|Year : 2015 | Volume
| Issue : 1 | Page : 19-24
Non-nutritive sucking habits after three years of age: A case-control study
Izabella Barbosa Fernandes, Túlio Silva Pereira, Monize Ferreira Figueiredo de Carvalho, Joana Ramos-Jorge, Leandro Silva Marques, Maria Letícia Ramos-Jorge
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of the Jequitinhonha and Mucuri Valleys, Diamantina, Brazil
|Date of Web Publication||9-Jan-2015|
Izabella Barbosa Fernandes
324 Paulino Guimarăes Júnior Street, 39100-000, Diamantina, MG
Source of Support: Research Foundation of Minas Gerais State
(FAPEMIG), Conflict of Interest: None
| Abstract|| |
Background: Non-nutritive sucking habits can result in negative consequences on the development of orofacial structures and occlusion. Aim: Assess factors associated with non-nutritive sucking habits in children after 3 years old. Materials and Methods: A case-control study was carried out in two stages. In the first stage, a cross-sectional study was conducted with 638 children aged 3-6 years. In the second stage, a case-control study (1:2) was conducted. The case group included all children who presented some non-nutritive sucking habits in the first stage of the study (n = 110). The control group (n = 220) was made up of children who had never presented non-nutritive sucking habits, matched to the case group for gender and age. The data were collected during the national poliomyelitis vaccination campaign, through a questionnaire applied to parents/guardians with questions related to the presence of sucking habits, sociodemographic aspects, birth aspects, and early life of the child. Statistical analysis involved descriptive analysis, chi-square test, Mann-Whitney test, and conditional logistic regression. Results: Reduction in maternal education was a protective factor for the development of non-nutritive sucking habits (education ≤8 years OR = 0.38, CI 95%: 0.16, 0.89, P = 0.025). Prematurity (OR = 3.30, CI 95%: 1.13, 9.69, P = 0.030) and a longer period using a baby bottle (OR = 1.03, CI 95%: 1.01, 1.05, P = 0.006) remained associated with a greater possibility of the occurrence of sucking habits, regardless of monthly family income. Conclusion: Non-nutritive sucking habits were associated with maternal education, premature birth, and greater time of bottle feeding in children after 3 years old.
Keywords: Dentition, habits, preschool, sucking behavior
|How to cite this article:|
Fernandes IB, Pereira TS, de Carvalho MF, Ramos-Jorge J, Marques LS, Ramos-Jorge ML. Non-nutritive sucking habits after three years of age: A case-control study. J Indian Soc Pedod Prev Dent 2015;33:19-24
|How to cite this URL:|
Fernandes IB, Pereira TS, de Carvalho MF, Ramos-Jorge J, Marques LS, Ramos-Jorge ML. Non-nutritive sucking habits after three years of age: A case-control study. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Aug 17];33:19-24. Available from: http://www.jisppd.com/text.asp?2015/33/1/19/148965
| Introduction|| |
Non-nutritive sucking habits can have negative consequences on the development of orofacial structures and occlusion if they persist after the individual passes 3 years of age.  These habits have been associated with risk factors for abnormalities such as dental caries,  malocclusion, ,,,, speech disorders,  atypical swallowing, and otitis media.  The prevalence of non-nutritive sucking habits in children aged 3 years or more has been estimated at between 40% and 76.1%. The most common non-nutritive sucking habits are thumb sucking and the use of a pacifier. ,,,,,
Studies have shown that social determinants such as parental education, ,,,,, maternal age,  income,  the mother's occupation,  maternal civil status,  the number of siblings,  the maternal breastfeeding period, and the use of a baby bottle ,,,,, are factors that predispose the development and persistence of non-nutritive sucking habits. However, most of these studies were of a cross-sectional design, preventing the possibility of determining the causality among these factors and the presence of non-nutritive sucking habits. ,,,,,
Studies have also addressed non-nutritive sucking habits as risk factors for malocclusion, ,,, or assessed associations between these habits and the period of maternal breastfeeding or the use of a baby bottle. ,,,,, The association between sociodemographic variables and aspects related to the health of the child as possible risk factors for the development of non-nutritive sucking habits requires further investigation. Knowledge of the risk factors for the presence of these habits after 3 years of age helps provide a better understanding of the phenomena and is of great significance to the establishment of preventive measures, which can avoid the damage caused by the persistence of these habits.
The aim of the present case-control study was to investigate factors associated with non-nutritive sucking habits in Brazilian children aged 3 years or more.
| Materials and Methods|| |
The present study was approved by the Human Rights Ethics Committee of the Universidade Federal dos Vales do Jequitinhonha e Mucuri in Brazil. Parents/guardians voluntarily signed an informed statement of consent.
The design selected was a case-control study nested to a prevalence inquiry, which was performed with a sample in the city of Diamantina, located in the northern part of the state of Minas Gerais in the southeast of Brazil. According to the most recent demographic census conducted by the InstitutoBrasileiro de Geografia e Estatística (IBGE), the population of Diamantina is 45,880 inhabitants. 
The present study was developed in two stages. First, a cross-sectional study was carried out to estimate the prevalence of non-nutritive sucking habits in pre-school children aged between 3 and 6 years and enrolled in basic health units during the national Polio vaccination campaign from 2011 to 2012. The vaccination program in Diamantina exhibited uptake rates in excess of 90%. To calculate the size of the sample, a prevalence of non-nutritive sucking habits among pre-school children of 50%, a confidence interval of 95%, and a standard error of 5% were considered, determining a minimal sample of 384 children for the present study. A correction factor of 1.5 was applied to increase precision (n = 576 children), and 63 individuals were added to compensate for possible losses, giving a total sample of 638 children. A systematic sample was adopted for randomization. During the randomization, the children and mothers were organized in a line. Every second mother in the line was interviewed. The prevalence of non-nutritive sucking habits among children aged between 3 and 6 years was 17.2% (110 children).
In the second stage, a case-control study (1:2) was developed to identify the factors associated with the presence of non-nutritive sucking habits. The children in the case group (n = 110), in other words, children who habitually sucked their thumb or a pacifier after 3 years of age in the first stage of the study, were paired according to gender and age with children who never exhibited non-nutritive sucking habits (n = 220). Thus, the total sample was 330 children.
A pilot study was performed before the data collection. A sample of 30 children and mothers were visited in their homes to test the questionnaire and data collection methodology. During the pilot study, an assessment of the questionnaire was carried out in duplicate, with two separate applications (interval of 14 days) among the parents/guardians. The minimal agreement value between the answers in the two applications was Kappa = 0.86. Based on this pilot study, it was possible to confirm if the questionnaire was well structured and provided the data required for the development of the present study. In addition, the manner of application (interview) was found to be an effective method of attaining satisfactory responses, given that it enabled the parents/guardians to understand the questions. The parents/guardians who were interviewed in the pilot study did not participate in the main study.
Data collection was carried out by applying a questionnaire through interviews with parents/guardians. This questionnaire was composed of closed questions related to sociodemographic aspects (age of the mother and child, education of the parents/guardians, monthly family income, number of children, family situation), the general health of the child (health problems), aspects of the birth and early years of the child's life (gestational age, maternal breastfeeding, and use of a baby bottle), and the presence of non-nutritive sucking habits.
Family income was measured in terms of the Brazilian minimum wage, a standard measurement for this type of assessment, which corresponds to approximately US$ 320.00 per month, dichotomized into >2 minimum salaries and ≤2 minimum salaries. The education of the parents/guardians was assessed in terms of years of study and classified as follows: 12 years of study or more, which corresponds to higher level education; between 9 and 11 years of study, corresponding to secondary education; and 8 years of study or less, which corresponds to primary education. Family structure was classified as nuclear or non-nuclear. Gestational age was classified as "full term" (37 or more weeks of gestation) and "premature birth" (less than 37 weeks of gestation). The history of maternal breastfeeding (period and frequency) and the use of a baby bottle (period and frequency) were also confirmed. The parents/guardians were also questioned about their child's non-nutritive sucking habits after 3 years of age. This age group was established due to the fact that the persistence of these habits after 3 years of age represents a significant increase in the probability of developing dental arch problems and/or undesirable occlusal characteristics.  Thumb-sucking and the use of a pacifier are considered non-nutritive sucking habits.
The data analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows, version 20.0, SPSS Inc. Chicago, IL, USA) and included the distribution of frequency and association tests. The period and frequency of breastfeeding and the use of a baby bottle were used as quantitative variables, with abnormal data distribution (Kolmogorov Smirnov test). Associations between non-nutritive sucking habits and the independent variables were first determined by the chi-squared and Mann-Whitney tests. The level of significance was 5% (P < 0.05). All of the independent variables that obtained a value of P < 0.20 in the univariate analysis (chi-squared and Mann-Whitney tests) were included in the conditional logistic regression model. The independent variables were only selected for the multivariate model if the P-value remained at P < 0.05 after adjusting for variables of the same levels. The odds ratio (OR) and confidence intervals (CI 95%) were calculated.
| Results|| |
All the parents interviewed in this study completed the questionnaire (positive response rate of 100%), and no questionnaires were excluded from the data analysis due to incomplete data. The prevalence of non-nutritive sucking habits in the first stage of the present study was 17.2%. Total 330 children, aged between 3 and 6 years, participated in the second stage of the study (case-control). The mean age of the children was 52.1 months (SD = 10.5 months) and 186 children (56.4%) were female. Most of the families that participated had a monthly income of less than two minimum salaries (81.8%) and a nuclear profile (62.5%). The majority of the mothers (43.0%) had secondary level education (between 9 and 11 years of study), whereas the majority of the fathers (65.5%) had a primary level of education (8 years of study or less).
Most of the children (90.1%) were born full-term (37 weeks or more of gestation) and 88.5% of the mothers breastfed their children. The mean period of maternal breastfeeding was 13.9 months (SD = 9.8 months). Baby bottles were used by 62.4% of the children for a mean period of 30.0 months (SD = 15.84 months).
In the univariate analysis, maternal education (P = 0.004), gestational age (P = 0.040), the period of breastfeeding (P = 0.002), and the period of use of a baby bottle (P < 0.001) were significantly associated with non-nutritive sucking habits [Table 1].
|Table 1: Univariate analysis for association between the presence of non-nutritive sucking habits and independent variables|
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In the final adjusted logistic regression model, a reduction in maternal education was a protective factor for the development of non-nutritive sucking habits (education ≤ 8 years OR = 0.38, CI 95%: 0.16, 0.89, P = 0.025). Prematurity (OR = 3.30, CI 95%: 1.13, 9.69, P = 0.030) and a longer period using a baby bottle (OR = 1.03, CI 95%: 1.01, 1.05, P = 0.006) were associated with a greater possibility of the occurrence of non-nutritive sucking habits, regardless of the monthly family income [Table 2].
|Table 2: Conditional logistic regression - Analysis unadjusted and adjusted to association between sociodemographic factors, general child health and feeding habits in relation to non-nutritive sucking habits|
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| Discussion|| |
Associations between maternal education, prematurity, the period of use of a baby bottle, and the presence of non-nutritive sucking habits were confirmed in the present study, suggesting that these factors affect the occurrence of this type of habit after 3 years of age.
Children that are born premature are 3.32 times more likely to have non-nutritive sucking habits. Studies have reported difficulties encountered while trying to breastfeed premature babies. , These challenges are the result of the difficulty of the transition from tube feeding to maternal feeding, as well as a lack of coordination between the sucking, swallowing, and breathing functions of the premature child.  In addition, mothers may have difficulty in maintaining their milk production due to the prolonged hospitalization and separation from their baby.  Studies have also shown that the transition of premature newborns from tube feeding to a baby bottle is better than to the mother's breast.  Thus, these premature children tend to be frequently fed with baby bottles. Previous studies have reported that children who use a baby bottle and were breastfed for a short period of time are more likely to develop non-nutritive sucking habits, ,,, which was also observed in the present study. The results of the present study suggest that this difficulty in breastfeeding, allied to the use of a baby bottle, among premature babies could favor the development of non-nutritive sucking habits.
Children who used a baby bottle for longer periods of time have been shown to be more likely to develop non-nutritive sucking habits. Other studies ,, have also demonstrated an association between the use of a baby bottle and an increased prevalence of non-nutritive sucking habits. In the literature, this association has been linked to the different sucking mechanisms associated with maternal breastfeeding and the use of a baby bottle.  While sucking the mother's breast, infants satisfy their nutritional needs as well as their physiological need for suction. , Mizuno & Ueda  demonstrated that when a child is fed with a baby bottle, less suction force is required to drink, due to the greater flow of milk through the artificial nipple, when compared to the maternal breast. Therefore, the emotional pleasure associated with suction may not be achieved and the child may try to satisfy it through non-nutritive sucking habits. The mother-child relationship needs to be examined in more detail because the subjectivity of this relationship is extremely important in the etiology of non-nutritive sucking habits.
Reduced maternal education was a protective factor for the development of non-nutritive sucking habits. Other studies performed in Brazil, Senegal, the United Kingdom, and Iran ,,,, have reported a significant association between better maternal education and the presence of non-nutritive sucking habits in children, corroborating the results of the present study. This association is due to their greater involvement in the job market and the consequent increase in time that these mothers spend outside of the family home. This results in a greater need of affection among these children, who are generally breastfed for a shorter period of time and use a baby bottle, thereby favoring the development of non-nutritive sucking habits. ,
The design adopted for the present study has certain advantages, including the control of variables, which could cause confusion in the pairing of cases with controls, as well as the possibility of establishing a cause-effect relationship. This design is also advantageous in financial terms and in relation to the time required to complete the study, since the study is part of the outcome: Children with non-nutritive sucking habits. Thus, it was possible to investigate risk factors without having to wait for the manifestation of the event, as is the case in a longitudinal study.  However, there is an inherent possibility of memory bias in case-control studies. Furthermore, the use of multivariate statistical analysis enables the identification of the risk factors for non-nutritive sucking habits without interfering in the other variables that were not controlled, thereby decreasing the risk of bias and increasing the precision of the associations between the variables studied. 
As a result of the limitations faced by mothers of premature babies in relation to breastfeeding and avoiding the use of a baby bottle, which is a risk factor for non-nutritive sucking habits, early multi-disciplinary assistance is essential for these children in order to prevent the persistence of these habits and the dangers they cause. In addition, the present study reinforces the need to strengthen the existing practices and policies of primary maternal and child health care in order to provide adequate prenatal care and monitoring, thereby avoiding premature births and their consequences on the growth and development of children.
In conclusion, maternal education is a protective factor and premature births and a longer period of baby bottle use are risk factors for the occurrence of non-nutritive sucking habits in Brazilian children aged between 3 and 6 years.
| Acknowledgement|| |
This study was supported by the Research Foundation of Minas Gerais State (FAPEMIG).
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[Table 1], [Table 2]