Where’s the evidence? Cochran Collaboration-nothing

PubMed:

1. Non-Nutritive Sucking Habits in Sleeping Infants.

Hanzer M, Zotter H, Sauseng W, Pichler G, Müller W, Kerbl R.

Neonatology. 2009 Jul 31;97(1):61-66.

2. Risks and Benefits of Pacifiers, Sexton S, Ruby N. Am Family Physician.2009 ;79 (8): 681-685

3. Infant Pacifiers: An Overview. Schwartz RH, Guthrie KL. Clinical Pediatrics. 2008; 47:327-331.

4. Changes in prevalence of non-nutritive sucking patterns in the first 8 years of life. Bishara S, Warren JJ et al. Am J Orthod Dentofacial Orthop. 2006;130: 31-36.

ADA EBD- nothing

AAPD Reference Manual :

1. Management of the Developing Dentition. http://www.aapd.org/media/Policies_Guidelines/G_DevelopDentition.

NNS Effect on Teeth and Jaws

• Duration - Days, weeks, months, years

• Frequency - Number of times per day

• Intensity - How strong?

• Placement of pacifier/digit - Where and how

• Discontinuation - When did NNS stop?

Iowa Studies on Oral Facial Development

Influence Of Feeding And NNS on Development of the Dental Arches:

Longitudinal Study at 30-36 Months*

Purpose

• The effects of initial feeding methods and NSS on dental arch development at 30-36 months.

Subjects

• 104 children from midwest communities; healthy full-term infants; no apparent congenital anomalies.

*Nowak, Bishara et al. *Nowak, Bishara et al. Pediatric DentPediatric Dent

Influence of Feeding and NNS on Development of The Dental Arches: Longitudinal Study at 30-36 Months*(continued)

Methods• Clinical examination.• Health, feeding, NNS and trauma histories.• Nine arch measurements on plaster casts; overbite

and overjet

Findings• Dental arch changes are minimal between feeding

and NNS groups• NNS habits reduce substantially by 30 months.• No one feeding/sucking method can be

recommended

Effect of Prolonged Non-Nutritive Sucking on Dental

Arch Parameters*Purpose• Effects of non-nutritive sucking and the primary dentition

Subjects• 123 healthy, full-term infants at 4-5 years old• 20 habit; 90 no-habit

Methods• Non-nutritive sucking behavior data collected from birth• At 4-5 years-old, study models obtained• Categorized into groups depending on length of habit• Dental arch measurements

*Warren, J., Bishara, S., Nowak, A. et al., J Dent Res 79:283A, 2000

Effect of Prolonged Non-Nutritive Sucking on Dental Arch Parameters (cont.)

Findings Prolonged habit (3 years of age or older)

• Mandibular canine arch width greater• Maxillary molar arch depth greater• % overbite significantly less• Overjet significantly greater• More anterior open bites

Conclusions Prolonged habits may have a profound impact on

occlusal and dental arch characteristics in the primary dentition

*Warren J., Bishara, S., Nowak, A. et al J Dent Res 79:283A, 2000

6 wk 6 mo. 12 mo. 24 mo. 36 mo. 48 mo.(n=1,237) (n=1,046) (n=794) (n=606) (n=496) (n=221)

Any sucking habit (%) 87 89 68 53 23 21

Pacifier (%) 78 56 38 25 10 5

Digit (%) 48 73 31 22 14 12

Pacifier and/or digit (%) 85 87 60 44 22 17

Other objects (%) 19 66 32 15 6 6

*Pediatric Dentistry 22:189, 2000

Non-Nutritive Sucking Habits by Age

Factors Predictive of Prolonged Non-Nutritive Sucking● 600+ children followed 36 months or longer

● 23% -- prolonged habit at 36 months or older● Factors associated:

Older maternal age Higher maternal education level First-born child

Pediatric Dent 22:187-191, 2000

Effects of Prolonged NNS

Digits PacifiersAnterior Open bite Anterior Open bite

Narrowed Maxillary Arch Width Posterior Cross Bite

Elongated Maxillary Arch Depth Mandibular Arch Width

Shallower Palatal Depth

Duration and Posterior Crossbite

● No habits – 12 months – 5.8%● Ceased Habit – 24- 36 months – 13.0%● Continued habit – 48 months - >20%

JADA 2001

Duration of Prolonged NNS

12 Months vs. 36 Months

Mandibular Canine Width

Maxillary Canine Arch Depth

Overjet

JADA 2001

Duration of Prolonged NNS*

48 Months or Longer

• Narrow Maxillary Arch

Overjet

Prevalence of Open Bite

Prevalence of Posterior Cross Bite

*JADA 2001

Discontinuation Of NNS

PACIFIER DIGITS

Germany 2-3 Years 3 – 7 Years

Finland 5 – 8 Years 8 Years

USA - 2 – 6 Years

USA - 3 – 8 Years

USA 13.8 MO -

USA 20.5 MO -

Average 2 – 4 YEARS 5 – 6 Years

Sucking Prevalence

Evidenced Based Conclusions

● NNS associated with increased prevalence of malocclusion in the primary dentition

● Prevalence increases with increasing duration

● NNS associated with an increase in Class II malocclusion in the mixed dentition

● To minimize dental/oral effects, intervention to address sucking habits should be addressed by 2- 3 years of age

● Interventions may include:

a. Positive reinforcement

b. Aversive tasting solutions

c. Manage child’s stress and anxiety

d. Intraoral and extraoral

reminder devices.

Other NS and NNS facts or myths?Is there evidence?● Pacifiers interfere with the duration

of breastfeeding.● Pacifier use increases the risk for

otitis media.● Pacifiers should be given to infants

at nap and bed-time to reduce the risk of SIDS

● Breastfeeding and ECC● Ankyloglossia- treat?

MYTHBUSTERSMYTHBUSTERS

Trooth-Trooth-bustersbusters

Pacifers and breastfeeding

Evidence1. Cochrane: nothing

2. ADA EBD: nothing

3. PubMed:

a. Pacifiers and Breastfeeding. O’Connor NR et al. Arch Pediatr Adolescent Med. 2009;163: 378-382

b. Does the recommendation to use a Pacifier Influence the Prevalence of Breastfeeding?

Jenik AG et al. J Pediatr 2009; 155: 342.

Conclusions● 1. Evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity.

● Offering a pacifier at 15 days does not modify the prevalence or duration of breastfeeding.

Pacifiers and increased otitis media risk

Is there evidence?

1. Cochrane- no

2. ADA EBD- no

3. PubMed-

a. Risks and benefits of pacifiers.

Sexton S, Natale R.

Am Fam Physician. 2009 Apr 15;79(8):681-5. Review

b. Is pacifier use a risk factor for acute otitis media? A dynamic cohort study.

Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJ, Schilder AG.

Fam Pract. 2008 Aug;25(4):233-6. Epub 2008 Jun 17

c. Pacifier use in children: a review of recent literature.

Adair SM.

Pediatr Dent. 2003 Sep-Oct;25(5):449-58. Review.

4. AAP Guidelines-

a. PEDIATRICS .2004;113:1451-1465Diagnosis and Management of Acute Otitis Media

Conclusions1. Pacifier use associated with increased risk for AOM.

2. Pacifier use appears to be risk factor

3. AAP recommends weaning infants off pacifier in the 2nd 6 months of life

Pacifer and SIDS

Evidence? 1. Cochrane- no

2. PubMed-

Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis.

Hauck FR, Omojokun OO, Siadaty MS.

Pediatrics. 2005 Nov;116(5):e716-23.

3. AAP Policies-

1. AAP Task Force on SIDS. Pediatrics 2005; 116: 1245

Recommendation● AAP recommends offering a pacifier at nap time and bedtime to reduce the risk to SIDS