I've weaned my 2-year-old off the bottle. Now how can I get her to break the thumb-sucking habit?
It has long been recognized that non-nutritive sucking is a normal, pervasive method of self-soothing in infancy.1 In a longitudinal study of the sucking behavior in almost 800 children from birth to age 8 years, Bishara and colleagues2 found that at age 1 year, 31% of the children engaged in finger-sucking.
The parent of this 2-year-old thumb-sucker can be reassured that no treatment is needed at this time because most children will stop the behavior without any intervention by the time they reach the age of 3 to 4 years.3,4 In the study mentioned above, only 12% of the children still sucked their fingers at age 4 years.2 Thus, any attempt to break the habit should be discouraged until this child is a year or two older.
A habit that needs to be broken eventually. Although there is no urgency about stopping thumbsucking in a 2-year-old, prolonged finger-sucking can have a number of harmful effects and is definitely a habit that warrants intervention in older children. Commonly reported sequelae include digital deformities and infections, various dermatological conditions (eg, skin irritation, hyperkeratosis, onycholysis), a possible vulnerability to the development of trichotillomania, and social stigmatization. (For an example of another potential adverse consequence of fingersucking, see the Photoclinic case "Facial Veruccae") In addition, adverse dental effects may result, including malocclusion and malpositioning of anterior teeth. Because prolonged finger-sucking can lead to abnormalities in the permanent dentition, the American Academy of Pediatric Dentistry advises a professional evaluation to address the habit if it continues beyond the child's third birthday.5
Pediatricians are likely to be the first in line to provide parental guidance—both to help the child break the habit and to help the family establish a dental home. Various habit-breaking techniques, as summarized below, can easily be discussed with parents in the context of an office visit. The parents must then decide which technique is most likely to be effective for their child.
Recommended interventions. Keep in mind that the following suggestions are evidence-based, but only to a limited degree, because of the small sample sizes of available studies.
Positive reinforcement. Verbally praising children when they are engaging in appropriate behaviors and not sucking their fingers is the mainstay of positive reinforcement. Providing the child with encouraging social support has been shown to be an important part of breaking the finger-sucking habit in children aged 5 to 15 years.6
Creating a reward system with the child's help is another way to provide positive reinforcement. For example, give the child a "star" on a calendar for each day he or she does not suck his or her finger; after an agreed-on number of stars in a month has been reached, a desired reward is earned. Such reward systems should be continued for several months to permanently end the habit.
Negative reinforcement. Verbal chastisement and physical punishment are certainly not advocated. However, some pediatricians do recommend the use of various deterrents as a type of negative reinforcement. Deterrents include topical bitter substances and bandages that are applied to the finger the child sucks, as well as glove-like devices, which have been reported to be effective in decreasing finger-sucking in cooperative children aged 7 to 10 years, especially during alone times and at bedtime.7
Distraction. Finger-sucking typically occurs when children are bored or trying to fall asleep. When a child watches television, the finger has a tendency to make its way to the mouth. Thus, an obvious strategy for breaking the habit is to limit television time and other forms of idleness and instead promote activities that require the use of both hands.
Woods and colleagues6 reported that children who received awareness training and who were able to respond to the urge to suck their thumb with an alternative behavior, such as fist or knee clenching, could successfully combat the thumb-sucking habit. Awareness training involved helping the children identify warning signs that indicated that they were about to start sucking their thumb. They learned to respond to these cues by instead clenching their fist or knee.
Scheduled thumb-sucking. This paradoxical approach forces the child to engage in thumb-sucking for a scheduled period each day,8 making it an obligatory rather than a voluntary activity. Parents may question your judgment if you suggest this unusual approach, but for a few children it may make the habit less appealing.
Dental appliance therapy. Bourne9 classifies orthodontic appliances as second-line therapy, which should follow the use of positive reinforcement and deterrents. Before choosing this intervention, it is helpful for the child to have a strong desire to stop the habit and to comprehend the role that the device will play in the process.9 Ideally, the child should have reached the age at which the first upper molars have fully erupted.9
Moore10 provides a comprehensive critical and historical review of the use of intraoral appliances as an intervention for finger-sucking, and he sheds a negative light on these devices. However, studies from the past several decades have shown varying degrees of efficacy for dental appliances, and these data must be considered along with reports of the adverse consequences of emotional distress, pain, dental changes and palatal irritation, infection, and embedment.10
In any event, if parents are considering the "last resort" of a dental appliance, remind them that it is important to consult a dental expert. Before providing one of these appliances, the dental expert should review the above-mentioned risks and benefits with the parents and the child.