Cochrane Database Syst Rev. 2015 Mar 31;3:CD008694. doi: 10.1002/14651858.CD008694.pub2.
BACKGROUND:
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.
OBJECTIVES:
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.
SEARCH METHODS:
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.
SELECTION CRITERIA:
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.
DATA COLLECTION AND ANALYSIS:
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.
MAIN RESULTS:
We
included six trials, which recruited 252 children (aged two 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 one 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 treatmentTwo 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; two trials, 70 participants) or
long term (RR 5.81, 95% CI 1.49 to 22.66; one trial, 37 participants) or
used in combination with a psychological intervention (RR 6.36, 95% CI
0.97 to 41.96; one trial, 32 participants). Psychological intervention
versus no treatmentTwo 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; I(2) = 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 comparisonsOnly 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).
AUTHORS' CONCLUSIONS:
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.
