Original Article

Inuence of straw type on feeding development in infants

Mutsuki Hara
a,b,
*, Ryo Ishida
a
, Mai Ohkubo
a
, Tetsuya Sugiyama
a
, Takahiro Kawata
c
,
Yoshinobu Ide
b
, Shinichi Abe
b
a
Department of Dysphagia Rehabilitation and Community Dental Care, Tokyo Dental College, Chiba 261-8502, Japan
b
Department of Anatomy, Tokyo Dental College, Chiba 261-8502, Japan
c
Combi Corporation, 2-6-7, Moto-asakusa, Taito-ku, Tokyo 111-0041, Japan
a r t i c l e i n f o
Article history:
Received 3 October 2012
Received in revised form
11 February 2013
Accepted 13 February 2013
Available online 19 April 2013
Keywords:
Infant feeding development
Feeding devices
Straw
Spoon
Intake of liquid
a b s t r a c t
The purpose of this study was to clarify the effect of a straw with a valve (SWV) on the
development of liquid intake in infants. Twenty-six healthy volunteer infants (13 boys, 13
girls), ranging in age from 8 to 19 months, participated in this study. First, a face-to-face
interview was conducted with the parents using a structured questionnaire. The infants
taking liquid from a straw or a spoon with parental support were then observed and vid-
eotaped. During straw or spoon feeding, opening and closing of the jaw were evaluated. For
spoon feeding, lip closure was also evaluated. The questionnaire revealed a signicant
difference between the SWV and straw-without-a-valve (SWOV) groups in terms of num-
ber of parents using a spoon and duration of baby food intake. No other signicant dif-
ference was revealed. Videotapes revealed a signicant difference in jaw movement
between the SWV and SWOV groups when using a straw ( p < 0.01) and lip closure when
using a spoon ( p < 0.01). No signicant difference was observed in jaw movement when
using a spoon ( p > 0.05). An SWV may hamper the development of lip closure and affect
the development of drinking ability in infants.
2013 Published by Elsevier Ltd. on behalf of the Japanese Society of Pediatric Dentistry.
1. Introduction
Various devices including spoons, cups, and straws are
commonly used for drinking. Among these, straws may be
useful for caregivers of infants. Ishida et al. [1] showed that the
mother often gave the infant liquid with a spouted mug or
through a straw in the early stages of development. They
suggested three reasons for this: (i) if the infant could accept
liquids for a short period with a spouted mug or through a
straw, the mother did not have to worry about spillage, thus
decreasing the burden on the mother; (ii) the mother was able
to feed the infant liquids with minimum delay; and (iii) the
infant was able to take in a larger volume of liquid. However,
Ishida et al. [1] proposed that the introduction of a straw
would be appropriate after an infant acquired the ability to sip
liquid from a spoon and/or cup. This is because infants who
began using a straw earlier than a spoon and cup required a
long training time to functionally develop the ability to take in
liquid using a spoon and/or cup.
Anumber of mugs withstraws have beendesigned to avoid
spillage. Straws with a valve (SWVs) are one such type. Avalve
is located at the tip of a straw. And this type of straw in-
corporates a valve that normally remains closed. The valve
opens when crush force is applied to the straw up and down.
When infants use such a straw, they insert it deeply behind
the incisors and bite on it to keep it in place, moving their
* Corresponding author. Department of Dysphagia Rehabilitation and Community Dental Care, Tokyo Dental College, 1-2-2 Masago,
Mihama-ku 261-8502, Japan. Tel.: 81 43 270 3531; fax: 81 43 270 3570.
E-mail address: haramutsuki@tdc.ac.jp (M. Hara).
Available online at www.sciencedirect.com
Pediatric Dental Journal
j ournal homepage: www. el sevi er. com/ l ocat e/ pdj
p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 3 2 e3 6
0917-2394/$ e see front matter 2013 Published by Elsevier Ltd. on behalf of the Japanese Society of Pediatric Dentistry.
http://dx.doi.org/10.1016/j.pdj.2013.03.005
tongue backwards and forwards to create negative pressure
and extract the liquid inside.
There are two distinct differences between suckling and
sucking inearly infant feeding [2e5]. Suckling is the initial type
of feeding pattern that is established [5]. The tongue begins a
distinctive, rhythmical, backward-forward movement that
helps draw liquid into the mouth [6]. External observation re-
veals that the peristaltic tongue movements are synchronized
withthe jawmovements [7]. Tamura et al. [8] reported that the
lower jaw was closed until the medial portion of the tongue
was elevated. During this movement, the inside diametric
height of the teat decreased and the suckling pressure was
positive. After the jaw closed, the elevation of the tongue
shiftedposteriorly andthe suckling pressure became negative.
At that time, the jawwas retrusive andopen. Insucking, onthe
other hand, thetongueloses thebackward-forwardmovement
that predominates in suckling and shifts to an up-down
movement [4]. In addition, the lips have a stronger seal
caused by shifting of the tongue motion [9]. As a result, the
open and closed jaw movement decreases [2]. Sucking move-
ments are used not only during breastfeeding, but also when
drinkingfroma spoon, cup, or straw. Uptothe age of 6 months,
infants use suckling for feeding [10]. Subsequently, between
the ages of 6 and 9 months, their type of feeding pattern shifts
fromsuckling to sucking [2]. At around 8 months, they become
capable of using feeding devices in addition to the breast [11].
However, in clinical practice, regression to suckling has been
observed following the use of SWVs.
To date, there have been no studies on how the SWV af-
fects feeding development of infants. The purpose of this
study was therefore to clarify the effect of an SWV on the
development of liquid intake in infants. Such knowledge
might prove useful in preventing interruption of feeding
development.
2. Methods
Twenty-six healthy volunteer infants (13 boys, 13 girls),
ranging in age from 8 to 19 months, participated in this study.
All of the infants were recruited with guardian consent. The
caregivers were interested in letting their infants use a straw
and all of the infants had used a strawto take in liquid before a
spoon and cup. All infants used a straw during meals, snacks,
walks, etc. The caregivers were allowed to select the strawof a
particular brand for regular use. A questionnaire survey was
conducted on the selected brand. The infants were divided
into two groups. Twelve infants (7 boys, 5 girls) aged 9e19
months (mean: 12.4 months) used the SWV for liquid intake
mainly. Their mean body weight at birth was 3030 376.5 g.
The Hellmans dental age was IA in one infant and IC in 11
infants. Fourteen infants (6 boys, 8 girls), ranging in age from8
to 12 months (mean: 10.4 months), used the straw-without-a-
valve (SWOV). Their mean body weight at birth was
3036 488.9 g (Table 1). All infants had a Hellmans dental age
of IC.
The Ethics Committee of Tokyo Dental College, Ethical
Clearance Number 268, approved the experiment.
2.1. Questionnaire
A face-to-face interview was conducted with the parents
using a structured questionnaire, which included questions
on the following information: (i) weaning from breast or bot-
tle; (ii) type of suckling; (iii) frequency of suckling a day; (iv) age
of starting straw feeding; (v) initiation of spoon feeding; (vi)
duration of baby food intake (Table 2).
2.2. Observation
The infants taking liquid from a straw or a spoon with
parental support were observed and videotaped. The parent
used the SWOV and the teteo Cupspoon

(Combi Co., Tokyo,

Japan) (Fig. 1). The teteo Cupspoon is hemispherical in shape,
lets infants drink liquid from any direction, has a bowl width
that is appropriate for an infants mouth, and has a spoon size
that corresponds to one mouthful for an infant [12]. Infants
were free to choose their favorite beverage: water, tea, fruit
juice, or isotonic beverage.
The assessment was carried out later based on the video
images. The assessment was drawn from Morriss checklist
[2]. We evaluated the open and closed jaw movement during
straw feeding. In Stage 1, an infant uses a wide excursion of
the jawwhile drinking liquid and the jawmovements are wide
and ungraded (Fig. 2a). In Stage 2, the infant keeps the jaw in a
stable position while drinking liquid (Fig. 2b). We evaluated
the lip closure as well as open and closed jaw movement
during spoon feeding. Lip closure was evaluated as follows. In
Stage 1, the upper lip does not assist in drinking liquid with
the spoon (Fig. 2c). In Stage 2, the upper lip is closed on the
edge of the spoon, providing a better seal for drinking (Fig. 2d,
Table 3). Jaw movement was evaluated using the same
assessment method as for straw feeding.
The infants characteristics, parents responses to the
questionnaire, and results of observation when using SWV or
Table 1 e Infants characteristics.
SWV group SWOV group
n 12 14
Birth weight
a
3030 376.5 g 3036 488.9 g
Age
a
12.4 2.8 months 10.4 1.4 months
Boys/girls 7/5 6/8
SWV, straw with valve; SWOV, straw without valve.
a Data are expressed as mean standard deviation.
Table 2 e Questionnaire.
Q1. Has your child weaned from breast or bottle?
1) Yes 2) No
Q2. What type of suckling feeding did your child have?
1) Breastfeeding 2) Bottle feeding 3) Mixed feeding
Q3. What is the frequency of suckling feeding per day?
Q4. When did your child start drinking from a straw?
Q5. Does your child drink with a spoon?
1) Yes 2) No
Q6. How many months ago did your child start eating baby food?
p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 3 2 e3 6 33
SWOV were statistically compared with chi-square test,
Fishers exact test, or ManneWhitney U test, where appro-
priate. Fishers exact test was used for 2 2 categorical data
and chi-square test for categorical data sets larger than 2 2.
The ManneWhitney U test was used for non-normally
distributed data and ordinal data. A probability of less than
5% was considered signicant.
SPSS v19 (SPSS Inc., Chicago, IL, USA) was used to perform
all data analyses.
3. Results
The characteristics of the groups using SWV and SWOV and
the responses to the questionnaire are summarized in Table 4.
The questionnaire revealed a signicant difference between
the SWV and SWOV groups in terms of number of parents
using a spoon and duration of baby food intake. No other
signicant difference was revealed.
The results of straw feeding are shown in Table 5. All in-
fants in the SWV group drank liquid with an open and closed
movement of the jaw. On the other hand, in the SWOV group,
ve infants drank liquid with open and closed movement of
the jawand nine infants kept the jawin a stable position while
taking in liquid.
The results of spoon feeding were as follows (Table 5). Only
two infants drank with the right lip closure, while 10 infants
drank with wrong lip closure in the SWV group. Two of the 10
infants had been weaned. However, 10 infants drank with the
right lip closure and only 4 infants drank with wrong lip
closure in the SWOV group. All the infants in the SWV group
drank liquid with open and closed movement of the jaw. In
the SWOV group, 11 infants drank liquid with open and closed
jaw movement and 3 infants kept the jaw in a stable position
while drinking (Table 5).
Videotapes revealed a signicant difference in jaw move-
ment between the SWVand SWOVgroups when using a straw
( p < 0.01) and lip closure when using a spoon ( p < 0.01). No
signicant difference was observed in jaw movement when
using a spoon.
4. Discussion
In this study, all the infants in the SWVgroup exhibited a wide
jaw excursion when drinking from a straw. External
Fig. 1 e The teteo Cupspoon. The teteo Cupspoon spoon
has the following characteristics: it is hemispherical in
shape, the shape allows infants to drink liquid from any
direction, the width of the bowl is an appropriate size for
an infants mouth, and the size of the spoon corresponds
to one mouthful for an infant.
Fig. 2 e (a) Wide jaw excursion is recognized and the lips are open because lip closure is weak. (b) The jaw remains in a
stable position and the lips are kept closed. (c) The upper lip does not close over the spoon and lips do not assist in drinking
liquid. (d) The lips are closed and upper lip is closed on the edge of the spoon, providing a seal for drinking.
p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 3 2 e3 6 34
observation reveals that the peristaltic tongue movements in
suckling are synchronized with the jaw movements [7].
Tamura et al. [8] reported that the lower jaw was closed until
the medial portion of the tongue was elevated. During this
movement, the inside diametric height of the teat decreased
and the suckling pressure was positive. After the jaw closed,
the elevation of the tongue shifted posteriorly and the suck-
ling pressure became negative. At that time, the jaw was ret-
rusive and open. Therefore, this was similar to the jaw
movement seen during suckling. In the SWOV group, how-
ever, the lower jaw was stable in 64% of infants. Morris [2]
reported that the open and closed jaw movement decreases
in accordance with the shift in the type of feeding pattern
from suckling to sucking. This indicates that the type of
feeding pattern in the SWOV group shifted from suckling to
sucking. The feeding pattern changes from suckling to suck-
ing between the ages of 6 and 9 months [2]. Considering the
age of participants, both the SWV group and the SWOV group
must have shifted from suckling to sucking. However, this
transition had not occurred in the SWV group. From these
observations, it appears that SWVs hamper the shift in the
type of feeding pattern from suckling to sucking.
In the present study, signicantly more infants started
drinking liquids from a spoon in the SWV group compared
with the SWOV group. Despite this, signicantly more infants
in the SWV group than in the SWOV group drank liquids from
a spoon with incomplete lip closure. This result shows that
SWVs may affect the lip closure. Because infants drink from
SWVs by biting the straw to hold it in place and inserting the
end of the straw deeply into the mouth, they extract liquid
using the same movement as with breastfeeding [2]. When
trying to extract liquid using a straw normally, it is necessary
to seal the tip of a straw by lips [2]. However, when extracting
liquid using the same movement as with breastfeeding, the tip
of a straw is sealed by the tongue and palate. Thus, liquid can
be extracted without lip closure. The same movement as with
breastfeeding does not require such a strong degree of lip
closure [9]. Therefore, the structure of SWVs may hamper the
development of lip closure when using feeding devices during
the weaning period.
Both groups exhibited a wide jaw excursion when drinking
from a spoon. Morris [2] reported an association between
improved lip closure and wide jaw excursion. In the SWV
group, 10 infants (83%) had incomplete lip closure. This sug-
gests that the incomplete lip closure evident in the SWVgroup
was related to open and closed jaw movement. Morris [2] also
suggested that when some motor elements that had not pre-
viously been experienced were introduced into existing
movements, those movements tended to revert to the earlier
patterns while those new elements were being mastered. In
the SWOV group, 12 infants (86%) had not started drinking
from a spoon. As described in the above report, almost all
infants in the SWV group who had not experienced drinking
from a spoon exhibited a wide jaw excursion. In other words,
wide jaw excursion was thought to have resulted from
different causes in the SWV and SWOV groups. Moreover,
Table 3 e Assessment of jaw movement and lip closure.
Jaw movement
Stage 1 The infant uses a wide excursion of the jaw while
he/she drinks liquid.
The jaw movements are wide and ungraded.
Stage 2 The infant keeps the jaw in a stable position while
he/she drinks liquid.
Lip closure
Stage 1 The infant does not use his/her upper lip when
drinking liquid with the spoon.
Stage 2 The infant keeps his/her upper lip closed on the
edge of the spoon, providing a better seal for drinking.
Table 4 e Characteristics of SWV and SWOV groups.
SWV (%) SWOV (%) p
n 12 14
Birth weight
a
(g) 3030 376.5 g 3036 488.9 g 1.000
Age
a
(months) 12.4 2.8
months
10.4 1.4
months
0.060
Sex Boys 7 (58%) 6 (43%) 0.431
Girls 5 (42%) 8 (57%)
Q1. Weaning from
breast or bottle
4 (33%) 1 (7%) 0.091
Q2. Type of suckling feeding
Breastfeeding 7 (58%) 11 (79%) 0.219
Bottle feeding 0 (0%) 1 (7%)
Mixed feeding 5 (42%) 2 (14%)
Q3. Frequency of
suckling feeding
a day
a
2.9 2.6 4.1 2.1 0.166
Q4. Age of starting
straw feeding
a
7.0 1.7 6.4 1.0 0.595
Q5. Presence of
spoon drinking
7 (58%) 2 (14%) 0.019*
Q6. Duration of baby
food intake
6.8 2.6
months
4.1 1.8
months
0.006**
*p < 0.05. **p < 0.01.
Fishers exact test was used for 2 2 categorical date, chi-square
test for categorical data sets larger than 2 2. The Man-
neWhitney U test was used for non-normally distributed data and
ordinal data.
SWV, straw with valve; SWOV, straw without valve.
a Data are expressed as mean standard deviation.
Table 5 e Results of the assessment.
Groups SWV SWOV p
n 12 14
Straw feeding
Jaw movement Stage 1 12 (100%) 5 (36%) 0.001**
Stage 2 0 (0%) 9 (64%)
Spoon feeding
Lip closure Stage 1 10 (83%) 4 (29%) 0.005**
Stage 2 2 (17%) 10 (71%)
Jaw movement Stage 1 12 (100%) 11 (79%) 0.140
Stage 2 0 (0%) 3 (21%)
**p < 0.01.
SWV, straw with valve; SWOV, straw without valve.
p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 3 2 e3 6 35
these ndings suggest that SWVs indirectly cause wide jaw
excursion by hampering the development of lip closure.
Nipple confusion is the interference of articial nipples with
thesuccessful initiationof breastfeeding[13]. Amongtheweaned
infants, two subjects in the SWV group exhibited wide jaw
excursion during both strawand spoon feeding, and also had an
incompletelipclosure. Weanedinfants shouldnot takeinliquids
by protruding their tongue or using a backward-forward move-
ment of the tongue. However, the two infants had been weaned
despite not having shifted to sucking. SWVs are assumed to be
the main method of liquid intake in these infants, who subse-
quently had difculty with breastfeeding. And caregivers may
have misinterpreted nipple confusion as weaning.
In the present study, the duration since initiation of baby
food intake was signicantly longer in the SWV group
compared to the SWOV group. However, delays in feeding
development were seen in the SWV group compared to the
SWOV group for both straw and spoon feeding. The period
during which baby food intake is initiated, from around eight
months to three years of age, is extremely important in
development [2]. In particular, intake using new types of
feeding devices such as spoons, cups, and straws is initiated.
Bosma [14] reported that sensory experience played an
important role in functional development in the oral and
pharyngeal regions. It is considered advisable to avoid using
feeding devices that affect the development of the lips, suchas
SWVs, during this period. In addition, there are various limi-
tations to development in disabled children. Feeding devices
that enable smooth development must be used for children
with developmental disabilities. It is therefore necessary to
avoid the use of feeding devices that articially hinder devel-
opment in children with developmental disabilities.
An SWV may hamper the development of lip closure and
affect the development of drinking ability in infants. It is un-
clear at this point whether infants will develop the ability later
or whether this effect will continue in the future. Long-term
continued monitoring of infants in the SWV group is there-
fore required.
Disclosure
None of the authors have no conicts of interest that should
be declared.
Acknowledgments
The Combi Corporation supported the work of the rst author.
The Combi Corporation had no inuence on the study or the
writing of this report. The authors extend special thanks to the
mothers and infants who participated in this study.
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