Behavior: Ask the experts

BEHAVIOR: ASK THE EXPERTS

THUMB SUCKING AND DENTAL PROBLEMS

Q The parents of a 4-year-old boy are concerned that their son sucks his thumb. The child has been to a pediatric dentist, who noted that the habit may cause problems in the future. In addition, the child soon will be having speech therapy for disarticulation. What are some nonpunitive approaches the parents can use to help the child give up this habit?

Mindy E. Steinholz, MD
Montrose, NY

A As all parents and pediatricians know, thumb sucking is a common behavior and generally is thought to be a way for the child to comfort himself as he faces the stresses in his world. Since this child has problems with articulation, sucking his thumb may help him cope with the frustration of not being understood.

The most common adverse effect of thumb sucking, especially if it persists beyond 4 years of age, is malocclusion of both primary and permanent teeth. The risk is highest among children who suck persistently, day and night, so it's important to determine whether the child sucks his thumb only in response to stress or virtually all the time. Another negative consequence of thumb sucking is the criticism, ridicule, and teasing it inspires, which may have a bad effect on the child's self-esteem. This child may be especially likely to be teased because of his articulation problems, which may make him seem younger and less mature than his peers.

I would recommend weaning the child from sucking his thumb only if he is sucking persistently day and night or is the target of ridicule. Behavioral strategies for putting a stop to the sucking probably won't work unless the child wants to stop, and this desire usually is outweighed by the consolation sucking provides in times of stress. When the child does want to stop, applying a bitter-tasting substance (available over the counter) to the thumb in the morning, at night, and every time the child is seen sucking his thumb can be the reminder and negative reinforcement that a 4-year-old needs to turn the corner. When the child has not sucked his thumb for a week, the parents can drop the morning application; as he continues to resist temptation, they can drop the evening application. It's important to tell the child that the bitter-tasting substance is a reminder, not a punishment.

Another approach is to change thumb sucking from a pleasurable experience to an obligatory one. Suggest that the parents ask the child to go to his room for 15 minutes every day and suck all 10 fingers, not just the thumb. In some children, thumb sucking then loses its appeal. Rewards such as stickers, extra story time, and praise are always good positive reinforcers.

Barry S. Zuckerman, MD
Boston, MA

DR. ZUCKERMAN is Chief of Pediatrics and Medical Director, Boston Medical Center, and Professor and Chairman, Department of Pediatrics, Boston University School of Medicine.

CRYING TO SLEEP CAUSES VOMITING

Q Frustrated and tired parents often ask me how to help their children sleep through the night. In the most common scenario, an infant more than 6 months old wakes up two to three times a night--at about the same times every night. I explain to the parents that waking up has become a habit and advise them how to help the child break the habit. The bottom line, I indicate, is to let the child cry herself back to sleep. This usually works, but some parents say the technique backfires because their child throws up when she becomes upset. What do you suggest?

Cynthia Miller Lovell, PNP
Battle Creek, MI

A A baby who is upset enough to throw up is showing that she is under significant stress and should not be left to cry herself to sleep. I suspect that many babies left to cry alone experience a higher level of stress, caused by hunger, fear, or loneliness, than we would expect most adults to tolerate. A sleep-training method that works for some babies is not necessarily good for every child. Different kinds of responses are needed for children with varying metabolisms and temperaments. Some breastfed babies, for example, may get hungry at night long after they are 6 months old and often can nurse themselves back to sleep easily.

We can aid parents who ask for help with night waking by helping them realize that all babies need some kind of nurturing response to their cries, even during the night, even when it's not convenient. They should know that many normal healthy babies wake at night but do grow out of it as they develop. Parents need support and suggestions for dealing with their own fatigue, such as sharing nighttime duties with their partners, adjusting their own sleep schedules, and investigating the option of cosleeping. Families come to us from a multitude of different cultural backgrounds, and parenting styles differ dramatically. If the timed crying methods recommended by many magazines and parenting books do not work for their child, or do not align with their belief systems, they need affirmation that attending to their baby's needs in a loving way is good for their baby.

I also suggest recommending to parents the book Nighttime Parenting: How To Get Your Baby and Child To Sleep by Dr. William Sears, which is full of information about infant sleep patterns and suggestions for helping babies sleep. Good luck!

Kathi J. Kemper, MD
Boston, MA

DR. KEMPER is Director, Holistic Pediatric Education and Research, Children's Hospital, Boston.

TODDLER ATTRACTED TO SKIN

Q The mother of an 18-month-old boy in my practice is concerned about the excessive physical affection her son shows for his 9-month-old sister. He seems to be attracted to her skin, as well as to his mother's. The mother says if he is playing and she leaves the shower wrapped in a towel, he will stop whatever he is doing to rub his skin against hers. On one occasion, he lifted his shirt to rub his belly to his baby sister's feet. The child's growth and development are normal and he has a sweet, unaggressive personality. He has always been cared for by his mother at home and has his own bedroom.

Jane Memezes, MD
M iami Beach, FL

A For most infants and young toddlers, the touching that is part of gentle patting, stroking, cuddling, rocking, being carried, or a warm bath is soothing. They often comfort themselves with tactile behaviors, such as thumb sucking, patting the mother's hair, stroking a soft stuffed animal, touching their genitalia, rubbing their ear lobe while nursing, or rubbing against the parent or a sibling, as the child you describe does. Assuming this child is receiving adequate comforting from the parents and appropriate environmental stimulation, I would simply tell his mother that his need for touching is normal and comforting. Reassure her that the behavior will phase out with maturation and other gratifying experiences. If the mother is uncomfortable about the child's habit of rubbing against her after her shower, I would suggest that she bathe while the child is sleeping or slip on a bathrobe instead of a towel.

Morris Green, MD
Indianapolis, IN

DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana University School of Medicine, Indianapolis, and a member of the Contemporary Pediatrics Editorial Board.

CHILD WHO DOESN'T CRAWL

Q I occasionally encounter a child with otherwise normal development who never learns to crawl. The child seems to go from sitting to pulling to standing to cruising, passing over the crawling stage. In an otherwise normal child, is it okay not to crawl? If not, at what age should I become concerned if the child has not achieved mature crawling? What work-up might be indicated? Should a pediatric neurologist see the child?

Paul Weber, MD
Troy, OH

A This interesting question brings up the issue of when different patterns of motor development are variants of normal behavior and when they indicate developmental problems. Most children crawl by the time they are 11 months old, but children with abnormalities of muscle tone or general delays in development may not crawl until later. About 10% to 15% of children walk without ever having crawled, however. Unlike late crawlers, these children do not appear to have developmental problems; in fact, they often walk earlier than other children and may be precocious in meeting other developmental milestones. You do not need to give these children a medical work-up or refer them to a subspecialist.

Nathan J. Blum MD
Philadelphia, PA

DR. BLUM is Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine and Children's Seashore House of Children's Hospital of Philadelphia.

Readers: Questions wanted!

You like "Behavior: Ask the experts." We know because you've told us in reader surveys. In addition, our mail bag is full of your comments on our experts' responses to submitted questions. But we need more of these queries to keep this department running smoothly--or running at all. Please think about the most interesting or difficult behavioral or developmental issues that have come up in your practice in recent weeks and write us about them. We'll be grateful, other readers will be grateful, and you'll get some good advice about your patient.

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Behavior Q/A
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Marian Freedman. Behavior: Ask the experts. Contemporary Pediatrics 1999;11:33.