asthma.

Additional tests should be so that it is not misinterpreted by the need to treat the underlying illness,
guided by clinical suspicion. family as a lack of concern. Cough rather than the symptom, should be
Often, careful reexamination and suppressants in children recently have stressed.
evaluation is warranted before costly been shown to have no benefit over a
and misguided evaluations are pur- placebo. Their use should be discour- Jeffrey M. Ewig, MD
sued. If the former approach is taken, aged, again with careful explanation Albert Einstein College of Medicine
the physician should explain why he to the parents. The importance of Montefiore Medical Center
or she is undertaking this approach cough as a protective reflex and the Bronx, NY

IN BRIEF

Thumbsucking
Oral Habits: A Behavioral Approach. thumbsucking can affect dentofacial friend, seatmate, or playmate.
Peterson J, Schneider P. Pediatr Clin North
structures, the thumb, or both; can Illingsworth states that the danger of
Am. 1991:38:1290-1296
Thumb-sucking: Literature Review. Johnson
serve as a source of infection or acci- thumbsucking is not in the habit it-
E, Larson B. J ASDC Dent (‘hild. l993;60: dental poisoning: and can affect a self but in what parents do about it.
385-391 child’s social acceptance and self- Unhappiness, resentment, and insecu-
Thumb Sucking. Leung A. Robson L. Am esteem. rity can result from constant parental
Fat,, Physician. I 99 I :44:1724-1728
Johnson and Larsen summarize the nagging and reprimands.
Illingsworth R. The Nortnal Child. 9th ed.
New York, NY: Churchill Livingston; 1987:
potential dentofacial changes caused Treatment aimed at eliminating
345-347 by prolonged thumbsucking as those prolonged thumbsucking should be
Influence of Thumb Sucking on Peer Social affecting the maxilla and mandible, considered when any of the previ-
Acceptance in First-Grade Children. the interarch relationship, lip place-
Friman PC, McPherson KM. Warzak WJ,
ously mentioned complications affect
ment and function, and tongue place- the child’s health or functioning.
Evans J. Pediatrics. l993;9l:784-786
A Thermoplastic Thumb Post for the ment and function. Temporomandibu- However, treatment generally is not
Treatment of Thumb-Sucking. Allen K. lar joint problems, sublingual considered necessary before 4 to
Flegle J, Watson 1. Am J Occup Tizer. mucosal ulceration, and apical root 6 years of age. Options include phys-
1991:46:552-554
resorption also have been reported. ical barriers, orthodontic appliances,
An Effective and Acceptable Treatment
Alternative for Chronic Thumb- and
Some spontaneous correction of the aversive taste treatments, and when
Finger-Sucking. Friman P. Leibowitz J. dentofacial effects can be expected if
appropriate, psychological counseling.
J Pediatr Psvchol. 1990: I 5:57-65 the habit persists until 9 years of age Physical barriers as simple as band-
Thumbsucking is a form of non- and then is stopped, with most of the
aids, mittens, socks, and tape or those
nutritive sucking occurring as early correction occurring within the first
somewhat more complex. such as the
as the 29th week of gestation; it is year after the habit ceases.
thermoplastic thumb post described
seen commonly in infants and peaks Orthopedic problems that have re-
by Allen et al, have met with van-
at 18 to 2 1 months of age. Develop- suited from prolonged thumbsucking
able degrees of success. The dental
mentally normal children possess an include the development of a radial
literature is replete with descriptions
inherent biological drive for sucking, angular deformity, with the digit mal-
of devices such as a ‘hayrake,’ a
‘ ‘

the explanation for which can be aligned as much as 40 degrees. Other

palatal bar fixed to the molars that
found in both psychoanalytic and commonly occurring effects to the
does not interfere with occlusion but
learning theory. Psychoanalytic thumb include soreness and callous
serves to break the seal caused by the
theory contends that non-nutritive formation, chronic paronychia, irri-
sucking action. Such devices, while
sucking represents a biological drive tant eczema, and herpetic whitlow.
Thumbsucking also has been reported effective, are expensive.
resulting from pleasurable stimulation
to be a source of introducing infec- Aversive taste treatments applied
of the lips and mouth; learning
tion such as Candida or of accidental locally to the thumb have been effec-
theory proposes that the infant learns
ingestion of harmful substances in tive. Fniman and Liebowitz per-
to associate sucking with pleasurable
feelings such as satiety or being held. contact with the digit and then intro- formed a randomized clinical trial on
Whatever the theoretical basis, duced into the mouth. 22 thumbsuckers ages 4 years and
thumbsucking generally is viewed as Psychological consequences of older using aversive taste coupled
a biological drive that develops into a thumbsucking cannot be underesti- with a reward system and reported
habit, which in the majority of cases mated. Friman et al assessed the ef- 12 cessations within 3 months and
resolves by age 4 years, but can per- fect of chronic thumbsucking on so- 20 cessations within 1 year.
sist much longer. cial acceptance among 40 first-grade Finally, it must be recognized that
Sequelae of thumbsucking depend children. The children rated photo- thumbsucking or other chronic habits
on the habit’s duration, frequency, graphs of thumbsucking peers as less may indicate underlying frustration.
and intensity, as well as the position intelligent, happy, attractive, likable, emotional stress, anxiety, or other
of the thumb in the mouth. Prolonged and fun, and less desirable as a phenomena that suggest the need for

Pediatrics in Review Vol. 16 No. 2 February 1995 73

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a closer look at the child and tional stress, anxiety. or other phe- satisfactorily with what may be caus-
family’s psychosocial functioning. nomena should be a red flag for the ing the need to suck non-nutritively.
pediatrician. Children express their We merely may be substituting
Mans D. Rosenberg, MD
insecurities in a number of different symptoms if we do not pay serious
Montefiore Medical Center
ways: the degree of this insecurity attention to those underlying anxi-
Albert Einstein College of Medicine
potentially is reflected in this exces- eties. Time well spent uncovering the
Bronx, NY
sive need to suck the thumb. Clearly insecurities may lead to healthier out-
Comment: For pediatricians, the pediatricians must identify these inse- comes down the road.
most important paragraph of this ab- curities and develop means for inter-
stract is the last one. Prolonged vention. Simply removing the symp- Steven P. Shelov, MD
thumbsucking as a potential expres- tom by aversive therapies or other Editor, In Brief
sion of underlying frustration. emo- suggested interventions will not deal

PIR Quiz-CME Credit

The American Academy of Pediat- contact hours should submit proof PREP EDUCATION AWARD:
rids is accredited by the Accredita- of participation and verification of The PREP Education Award pro-
tion Council for Continuing Medi- PREP accreditation to the NAP- vides recognition and support for
cal Education to sponsor NAP National Office. those Academy Fellows and Candi-
continuing medical education
for The questions for the PIR quiz date Fellows who participate in
physicians. are located at the end of each arti- PREP. Individuals who qualify for
The American Academy of Pedi- cle in this issue. Each question has the PREP Education Award will
atnics designates this continuing a SINGLE BEST ANSWER. To receive their award automatically.
medical education activity for 56 To be eligible for this award, a
obtain credit, record your answers
credit hours in Category I of the Fellow or Candidate Fellow of the
on the PIR Quiz Card found in the
Physician’s Recognition Award of American Academy of Pediatrics
January issue and return the card to
the American Medical Association. must receive, over a 3-year period,
the Academy. (PREP group partici-
This program has been reviewed 150 hours of Category I CME
pants will receive the PIR Quiz
and is acceptable for 56 Prescribed credits from the following sources:
Card and Self-Assessment Credit
hours by the American Academy
Reply Sheet under separate cover.) #{149}
75 hours must be obtained from
of Family Physicians. (Term of
To receive CME credit on the 1995 participation in PREP (the Self-
approval: beginning date January
annual credit summary. you must Assessment Exercise and/or Pe-
1995. Enduring materials are ap-
be enrolled in PREP or subscribe diatrics in Review) or PREP:
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request renewal.) For specific in-
the PIR Quiz Card by February 28, #{149}
The balance (75 hours) of the
formation, please consult with the
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AAFP Office of Continuing Medi-
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This program has been reviewed
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and is acceptable for 32 AOA Cat-
accepted through December 31, AAP Spring Session or Annual
egory 2-B CME hours by the
1997. Meeting. CME courses, Acade-
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The PIR Quiz Card is bound my-approved courses, the Pediat-
For specific information, please
into the January issue. Complete ric UPDATE audiocassette tape
consult with the AOA Department
program, or AQUIP.
of Education. the quizzes in each issue and send
In addition, this course has been to: American Academy of Pediat- The correct answers to the ques-
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74 Pediatrics in Review Vol. /6 No. 2 February /995

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 Thumbsucking
Maris D. Rosenberg
Pediatrics in Review 1995;16;73
DOI: 10.1542/pir.16-2-73

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 Thumbsucking
Maris D. Rosenberg
Pediatrics in Review 1995;16;73
DOI: 10.1542/pir.16-2-73

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org/content/16/2/73

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