The FDA has warned against benzocaine gels in under-2s due to methaemoglobinaemia risk, and homeopathic teething tablets were recalled after belladonna contamination in 2017. The MHRA in the UK advises against lidocaine-containing gels in under-2s.
