Patient Presentation
A 10-month-old female came to clinic with fever for 24 hours and pulling on her ears. She had had upper respiratory tract infection symptoms and was not sleeping well for 2 days. The past medical history was unremarkable.
The pertinent physical exam showed a slightly cranky but consolable female who was afebrile and had growth parameters in the 50-75%. HEENT showed bilateral bulging eardrums with loss of landmarks, erythema, and no movement with insufflation. She had an amber-colored teething necklace around her neck. Her lungs were clear and her skin showed no rashes. The rest of her examination was negative.
The diagnosis of a female with bilateral supprative otitis media was made and oral antibiotics were prescribed. The pediatrician asked the mother about the necklace. “It’s an amber teething necklace to help her with teething. She has a lot of drooling and I think this helps,” the mother said. The pediatrician discussed that the necklace posed a choking hazard. “Oh, she only has it on when she is awake and I can watch her,” the mother responded. “I understand that that is always your intention, but things can happen like her falling asleep and you forgetting to take it off,” he said, and added “We don’t recommend any jewelry for children because of the risks, but if you are going to use it, can it be pinned to the inside of the clothing still touching the skin, or even placed on an ankle where it is less likely for her to be strangled or for her to get a loose bead into her mouth?” The mother didn’t respond. At a routine health supervision visit, the child was still wearing the necklace on her neck. The pediatrician again tried to engage the mother about the potential risks and was told directly that the mother intended for the child to continue to wear it around her neck.
Discussion
Amber is fossilized tree resin that is prized for its beautiful colors from deep brown to caramel, yellow, green or even white. It is promoted for its “healing properties” although there is not scientific evidence that supports the many potentiated mechanisms of these properties. One of the most consistent is that amber contains succinic acid which proponents believe is absorbed through the skin and is a pain reliever. Succinic acid was actually first purified from amber in 1546 by a German chemist. Succinic acid in humans is an important part of the Krebs cycle and acts as an important metabolite in several metabolic pathways including hypoxia, tumorigenesis, superoxide radicals and in inflammation. Elevated succinate occurs in various disease states including hypertension, inflammatory bowel disease and type 2 diabetes in animal models and bacteria. Even with increased amounts of succinic acid in an amber teething necklace, the amount that would be have to be released, then absorbed through the skin (which is difficult) and then make it through the circulatory system to potential mediators of dental inflammation is certainly not a therapeutic amount. Amber necklaces may not even be amber as plastic, glass, phenolic resins and copal are easily substituted and passed off as real amber. Real amber is relatively expensive and many items on the market that claim to be amber are not.
Teething occurs usually from 6-30 months with the eruption of 20 primary teeth. The individual tooth eruption occurs over ~7-8 days which includes the 4 days before and 3 days after the eruption. While many people attribute many symptoms to teething including fevers and diarrhea, there is not much evidence that supports these ideas. Some children will have some discomfort for a short amount of time around eruption and may have more drooling around this time. This is also a time period during the child’s life when many other childhood illnesses occur especially viral illnesses.
Recommended options for teething symptoms includes:
- Gum massage with soft cloth or clean fingers
- Chewing items that are chilled, not frozen as they are too hard. Rubber teething rings are one such item. All items, but especially plastic teething rings, should be cleaned following the manufacturer’s instructions. Plastic rings placed in boiling water or a dishwasher may lose their integrity.
- Unsweetened teething biscuits or rusks for children > 6 months who are eating solid foods
- Oral pain relievers such as acetaminophen or ibuprofen. Oral teething gels containing benzocaine are not recommended because of the risk for methemoglobinemia.
- Drying saliva on the skin to prevent irritation
Learning Point
Because of the strangulation risk, in 2010, the Canadian federal public health department issued a consumer product safety warning. France and Switzerland also have banned sales of amber teething necklaces in their pharmacies.
A study from France, showed that even when families are given the information about amber necklaces risks, they often still continue the practice. “When informed of the danger of strangulation, numerous families preferred to continue this practice: their irrational fear of seeing their child suffer [while teething] surpassed their fear of the risk of strangulation[,]” the study concluded.
Risks for amber necklaces include:
- Strangulation – manufacturing standards are lacking and therefore safety clasps may not be present or may not work
- Choking hazards – beads or other necklace parts could be ingested and/or aspirated. Some believe that individual knotting between the beads only allows 1-2 beads to fall off if the necklace is broken, but even 1-2 beads can cause a choking hazard
- Infectious disease – amber necklaces are highly colonized with commensal bacterial with a median of 4 bacteria/necklace (range 1-9) mainly coagulase-negative Staphylococci. These bacteria could become pathogenic in the right conditions.
It is important for health care providers to try to work with parents to understand the cultural, religious, or other significance of necklaces, bracelets, strings, or other bodily adornments that often encircle the neck, extremity or body of children. For some, the item was given by a family member or friend and the parents want to honor that person by having the young child wear the item. For others, it is a customary practice which parents follow and may or may not be aware of the reasons for the practice. For many families discussing with them the reasons for the practice and what is important about the practice and needs to be maintained, usually helps to clarify expectations. For example, for some Hispanic families, gold necklaces and bracelets are believed to ensure general safety of the child, and for many of these families the item does not have to encircle the body but just needs to be touching the skin to maintain its believed effectiveness. Some of these families will remove the item or be willing to move it to another location on the body or pin it inside the clothing to decrease the risks but still maintain skin contact with the item.
For a review of risks in everyday life click here.
Questions for Further Discussion
1. What other cultural or religious practices do you see in your practice that have potential health or safety risks?
2. How do you advise families about these risks?
Related Cases
- Disease: Child Safety | Dental Health
- Symptom/Presentation: Ear Pain
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Child Safety and Child Dental Health.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
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Jacobson R. Amber Teething Necklaces Pose Choking Hazard. New York Times. October 11, 2013. Available from the Internet at http://well.blogs.nytimes.com/2013/10/11/amber-teething-necklaces-pose-choking-hazard/?_r=0 (cited 12/20/16).
Snyder S. Amber Waves of Woo. Science-Based Medicine. April 11, 2014. Available from the Internet at https://sciencebasedmedicine.org/amber-waves-of-woo/ (cited 12/20/16).
Mills E, O’Neill LA. Succinate: a metabolic signal in inflammation. Trends Cell Biol. 2014 May;24(5):313-20.
Tretter L, Patocs A, Chinopoulos C. Succinate, an intermediate in metabolism, signal transduction, ROS, hypoxia, and tumorigenesis. Biochim Biophys Acta. 2016 Aug;1857(8):1086-101.
Machet P, Lanotte P, Giraudeau B, Leperlier M, Tavernier E, Maruani A. Amber necklaces: reasons for use and awareness of risk associated with bacterial colonisation. Eur J Dermatol. 2016 Nov 21. [Epub ahead of print]
Cox C, Petrie N, Hurley KF. Infant Strangulation from an Amber Teething Necklace. CJEM. 2016 Aug 9:1-4. [Epub ahead of print]
Australian Academy of Paediatric Dentistry. Teething. Available from the Internet at http://aapd.org.au/articles/teething (cited 12/20/16).
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 