Review question
This review has been produced to assess the effects of interventions to stop sucking habits in children, which are not linked to food. Important considerations are: which treatment or combination of treatments work most effectively, when should treatment be started, what is the optimum length of time for the intervention and what causes least upset to children and their parents?
Background
Often babies and children develop a habit of sucking objects to comfort and calm them. They frequently suck dummies (known as pacifiers in the USA), fingers, thumbs or other items like blankets. Eventually, most children grow out of the habit, or stop due to encouragement from their parents. Some children, however, continue sucking as a habit. If they continue to do so as their adult teeth start to grow through (around the age of six), there is a risk that these adult teeth will grow into the wrong position causing them to stick out too far or not meet properly when biting. As a result these children often need dental treatment to fix the problems caused by their sucking habit.
Possible treatments to help children break their sucking habits examined in studies in this review include the use of two different braces in the mouth; giving advice and incentives for changing behaviour (known as psychological advice/treatment); applying a bitter, nasty tasting substance to the children’s thumbs/fingers or combinations of these treatments. None of the studies included looked at barrier methods, for example the use of gloves or plasters or withdrawal of dummies.
Study characteristics
Review authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 8 October 2014. The review includes six studies published from 1967 to 1997, which involved 252 children as participants (although data were supplied on only 246 of the children). Three of the studies were carried out in the USA, one in Canada, one in Sweden and one in Australia.
Not all of the studies gave the ages of children involved; in four of the studies children were aged from two and a half to 18 years old, in one study they were aged four years and over and in another nine years and over.
Results
Use of an orthodontic brace (such as a palatal crib or arch) or a psychological intervention (such as use of positive or negative reinforcement), or both, was more likely to lead to cessation of the habit than no treatment. Most of the trials that compared two different interventions were inconclusive but one study suggested that, of two different types of braces,a palatal crib is more effective than a palatal arch design.
Quality of the evidence
The evidence presented is of low quality due to the small number of participants in the few available studies and problems with the way in which the studies were conducted. There was a high risk of bias across the studies.
Conclusion
Orthodontic braces or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.
This review found low-quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low-quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high-quality trials evaluating interventions to stop non-nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials.
Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non-nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit.
The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent- or carer-centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost-effectiveness.
We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary.
Randomised or quasi-randomised controlled trials in children with a non-nutritive sucking habit that compared one intervention with another intervention or a no-intervention control group. The primary outcome of interest was cessation of the habit.
We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta-analysis could be carried out.
We included six trials, which recruited 252 children (aged 2 and a half to 18 years), but presented follow-up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no-intervention or waiting list control group and one study made a head-to-head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow-up times ranged from 1 to 36 months. Short-term outcomes were observed under one year post-intervention and long-term outcomes were observed at one year or more post-intervention.
Orthodontics appliance (with or without psychological intervention) versus no treatment
Two trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; 2 trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; 1 trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; 1 trial, 32 participants).
Psychological intervention versus no treatment
Two trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co-operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I2 = 0%). One study, with data from 57 participants, reported on the long-term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65).
Head-to-head comparisons
Only one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59).