Professional Brochure – The soother EN by bibi - a swiss brand

EXPERT BROCHURE FOR HEALTHCARE PROFESSIONALS

The soother FROM A SCIENTIFIC PERSPECTIVE

Edition 2017 Medical review: Dr. Corinne Mathys Zulauf Images: Shutterstock.com

TABLE OF CONTENTS Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The first reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Rooting, sucking and swallowing reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Facial and oral anatomy of the neonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The orofacial system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Development of orofacial movement patterns . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Development of motor skills

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Exploring in and with the mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Breastfeeding and soothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Non-nutritive sucking (NNS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Use of the soother against restlessness, pain and sudden infant death syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Soothing and fulfilling the need for non-nutritive sucking . . . . . . . . . . . . . . . . . . 24 The soother and SIDS (sudden infant death syndrome). . . . . . . . . . . . . . . . . . . . 27 Theories on the protection against sudden infant death syndrome . . . . . . . . . 28 The soother and pain perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 The soother and middle ear inflammation (otitis media) . . . . . . . . . . . . . . . . . . . 34 Soothers and oral health: from a dental and speech therapy perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Orofacial health and the requirements for the soother . . . . . . . . . . . . . . . . . . . . 38 Duration is the key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Effects of the soother on language development . . . . . . . . . . . . . . . . . . . . . . . . 39 The soother is preferable to the thumb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 The soother and parents – interesting facts for parents . . . . . . . . . . . . . . . . . . . . . 42 Responsible use of a soother, recommendations by experts . . . . . . . . . . . . . . . 44 What is the right soother size? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 When is the right time to break the soother habit?. . . . . . . . . . . . . . . . . . . . . . . . 48 bibi ® Happiness soother generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Ergonomic design criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 The planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 The implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 ErgoComfort Shield . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 bibi ® Happiness soother teat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Dental teat form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Natural teat form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Newborn teat form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

FOREWORD

The standards for baby products are very high, and rightly so. Thanks to various research projects and new findings from medicine and ergonomics, we know in increasing detail what characteristics products need to have in order to support babies in their development. The new bibi ® product generation ‘Happiness’ reflects these findings: barely noticeable modifications make the new bibi ® generation even safer and more comfortable with higher quality. A lot of work has been done over the past few years when it comes to the much-loved soother. Recent research shows more and more clearly that it is useful to give babies a soother in certain situations. The advantages of prudent and controlled soother use significantly outweigh any disadvantages. Epidemiological studies show that the soother can provide a possible protective effect against the risk of sudden infant death syndrome. It is also the most effective means of satisfying the temporary natural need for non-nutritive sucking. With correct soother use, the concern that the soother could lead to problems with breastfeeding is also unfounded. With a moderate, supervised and limited use of a soother, there should be no concern about causing malocclusion and dysgnathia. This summary of the current state of research is intended to enable parents to support their child in its natural and healthy development. Comprehensive knowledge and expertise are the keys to this know-how transfer, and we hope with this booklet that we have created a tool that will facilitate and support you in your daily consulting work.

Kim Kühni, BSN

Dr. Corinne Mathys Zulauf

Training & Product Consultant

Dentist and Speech Pathologist

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE FIRST REFLEXES Breathing, sucking and swallowing are natural reflexes which become essential for survival immediately after birth. Already present in the womb, they represent the most complex neuromuscular interaction in the human body. The way a child drinks and swallows gives parents and baby experts key information about the state of health and the neurological development of a neonate or infant. 1

It is known that around the 12th week of pregnancy

to soothe itself. A lack of coordination of these three

the unborn child is able to ingest and excrete amni-

systems in newborns indicates a general functional

otic fluid. Even at this early stage of development,

weakness of the central nervous system. This is some-

sucking and swallowing are already coordinated

times observed in preterm infants. The rooting reflex is

sequences of motions. At the same time, the unborn

functional as early as the 28th week, and the preterm

child can already suck on its hands. In addition to

infant turns towards the nipple, clasps it and latch-

food intake, sucking also serves as a support in deal-

es on. However, food intake requires a combined

ing with various emotional needs. A baby or small

application of breathing, sucking and swallowing.

child can soothe itself by sucking, which also helps its

This interplay is already sufficiently developed in the

concentration. Sucking, together with some breath-

32nd week of pregnancy so that the infant would

ing-like movements which are already present quite

theoretically be capable of taking in food through

early before birth, serve as a preparation for the

the mouth. Since these very young preterm babies

breathing and swallowing functions. Furthermore,

tire quickly, in practice oral feeding is often difficult.

the sucking reflex is closely associated with the root-

From the 32nd to 34th week, the normally developed

ing reflex, which is triggered by touching the cheeks

baby is able to coordinate and sustain all necessary

or the corner of the mouth. In response, the neonate

functions for oral food intake. 2

turns its head in the direction of the stimulus, opens his mouth and extends its tongue in preparation for

A healthy full-term baby sucks with a more or less

imminent food intake. The rooting reflex is integrat-

regular pattern of mouth movement sequences

ed three to four months after birth and is present at

and pauses. Sucking appears to consist of 5 to 24

the latest, until the 12th month of life at the latest.

different clustered motion sequences. The pause in

Its presence should be considered when giving a

between is seen as a resting and recovery phase.

soother and also at the beginning when offering the

At the same time, the baby is processing cogni-

breast or bottle.

tive information. Mothers often look at their baby during such a pause, talk to it or caress it. 3 An intact

These automatic patterns of movement, which seem

coordination of breathing, sucking and swallowing

self-evident and simple to us, require complex coor-

involves that breathing is briefly interrupted during

dination: swallowing and breathing must be harmon-

the passage of food through the pharynx (swallow-

ised with one another. The depth and number of

ing apnoea) and that an exhalation occurs before

breaths change when a baby drinks or when it sucks

and usually immediately after swallowing.

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

Because of the stability of the sucking reflex produced in early gestation through the central nervous system, it is used by researchers to measure certain behaviors: sensory discrimination, conditioning, learning ability, orientation and attention. The fact that sucking can also be a form of self-regulation can be observed in a neonate that moves from a quiet state to crying. Its attempts to make hand-to-mouth contact in order to keep itself under control are fascinating to observe. As soon as the baby has managed to put a finger in its mouth and suck on it, it is gratified and soothed, and its facial expression relaxes. The baby seems receptive, while at the same time anxious to sustain this form of self-regulation. This is the clearest evidence that a baby behaves in a goal-oriented manner and can initiate this behavioural pattern for itself. A soother can have the same quieting effect on an upset baby but may not satisfy the self-regulation system in the same way as when the baby regulates itself.

ROOTING, SUCKING AND SWALLOWING REFLEXES Rooting and sucking reflexes are

lips with the breast nipple, a finger

The vacuum formation plays an

behaviour patterns which are reli-

or a soother. From this first reflex

important role in emptying the

ably triggered by certain stimuli.

stimulus

condi-

breast. The anterior part of the

In infancy, together with the swal-

tioned reflex develops with the

tongue holds the nipple firmly but

lowing reflex they are essential for

vision of the breast or bottle and

shows no peristalsis; the posteri-

the purpose of food intake.

the head positions itself accord-

or part drops down, producing a

ing to the source of the food.

negative pressure. At the same

response,

the

time, the tongue moves in a

When a baby is touched at the corners of the mouth or on the

The

used

wave-like motion to transport the

cheeks, this reflexively triggers

by an infant when it empties the

milk into the pharynx and swallow

movements toward a food source

breast is still the subject of profes-

it. This is important in order to swal-

in the direction from which the

sional debate. Recent studies with

low the liquid. 4, 5, 6

stimulus comes. We call this the

ultrasound scanning show that

rooting reflex.

this mechanism uses a combina-

precise

mechanism

tion of intra-oral vacuum formaThe sucking reflex, on the other

tion and movement of the posteri-

hand, is triggered by touching the

or portion of the tongue.

FACIAL AND ORAL ANATOMY OF THE NEONATE In neonates, the facial skeleton (viscerocranium) is underdeveloped in relation to the neurocranium, the larynx is still very high, the lower jaw sits back and the oral cavity (cavum oris proprium) is almost completely filled by the tongue, which is in contact with the lips, cheeks and palate. The swallowing process is physiologically different from that of children with teeth and advanced facial skeleton development. Often in neonates the tip of the tongue continues beyond the alveolar processes and thus seals the oral cavity in front, where it makes contact with the lips. This allows an intra-oral vacuum to be created. Full-term infants are born with so-called buccal fat pads (corpus adiposum buccae). These pads of fat and the active lip and cheek muscles stabilise the lower jaw when sucking. The larynx is still sitting higher than in adults or older children. Its closure in the first months of life does not yet fully function, which is why infants and toddlers can choke more easily. Furthermore, the full development of a coordinated swallowing process with intact oral, pharyngeal and oesophageal sequences of motions is not expected until between 6 and 12 months of age. This maturation process accompanies the growth-related anatomical changes during dentition and facial development in the first few years of life, and ends at the transition from infantile to somatic swallowing. This characteristic anatomy changes with the growth and development of the child. The growth of the jaw is positively influenced by breastfeeding, as well as from the time of tooth eruption, by serving age-appropriate pureed/mashed and solid foods. Varied oral explorations and orofacial activities futher stimulate the childâ&#x20AC;&#x2122;s physiological development. Hands, fingers and objects (including teething rings) are licked, sucked, bitten and sometimes chewed periorally, with the lips, tongue and alveolar ridge. 7

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE OROFACIAL SYSTEM In the first months of life, the oral cavity is a dominant sense organ with which the child explores its environment. 8 The oral cavity is part of the orofacial system, which enables not only the primary functions of breathing, sucking, swallowing and chewing, but also has a secondary role in phonation and also performs a valve function. Breathing, sucking and swallowing are vital mechanisms for the neonate; chewing, on the other hand, only develops in the course of the first year of life. 9 The oral mucosa and particularly the moving parts of the lips and tongue, but also the anterior region of the palate, enable the ability to perceive and recognise objects and their nature. Spatial position, shape and size, surface texture, consistency and temperature are studied and identified through oral exploration. The mouth investigates and categorises properties and function of things: Who? What? How? Where? How much? Why? What for? With increasing maturity, the hands become more involved in these voyages of discovery and are later supplemented by visual and auditory impressions. Exploring objects with the mouth is also used to ascertain how far an object can be inserted into the mouth. During these manoeuvres, the gag reflex moves back towards the palatal arches and root of the tongue. Through the experiences of oral exploration, the interplay of lips, tongue, lower jaw, palate, hand and fingers becomes increasingly finer and more differentiated. It is assumed that this interplay is an important and essential prerequisite for subsequent undisturbed speech.10 An equally important role in the individual’s ontogenetic development is played by slurping and sucking. Infants, and even foetuses, exhibit a multitude of slurping and sucking habits, which must be seen not as ‘bad habits’ but as precursors of physiological swallowing habits. The urge to orally explore, suck and nibble is part of the healthy development of the human individual.11

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

DEVELOPMENT OF OROFACIAL MOVEMENT PATTERNS

1-3 MONTHS

4-6 MONTHS

•• Coordination of breathing and integrated

•• The orofacial movement pattern is augmented

rhythmic sucking-swallowing motion with

by vertical movement patterns of lip, tongue

simultaneous movement of lower jaw, lip and

and lower jaw

tongue; from 7th post-natal week: sagittal

•• Differentiated movements, playful and

anterior-posterior tongue movements are

increasingly voluntary use of the orofacial

predominant

muscles, biting

•• Tongue resting position: tongue almost

completely fills the oral cavity and is in contact

with lips and cheeks

with lips and cheeks; from 6 months: lip closure

•• Swallowing pattern: wave-like anterior-posterior

movements of the tongue with activity of the lips and cheek muscles •• Reflexes: in the first post-natal weeks: rooting

reflex is pronounced; gag reflex is increasingly

increases when at rest •• Swallowing pattern: wave-like anterior-posterior

movements of the tongue with activity of lips and cheek muscles •• Reflexes: sucking and swallowing reflexes

reduced through dorsal displacement of the

are partially overlapped by voluntary

trigger zone; after 3 months the Moro reflex,

motor activity; asymmetric tonic neck reflex

rooting and sucking reflexes, grasping reflex,

integrated; Landau reflex, amphibian reflex,

tonic labyrinthine reflex are diminished (up to

segmental rolling reflex, tonic neck reflexes are

3½ years)

active

•• Dentition: normally no teeth

•• Dentition: eruption of the lower front teeth

•• Food: exclusively milk from breast or bottle

•• Feeding: milk from breast or bottle, pureed/

mashed consistency, starts to take food from a spoon

7-12 MONTHS

13-24 MONTHS

•• The orofacial movement pattern is augmented

•• Purposeful biting off of food, differentiation of

by lateral movements of tongue and lower

the chewing process with adaptation to the

jaw, further development of differentiated

respective food consistency

movements with playful and increasingly

•• Tongue resting position: further development

voluntary use of the orofacial muscles,

of the dorsal displacement of the tongue;

chewing

in conjunction with eruption of the posterior

•• Tongue resting position: gradual dorsal displacement of the tongue in conjunction

with an increase in space; due to growth

teeth, retraction of the tongue inside the rows of teeth •• Swallowing pattern: further development of

and the development of chewing, the size

the infantile swallowing pattern to the adult

discrepancy between oral cavity and tongue

swallowing pattern, with anterior-posterior

decreases

movements of the tongue and activity of the

•• Swallowing pattern: food is reduced to small

muscles of mastication to stabilise the lower

pieces by biting and chewing; wave-like

jaw; reduction of activity of the lips and cheek

anterior-posterior movements of the tongue

muscles

with activity of lips and cheek muscles •• Reflexes: sucking and swallowing reflexes

•• Reflexes: neonatal reflexes integrated; Babinski

reflex integrated from 24 months; Landau,

can be produced voluntarily; gag reflex is

amphibian and segmental rolling reflexes still

significantly reversed (up to the 7th month

present; likewise tonic neck reactions

premature triggering occurs physiologically); tonic labyrinthine reflex forwards, asymmetric tonic neck reflex integrated; symmetric tonic neck reflex backwards and forwards, and Babinski reflex temporarily present •• Dentition: complete eruption of the front teeth •• Feeding: pureed/mashed food to semi-

solid consistency, from 9th month of life firm consistency is possible

•• Feeding: solid food

DEVELOPMENT OF MOTOR SKILLS 1-3 MONTHS

4-6 MONTHS

7-12 MONTHS

•• Body position: flexion in

•• Body position: extension

•• Body position: asymmetrical

prone position, extension

in prone position; flexion in

movement of legs, arms and

in supine position (reflex-

supine position; rotation from

torso; inclined sitting position;

dominated)

prone and supine position to

sitting on knees, walking

•• Head control: in prone position reflexive head

the side •• Head control: improved head

•• Head control: accommodation of proximity

rotation to the side is possible,

control; head alone can be

and distance through freely

without actual raising of the

moved to the side, up and

movable head in prone

head; from 3 months: in supine

down; raising of the head in

position / sitting back on the

position support on elbows

supine position; head control

heels / on all fours

with head raised

in sitting position

•• Exploring the environment:

•• Exploring the environment: shifting of weight and

beginning of oral self-

shifting of weight and

purposeful grasping attempts,

exploration; first visual

purposeful grasping attempts,

oral exploration of objects,

accommodation

oral exploration of objects

mobility

Source: Mathys C, Suter A, Bewegen und Sprechen: Sensomotorik im orofazialen Bereich, SAL Bulletin (Schweizerische Arbeitsgemeinschaft für Logopädie) No. 124, June 2007.

EXPLORING IN AND WITH THE MOUTH The infant’s first active interaction with its environment is via the mouth. From the beginning the mouth acts as an exploratory organ with which the infant increasingly gathers information about its environment. The first primary movement patterns such as sucking and swallowing and the increasingly rotating jaw movements are the basis for the subsequent acquisition of language. Sucking, chewing and swallowing are based on activities of what is known as oral stereognosis, i.e. the ability to identify and distinguish between objects using the mouth. Swiss psychotherapist and speech therapist Félicie Affolter stresses that comprehensive movements are performed not only with the hand / fingers, but very intensively with the mouth. “In oral exploration, a wide range of objects is inserted into the mouth and investigated by means of various movements of the different parts of the mouth; e.g. by biting on the object using jaw movements, by sucking and rotating the object with the tongue, by holding it with the lips and by licking it with the tongue. Often, the child attempts to put the entire object in its mouth – it is astonishing how large an infant’s mouth can be”. (Affolter 1987, p. 31) 12 Eyes, hands and mouth learn to coordinate; more and more, the hands take over the task of exploring and the mouth becomes noticeably mature and free for speaking. (Furtenbach 2013, p. 150) 13

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

BREASTFEEDING AND SOOTHERS It is no coincidence that professor and paediatrician Ruth A. Lawrence remarks in her guide for the medical profession on the subject of breastfeeding: “Nowhere in medicine does one’s personal interests or prejudices emerge more clearly than when counselling about child birth and breastfeeding. Nowhere else does personal experience influence medical management to such an extent. Since both mothers and infants differ, no simple rules can be established which guarantee success for everyone”. 14 (Lawrence 1985, p. 167)

THE RESEARCH SITUATION There is a widespread belief that the soother jeop-

culties or of the desire to wean the child?

ardises breastfeeding success. The International La Leche League recommends that soothers never

Since the early 1990s, UNICEF and the WHO have

be used as a substitute for the mother’s breast or

given the title ‘Baby-Friendly Clinic’ to materni-

as a comforter. However, its members agree that

ty wards that follow their ‘Ten Steps to Successful

the advantage of soothers in supporting a breast-

Breastfeeding’ programme. In 1997, the Neona-

feeding mother cannot be dismissed, but only if the

tal Study Group of the Lucerne Children’s Hospital

soother is given judiciously, for short periods and

examined whether, in western countries, Steps 6 and

under certain conditions. 15

9 of this programme needed to be adhered to as strictly as in countries with low hygienic standards.

The Canadian Paediatric Society recommends that

Step 6 prohibits the administration of food or drinks

mothers be routinely informed about the risk of using

other than breast milk unless medically indicated,

soothers immediately after birth. 16 The AAFP (Amer-

and Step 9 forbids the use of artificial nipples or

ican Academy of Family Physicians) recommends

soothers for breastfed infants. The authors conclud-

the use of soothers be avoided until breastfeeding

ed that the administration of liquid supplementary

has been securely and reliably established, with the

food by bottle, with or without the use of soothers,

exception of preterm infants, in whom the soother is

during the first 5 days post-partum did not result in a

used for oral training.

lower frequency or shorter duration of breastfeed-

ing in the first 6 months of life. 18 Looking at the research situation, it appears that most of the large-scale studies which concluded

Randomized controlled trials (RCTs) in which sooth-

that the soother could have a negative impact

ers are given at fixed times are best suited for find-

on breastfeeding are based on observations.

ing evidence of the causal relationship between

Controlled trials carried out subsequently have

breastfeeding problems and soother use. Argen-

tended to conclude that the soother does not

tinean researchers Alejandro G. Jenik and Nestor

shorten duration of breastfeeding. What the obser-

Vain conducted one of these trials. This multicenter

vation-based studies do not clarify is the following

randomized controlled trial involving 1,021 mothers

question: does the soother actually have a negative

aimed to clarify the effect of the soother on breast-

impact on breastfeeding, or is the use of the soother

feeding prevalance and duration after lactation

merely an indication of existing breastfeeding diffi-

was well established.

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

All mothers were highly motivated to breastfeed their

that the rate of exclusively breastfed children in the

newborn babies. Half of the mothers were instructed

mother-and-child

to offer their child a soother to help comfort them;

after soother use was restricted, from 79% from July

the other half used other alternatives to comfort

to November 2010, to 68% from January to August

their baby and did not offer a soother. The moth-

2011. At the same time, the rate of breastfed children

ers participated for 3 months. Result: the recom-

receiving supplementary feeding increased from

mendation to offer a pacifier once lactation is

18% to 28%. The percentage of infants fed exclusive-

well established (by day 15) does not affect the

ly with formula remained unchanged. â&#x20AC;&#x153;Our aim in

success and duration of breastfeeding. 19

publishing this data is to stimulate discussion and

ward

decreased

significantly

scientific inquiry into whether there are sufficient In a much-publicised overview study by Jenik and

grounds to refrain from offering breastfed infants a

Vain, no connection was found between the provi-

soother in the first few days of life,â&#x20AC;? says Kair. (Kair

sion of a soother and a shortened breastfeeding

2012, AAP News; Researchers Question Pulling Plug

time, except when the soother was given to the

on Pacifiers) 24

baby in the first five days of life. Multivariate analysis methods have shown that the giving of a sooth-

Despite these study results, the discussion of the use

er in the first five days of life, compared to giving a

of soothers in breastfed infants continues to be high-

soother four weeks after birth, was associated with a

ly controversial.

shorter breastfeeding duration. 20 A study conducted in Montreal, Quebec, compared two groups of mother-child pairs and monitored them for three months after birth. The researchers aimed to understand clearly whether there was a link between the giving of a soother and early weaning. Both groups of mothers were given advice that encouraged breastfeeding and were shown methods for soothing a crying baby. The experimental study group was counselled not to use a soother. The authors found a significant difference in the avoidance of soothers (38.6% versus 16.0%), but no difference in the frequency of weaning before the third month of life (18.9% versus 18.3%). These results determined in the randomised controlled trial disproved the link between soother use and early weaning found in observation studies. The researchers therefore concluded that the use of soothers may indeed be an indication of breastfeeding problems or low motivation to breastfeed, but is not a cause of early weaning. 21 Further studies gave similar results. 22, 23 A study by Kair and Phillipi revealed a surprising outcome. They analysed the feeding data of 2,249 infants born between June 2010 and August 2011. Results showed 18

CONCLUSION Recent studies at the highest level of evidence show that the soother has no negative impact on the duration of breastfeeding, and the number of mothers who give supplementary food does not increase. However, midwives recommend that it is wise to offer the baby a soother only after mother and child have become accustomed to breastfeeding and there are no problems. The American Association of Family Physicians (the AAFP) now also recommends that the soother should be used only when breastfeeding has become well established. The link between shortened breastfeeding duration and the use of a soother, which has emerged in some overview studies, is likely affected by additional factors such as breastfeeding problems or the mother’s desire to stop breastfeeding. Further quantitative and qualitative research is needed in order to fully understand the influence of the soother on breastfeeding. 28 Based on the data currently available, the prevailing view today is that mothers who are motivated to breastfeed their infants should be allowed to make their own decision about using a soother. 29

INFORMATION FOR PARENTS AND CARE PROVIDERS WHO WANT TO OFFER THEIR CHILDREN A SOOTHER •• Before the first use, a soother should be boiled for five minutes in boiling water. Then allow it to cool properly and if necessary squeeze any water out of the teat. •• From the outset, the soother should be used purposefully and with restraint. It should not be given indiscriminately, but mainly at bedtimes and to calm and quieten the child. •• Parents and caregivers should be urged to wash soothers routinely and to prevent siblings from sucking on the same soother. •• Parents should be informed that they should not put the soother in their own mouths (bacterial transfer), and that they should ensure that a clean soother is available when needed. •• The soother should be thoroughly examined before each use. It must be replaced at the first sign of wear or damage. •• Soother use should be restricted to between the ages of 2 and 3 at the latest. 30 The American Dental Association and the American Academy of Pediatrics (AAP) recommend that children be completely weaned off soothers by the age of 4 years at the latest. 31

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

NON-NUTRITIVE SUCKING (NNS) A distinction can be made between two types of sucking â&#x20AC;&#x201C; nutritive and non-nutritive (NNS). Nutritive sucking provides an infant with the essential nutrition needed by breast or bottle feeding and thus ensures the infantâ&#x20AC;&#x2122;s nourishment. The orofacial movement patterns differ when drinking from the breast and drinking from the bottle. Also the anatomy of the breast, the consistency of the tissue and the flow of milk require the infant to make adaptations in its sucking movements. Breastfeeding usually requires stronger sucking, creates an intraoral vacuum and normally lasts much longer than drinking from the bottle. This is one aspect why bottle-fed children are more prone to have a stronger demand for a soother.

Non-nutritive sucking is defined as sucking without receiving nourishment. In preterm infants, NNS is often used as stimulation to improve nutritive sucking and thereby to initiate and support oral food intake. The rapid sucking movements are interspersed with brief resting phases. In nutritive sucking by comparison, a slower and more continuous sequence is characteristic, with the presence of sucking episodes having up to 30 sucking actions. Sucking is a natural need that serves to calm and reassure, and it satisfies the desire for contact. Babies are able to satisfy this need at the breast, with a soother or other objects such as a toy, a blanket or thumbs and fingers. NNS is observed in both preterm and full-term infants. It should be regarded as an important part of a child’s overall sucking experience. NNS has a significant impact on a baby’s well-being; it gives it reassurance, security and enables it to explore its world with its mouth. NNS can also be an important first step towards the development of self-regulation and controlling emotions. 32 The intensity of the need to suck differs from child to child. Often it cannot be satisfied by breast or bottle feeding alone. How strong the sucking need still is after feeding is individual and also depends on the duration of the feeding period. The remaining need to suck is preferably satisfied by the child through further unrestricted sucking on the breast. If this is not possible, the child will suck its thumb or other fingers to obtain satisfaction. If the urge to suck is weak, it may be satisfied by physical closenes and cuddling. 33 American researchers such as R.H. Barrett and M.L. Hanson have also concluded that if feeding is too brief it will not satisfy all the child’s needs. “His belly may be full, but his need to suck has not been satisfied. From a normal baby, we can therefore expect nothing other than for it to resort to a finger, tongue or lips to satisfy this need.” (Barrett & Hansen 1978, p. 229). The authors are also of the opinion that this need to suck declines steadily from the age of about one year. Particularly in the case of emotional stress, however, it can last longer. 34

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE ETIOLOGY OF THE DIFFERENT SUCKING HABITS NON-NUTRITIVE SUCKING

BREAST

SUCKING URGE

BOTTLE CUP

FEEDING

SURPLUS SUCKING URGE

UNRESTRICTED BREAST-FEEDING THUMB

SATISFACTION

SOOTHER

FRUSTRATION

The etiology of the different sucking habits: Fig. 2

In their overview study, Brazilian researchers S. Diez

(Larsson 1985, p. 434)

Castilho and M.A. Mendes Rocha found no nega-

Larsson E., Odont Dr., Dahlin K., The prevalence and

tive psychological effects of NNS. On the contrary,

the etiology of the initial dummy- and finger-sucking

conflicts between libidinous impulse and external

habit. Am J Orthod. May 1985 Vol. 87: 432–435., p. 15.

prohibition (where the need to suck is suppressed) can cause frustrations, but also produce anxiety, stress or unnecessary pressure and may even lead to withdrawal and developmental deficits. 35 Other investigators go even further: according to researcher R.A. Lawrence, an infant’s unfulfilled need to suck leads to frustration, while the satisfaction of this need is a source of enormous joy, self-gratification, well-being and reassurance. 36 The need for NNS is most intense in the first 6 months. It usually disappears at the age of 1 to 3 years. NNS is a child’s first coordinated muscular activity. In contrast to nutritive sucking, non-nutritive sucking does not require the same high demands for the coordination of sucking, swallowing and breathing.

After the first 4 to 6 months, during which the infant

From approximately the 7th month of age, sucking

satisfies its hunger and thirst at the breast or bottle,

or the intake of liquids alone is no longer absolute-

there is a transitional phase in the babyâ&#x20AC;&#x2122;s diet. The

ly necessary. Food of a solid consistency can now

digestive system has now developed to the extent

also be given because the food can increasingly be

that it can tolerate food other than only milk. Gross

chewed. The need to suck in order to soothe or relax

and fine motor skills permit increasingly more reli-

starts to decrease and from a neurophysiological

able trunk and head control. With the onset of denti-

viewpoint may be regarded as no longer relevant. At

tion, the alveolar processes grow and the facial skel-

this point, the neuromuscular structures are mature,

eton moves forward and downward, resulting in an

the oral reflexes and oral reactions are increasing-

enlargement of the actual oral cavity. The range

ly integrated and voluntary oral motor movements

of motion of the tongue begins to expand from an

are possible. From about 6 months, the digestion is

originally dominating anterior-posterior movement

mature and developed to the extent that a child is

to a more mature pattern with some vertical move-

able to digest pureed/mashed foods, and from 7 to

ment, which now helps with the feeding of pap and

8 months it is ready to be given solid food. Sucking is

mashed food. 37

then replaced by chewing. 38

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

USE OF A SOOTHER AGAINST RESTLESSNESS, PAIN AND SUDDEN INFANT DEATH SYNDROME Whatever the soother shape and size, it calms, comforts and gives children a sense of security. Most importantly, it satisfies the infant’s innate need for non-nutritive sucking. In the following chapter, we provide an overview of the various functions of the soother, whose use has been documented for over thousands of years.

SOOTHING AND FULFILLING THE NEED FOR NON-NUTRITIVE SUCKING All babies have a need to suck, but the intensity of

The prevalence of non-nutritive sucking in a soci-

that need is very individual. Parents recognise their

ety is dependent on socio-economic factors and

child’s need to suck but are often unsure whether

current parenting trends. In western industrialised

they should give their child a soother. If they decide

countries, the use of a soother is common (45 to 60%

to do so, there is a large selection of soothers avail-

of all babies have a soother), closely followed by

able and many different shapes to choose from.

thumb- and finger-sucking (15 to 30%). During the

Soothers can help calm a child, help it relax and fall

last 30 years, the soother has increasingly gained in

asleep, relieve the discomfort of teething pain and

importance, while the sucking of thumbs and fingers

comfort it during stressful situations.

has continuously decreased. In Sweden, sucking

habits changed dramatically from 1950 to 1983. Breast or bottles are frequently used as a calmative

The soother use rate grew from 10 to 70% and the

agent to soothe a crying baby or help it fall asleep.

number of thumb-suckers fell from 50 to 15%. Sooth-

The practice of using the bottle to help a child fall

er use is most frequent in children between 2 to 3

asleep should be avoided because it can lead to

months of age; however, the soother is often given

caries in early childhood.

to the child in the 1st month of life. 42

Also breastfeeding at night may promote caries when the dentition is advanced.

Many parents decide before giving birth whether they want to give their child a soother or not. The

Psychoanalytical

human

results of a study done in 2008 showed that about

behaviour is controlled by conscious and uncon-

theories

state

that

1/3 of the mothers changed their mind about

scious processes. According to Freud, during the

soother use after giving birth. Either the mothers

first stage of psychological development (the oral

offered the baby a soother and it was rejected or

phase in the first year of life), the driving force of

the mothers initially refused to use a soother but

behavior (stimulus and libido) of an individual is

decided later to use one to soothe their baby.

in the mouth. This occurs because sucking on the

The prevalence of soother use at 5 months of age

breast fulfills an infant’s nutritional need and at the

was 78%. 43

same time it experiences pleasure. The need to suck usually decreases at the end of the first year and the child moves to the next developmental stage. 41

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

A 2000 study by Nowak and Warren showed that 50% of children had stopped sucking on a soother by 28 months, 71% by 36 months and 90% by 48 months. If a child is offered a soother, the parents and care providers are able to control its use. If a child gets used to sucking on its thumb or fingers, correcting this habit is much more difficult. It is not only in paediatric dentistry that the debate continues as to how long a child naturally sucks non-nutritively and at what stage this sucking constitutes a habit. A soother habit is a pathological practice which ultimately in the event of intense use and force could have a negative effect on the development of hard and soft tissue. Most chronic-pathological habits in the oral and facial area of children are associated to a greater or lesser degree with the sucking reflex. 45 Non-nutritive sucking has several advantages: •• It is an early step towards the child’s ability to regulate its own emotions •• It helps the child relax and focus its attention •• It provides comfort and security. A child sucks more often when it is tired, bored, anxious or agitated. 46

BOTTLE-FED CHILDREN Breastfeeding requires stronger sucking and more powerful muscle movements, and the feeding episode normally lasts longer than feeding from a bottle. 47 The need for non-nutritive sucking is often greater in children who are bottle-fed. How important NNS is for bottle-fed children is suggested by a study in which all mothers who did not breastfeed confirmed that their children were calmed immediately when they were given a soother.

The sooth-

er can therefore be offered to bottle-fed infants immediately after birth. Parents should be aware that a child may be restless for various reasons. The soother must never be used to delay a feeding or even replace one. When bottle-feeding, care should also be taken to ensure the child is given sufficient time to satisfy its need for non-nutritive sucking.

THE SOOTHER AND SIDS (SUDDEN INFANT DEATH SYNDROME) SIDS (Sudden Infant Death Syndrome), the sudden

tablished. The use of a soother after the 1st month

death of a baby, is a global problem, with children

is therefore possible with no negative impact on

from the western, industrialised world much more

breastfeeding. 52

frequently affected. The causes of this puzzling phenomenon are still unclear. However, there are

The American 'National Sudden Unexpected Infant/

significant indications that a soother could provide

Child Death & Pregnancy Loss Program Support

some protection against the risk of SIDS.

Center at First Candle (PSC)' is a major US institution which educates parents and professionals about

Most professional organisations advise that babies

sudden infant death syndrome. The PSC also recom-

be offered a soother towards the end of the first

mends the use of the soother as a measure against

month. Based on current knowledge, the Ameri-

sudden infant death syndrome for various reasons:

can Academy of Pediatrics (AAP) recommends in

•• The American Academy of Pediatrics (AAP)

its guidelines that children be given a soother to

recommends the use of a soother for SIDS

help them fall asleep at night and during naptime.

prevention. 53

The soother should not be forced on the child. If the

•• The US National Institute of Child Health and

soother falls out of its mouth while sleeping, it does

Human Development (NICHD) has adopted

not need to be put back into the child’s mouth.

these recommendations. 54

In addition, it should never be dipped in a sweet liquid.49 Health care professionals recommend that breastfed infants should not be offered a soother until breastfeeding has become well-established. A 2011 overview study on the subject of breastfeeding and

•• Epidemiological studies continue to suggest that soothers provide some protection against sudden infant death syndrome. 55 •• Possible problems caused by the soother (such as breastfeeding problems, malocclusion, ear infections) can be prevented or managed. 56

SIDS concluded that breastfeeding helps reduce the risk of SIDS and should therefore be recommended. 50 In non-breastfed children, to help protect against the risk of SIDS the soother can be offered immediately after birth. In children older than one year, the soother no longer has any protective effect, as the risk of sudden infant death syndrome no longer exists. 51 Even the traditionally soother-critical “Berufsverband der schweizerischen Stillberaterinnen” IBCLC (professional association of Swiss lactation consultants) has addressed the subject of SIDS prevention and concluded that the introduction of a soother one month after birth is not a problem and its benefits (prevention of sudden infant death syndrome) outweigh any disadvantages. After one month, an infant can usually distinguish easily between sucking at the breast and the calming effects of sucking on a soother. SIDS most often occurs in the 2nd to 6th month of life and therefore at the stage in which drinking at the breast should already be well-es-

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE THEORIES ON PROTECTION AGAINST SUDDEN INFANT DEATH SYNDROME The question of why the soother lowers the risk of sudden infant death syndrome has not yet been conclusively proven. There are a number of theories: Sleeping position: The soother may discourage the child from turning to the face down (prone) position while sleeping, which has been associated with a rise of SIDS. One study shows that children with a soother turn over less frequently, but change their sleeping position more often. 57 Infant arousal during sleep: Studies on infantile waking and soother use have shown that babies with soothers have a lower auditory threshold than children without soothers. 58 It could be that babies wake up more readily when the soother falls out of their mouth while sleeping. Effects on breathing: Sucking on a soother could make it easier for babies to keep their airways open by maintaining a forward position of the tongue. The precise influence on breathing and airways has not yet been clarified, but apparently there is some positive change in the respiratory tract area. Soothers may also reduce the number and severity of apneic pauses by stimulating the respiratory airway. They may facilitate the transition from nose to mouth breathing if the nose becomes blocked or simply train the muscles that help make oral respiration easier for the child. 59 The soother may stimulate saliva production, which may have some protective effect against SIDS. 60 The soother might reduce the likelihood of gastrointestinal reflux and subsequent apnea. Perhaps mothers of infants with soothers check on their sleeping babies more frequently. They do this to check whether the child has lost its soother. 61 As the soother is usually in the babyâ&#x20AC;&#x2122;s mouth only for a short time, it is difficult to conclusively prove any one of these theories. Video recordings show that babies spend most of the night without the soother in their mouths. 62

CONCLUSION The causes of sudden infant death syndrome are still not proven. The most frequently recommended measures to protect against SIDS are sleeping in the supine position and breastfeeding the child. In addition, epidemiological studies suggest that the soother provides some protection against sudden infant death syndrome. 63 Experts therefore advise that every baby be offered a soother at bedtimes. Breastfed babies should be offered the soother after breastfeeding has become established; non-breastfed babies can be given a soother in the first days of life. If the baby loses the soother while asleep, it should not be put back in its mouth.

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE SOOTHER AND PAIN PERCEPTION Treating pain in neonates and preterm infants is essential for both clinical and ethical reasons. Pain can worsen oxygen saturation, lead to haemodynamic instability and increase intracranial pressure. In the care of preterm infants that are receiving intensive care, the practice of administering painkillers intravenously is widely accepted. However, less severely ill children often are given no analgesic when they have to undergo painful procedures. Obviously, it is not useful to treat babies with chemical painkillers in order to take a blood sample, but it is important to find better accepted methods. 64 The American Academy of Pediatrics [AAP] lists the soother as one of the key effective methods for relieving pain in children less than ÂÂ6 months of age if they have to undergo minor medical procedures. The administration of a small amount of sugar solution (2 ml) given within 2 minutes of a procedure, offered with the soother, seems to increase the analgesic effect. 65 An overview study has revealed that non-nutritive sucking even without sugar solution, for instance during the Guthrie test, reduces behavioural stress in neonates. Studies support the theory that sucrose (because of its sweet taste) and pain relief are linked to one another via the bodyâ&#x20AC;&#x2122;s endogenous opioid system, which supplies natural painkillers. The analgesic effect of sucrose is blocked by the administration of naloxone, an opioid antagonist, which suggests that the sucrose activates the central system for endogenous opioids and does so by a process similar to that which occurs with opioid analgesics.

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

In preterm infants it is reported that the administra-

A 2002 study on 138 newborns who received before

tion of sucrose in conjunction with a soother is more

a Guthrie test either sweet solutions or sweet solu-

effective than sucrose alone; this was measured

tions and then a soother produced the following

using the pain scale of the Premature Infant Pain

results:

Profile (PIPP). For pain relief, a 12.5% dextrose or sucrose solution According to researchers, it is important to empha-

followed by a soother gave a better result than the

sise that the use of 24% sucrose causes no adverse

use of dextrose or sucrose alone. Sucrose followed

effects and is a safe analgesic for preterm infants.

by a soother resulted in lower pain levels and a short-

The current standard practice in venepuncture in

er duration of crying than the use of dextrose with a

newborns is to use no analgesic at all. A 2009 study

soother. The anti-nociceptive (reduction of sensitivi-

demonstrated the ease and convenience of using

ty to painful stimuli) effect of sweet solutions can be

sucrose and/or soothers and concluded that pain

enhanced by a soother. 67

relief should be used as a matter of routine during medical procedures in the first weeks of life in prema-

The Canadian Paediatric Society supports these

ture infants. This practice is supported by appropri-

recommendations. It also recognises the pain-re-

ate recommendations in guidelines on pain relief.

lieving and calming effect of the soother during

These guidelines suggest dipping the soother in 24%

painful procedures on both full-term and preterm

sucrose solution or direct oral application on the

infants. 68

tongue using a syringe (per drop > 0.2 ml), 1 to 2 minutes before or during a painful procedure. The administration of sucrose can be repeated as needed. 66

SUMMARY The administration of a sucrose solution and a soother is a simple and safe intervention to relieve pain during invasive procedures on newborns. 69 The use of a soother was researched and recommended by the American Association of Family Physicians in the following procedures: catheterisation, circumcision, heel pricks, vaccinations, insertion of an infusion, lumbar puncture, screening for retinopathy in preterm infants and venepuncture. 70 •• The analgesic effects of sucrose, glucose and soothers on newborns can be clearly established using a behaviour-based pain rating scale •• The use of a soother alone also has an analgesic effect •• With the combination of sucrose and soothers, a synergistic effect could be established •• Sweet solutions and soothers are simple and safe measures which can be used to provide pain relief for newborns during minor procedures 71

THE SOOTHER AND MIDDLE EAR INFLAMMATION (OTITIS MEDIA) Otitis media (AOM) is a viral or

this risk. Particularly for bottle-fed

study, the number of bacteria on

bacterial infection of the middle

infants it is important that they

the soothers of children who had

ear and usually occurs second-

are held at least at a 45 degree

recently experienced an episode

ary to an infection of the upper

angle while drinking from a bottle.

of AOM was investigated. The

respiratory tract. As a result of

Tobacco smoke and severe air

authors found that their soothers

the swelling in the upper respira-

pollution are further risk factors for

did not have an increased bacte-

tory tract, the Eustachian tubes

AOM.

rial count and that the soother therefore cannot be identified as

become blocked, which prevents the draining of secretions and

Various studies have established

a significant source of bacterial

germs from the middle ear. Otitis

a link between soother use and

transmission. 78

media can occur at any age, but

AOM. There are several hypothe-

babies between 3 to 36 months

ses as to how the use of a soother

of age and children between the

could lead to AOM: the backflow

ages of four to six years are most

of nasal discharges into the middle

commonly affected. 72

ear due to sucking on the soother or a dysfunction of the Eustachian

According to current findings,

tubes due to an altered dentition

sleeping in the supine position

structure are two of these hypoth-

and breastfeeding provide some

eses. 74, 75

protection against AOM. Children who have been breastfed

It is difficult to assess wheth-

for at least 4 months are much

er soother use actually caus-

less likely to suffer from a middle

es AOM. It is possible that chil-

ear infection.

dren who frequently suffer from

inflammation

are

often

In infants and small children, the

given a soother to help with

Eustachian tubes are more flexi-

their pain or to comfort them.76, 77

ble, shorter and more horizontal

The literature identifies the sooth-

than in adults. As a result, secre-

er as a risk factor for AOM. Espe-

tions and fluids are able to seep

cially in susceptible children who

more easily into the middle ear

suffer from recurrent infections, it

and cause inflammation. Feeding

may be sensible to advise parents

in a lying position can increase

to limit soother use. In a 1997

CONCLUSION Despite numerous studies and hypotheses on the relationship between AOM and soother use, there are no conclusive findings. Soothers seem to be a risk factor, but just one of many. The risk of infection increases with the duration and frequency of soother use. Given the present state of knowledge, the recommendation that soother use be limited in babies after 6 months of age due to the increased risk of otitis media is more specifically directed toward parents whose child suffers from recurrent AOM infections. For the other children, the proven value of soothers in reducing SIDS and in enhancing the childâ&#x20AC;&#x2122;s well-being must be given greater weight when considering the use of a soother. 80

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

SOOTHERS AND ORAL HEALTH: FROM A DENTAL AND SPEECH THERAPY PERSPECTIVE On this subject, there is almost overwhelming

result of motor, sensory and/or skeletal anomalies”.

evidence and scientific studies which support the

(Cited from: Lins 2010, p. 18). A multifactorial web of

theory that non-nutritive sucking on a soother or

causality is responsible for the development of these

finger results in malocclusion and deformation of

dysfunctions. In addition to jaw and occlusal anom-

the lower jaw in the primary dentition and on a

alies that may be genetically determined, innate or

sustained basis even for the permanent dentition.

acquired, inappropriate sucking habits or incorrect

However, this is only if the sucking habit is too inten-

feeding of infants and toddlers are also responsible.

sive with regard to force and duration and is pres-

ent for too long in terms of the child’s chronological age. The potential implications of non-nutritive

Parents should be aware of the negative effects of

habits for the oral structures are thus dependent

excessive soother sucking on oral health. According

on the intensity, direction and nature of the forces

to the Academy of General Dentistry (AGD), ideally

applied. Studies show that the influence on tooth

children should stop using a soother at two years of

position during the first 3 to 4 years of life is mainly

age. At this age, anomalies in dentition or skeletal

limited to the anterior region, which produces an

development are likely to resolve themselves within

anterior open bite. If the habit is given up, further

6 months once soother use is stopped. 83

physiological development of the dentition and jaw alignment is to be expected, so that tooth place-

The pattern of facial growth and the development

ment normalises during growth. If the habit remains,

of the teeth in the tooth-bearing alveolar bones are

particularly in the case of thumb-sucking, there

determined by genetic factors and external influ-

exists an increased likelihood of a link between suck-

ences. Furthermore, muscle tone and the pressure

ing habit and crossbite (an underdeveloped upper

exerted locally by the soft tissues of the lips, cheeks

jaw which occludes incorrectly with the lower jaw

and tongue have a considerable influence on the

on one or both sides).

shape of the dental arch and on tooth position.

The tongue plays an important role, in particular Although a multitude of factors contribute to maloc-

in the shape of the palate. Sucking on soothers,

clusion and dysgnathia, it is clear that soothers can

like sucking the thumb, differs from sucking when

also cause such malpositioning. In a large propor-

breastfeeding and therefore has a different effect

tion of children with malocclusion and dysgnath-

during the growth process. However, it is believed

ia, not only is an anomaly in the area of the hard

that these effects of force on the teeth, dental arch

tissue present, but abnormalities of the orofacial soft

and upper jaw, only have significant implications if

tissue function can also be seen. Orofacial dysfunc-

they happen continuously for more than six hours a

tions are defined as “dysfunctions of the muscle

day. A shorter duration does not produce any of the

tone, muscle function and/or sequences of move-

mechanisms that would be necessary to alter the

ments in the orofacial complex, which occur as a

tooth or tissue structure. 84

A number of studies show that the use of a soother in children over the age of three has an increasingly detrimental and often no longer spontaneously regressive effect on the developing dentition. The most noticeable changes are anterior open bite, lateral crossbite and a high, narrow palate. If the soother is used beyond 5 years of age, the effects were more severe and the development of the permanent dentition can be significantly impaired. 85

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

OROFACIAL HEALTH AND THE REQUIREMENTS FOR THE SOOTHER

DURATION IS THE KEY

In cooperation with speech and myofunctional

The ability of the organism to respond to external

therapist Mathilde Furtenbach, the interdisciplin-

effects of force has its value in orthodontic treatment.

ary working group on the topic of bottle teats and

Precise and regulated applied force can lead to the

soothers at the University Paediatric Clinic in Inns-

desired corrections of malocclusion and dysgnathia.

bruck (Universitätsklinik für Pädiatrie Innsbruck) has

Proffit’s studies (1986) of orthodontic patients showed

published some recommendations in ‘Requirements

that pressure and/or mechanical forces need to oper-

for a soother’, which should be addressed at this

ate for four to six hours a day in order to cause a signif-

time. The working group’s key conclusion is: wheth-

icant effect on tooth and jaw development.

er a soother has a detrimental effect on orofacial

2010, p. 21) Just as positive force effects must persist,

muscle function and the development of the denti-

detrimental influences such as sucking habits also

tion depends on the different ways the child sucks,

exert a certain duration of movement and pressure

the properties and form of the soother, but above all

on the hard and soft tissue which could produce

on the duration of sucking (and thus depends on the

deviations from normal development. When an

parents, who decide how often and for how long

occlusal interference develops, this can have a

they let their child have the soother). (Lins 2010, p.

domino effect involving the other teeth. 89

27)

(Lins

Almost 25 years later, the statement that it is not the Among the specific criteria mentioned for soother

intensity but rather the duration of the exposure to

selection are:

pressure, is the most important factor with regard to

•• Shape of the soother: the shaft of the teat must

the effects on jaw and tooth development. 90

be as thin and long as possible, so that the incisors are not impeded in their eruption and growth of the alveolar process is not hindered •• Material: a teat that is as supple and flexible as possible •• A soother needs to be as light as possible, so that the muscles of the mouth are not unnecessarily overworked •• A soother teat with a flat, compact shape allows more tongue movement. A flat oval shape with less volumn occupies the least space in the mouth.87

CONCLUSION The positive side of these findings: if the soother is used responsibly and use is discontinued early enough, no permanent malocclusions and dysgnathia are to be expected. Soothers are used in most countries around the world and have no permanent effect on tooth position if their use is discontinued at the age of two to three years.

Given the fact that 50% of children abandon the non-nutritive

sucking habit without parental intervention by the age of 24 to 28 months, there is a spontaneous remission of any temporary deviations of occlusion. 92

EFFECTS OF THE SOOTHER ON LANGUAGE DEVELOPMENT In the field of speech-language pathology, it is

tion. With its phonation and articulation functions

evident that many parents seem to know very

together with facial expression and body language,

little about the risks of a sucking habit that extends

it is the organ of participation, interaction and

beyond infancy. Often they are told only later about

communication in the human being. If a compo-

the effects. A detailed explanation is usually given

nent within this system is impaired in its function, this

when

malocclusions

leads to compensation mechanisms being activat-

and dysgnathia have already been diagnosed.

ed, which can throw the entire system into disequi-

Frequently the soother is given without considering

librium. According to the Argentinean rehabilitation

when to use it, and instead of only being offered

doctor and researcher Dr. Rodolfo Castillo Morales,

for specific purposes of calming the child or going

the coordination of the orofacial complex is essen-

to sleep, the soother (or the thumb or other sucking

tial for correct pronunciation or articulation. 94

items) often becomes a constant companion in the

A soother, but also the thumb or other objects

childâ&#x20AC;&#x2122;s life.

that are inserted into the mouth, interferes with

orofacial

dysfunctions

physiological functions. Even where hard tissue From the perspective of the speech therapist, the

anomalies diminish after habits have been broken,

consideration about how and when to use a soother

soft tissue dysfunctions initiated by such habits

is important. The need to suck can be additionally

may persist for a longer time and thus perpetuate

satisfied by a soother but parents and care providers

a malposition which has already been produced.

should avoid a situation where a strong sucking habit

Just as an assessment is carried out by a dental

occurs through offering the soother too frequently

specialist when a dysgnathia is present, it is also

and excessively prolonged use.

The focus of the

useful to consult a speech therapist after a habit

speech pathologist is not only on the development

has been discontinued and a persistent dysfunction

of the hard tissue, but greater importance should

is suspected.

be given to the functional aspects of the soft tissue. Correct physiological development of the orofacial soft tissue calls for unimpeded nose breathing, the suspension of the lower jaw when at rest, adequate lip closure, and a tongue position oriented towards the palate. The vocal tract provides for breathing and food intake and performs a natural valve func-

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE SOOTHER IS PREFERABLE TO THE THUMB Many studies, and virtually all expert groups, conclude that the soother is preferable to the thumb. This is above all with regard to the prevention of malocclusions. In contrast to the thumb, a soother very rarely continues to be used into the phase of the transitional dentition (when the second dentition has already erupted in the front), with the teat-induced effects (malpositioning of the jaw and teeth, dysfunctions of soft tissue parts) also being far less. 95 Both the Canadian and American Dental Associations recommend that the soother be preferred to the thumb. The authors believe the soother may have a preventive effect against thumb-sucking. 96 Other studies also support this theory. Children who were offered a soother at an early stage sucked their thumbs 7 times less often than children who had never been offered a soother. 97 Another factor against the use of the thumb is that it is much harder than a soother and therefore can cause more severe changes to tooth position and deformations of the upper jaw (high, narrow palate). Often the position of the lower canines and incisors is also altered and through the pressure of the thumb or hand on the lower jaw the forward development of these teeth can also be impeded. Furthermore, breaking the thumb-sucking habit is difficult, as the thumb is constantly available. When the sucking needs to be stopped, it is therefore harder for parents and care providers to influence and control thumb-sucking. 98 The IKG (Initiative Kiefergesundheit â&#x20AC;&#x201C; healthy jaw initiative) is also of the opinion that a soother is better than a thumb because compared to a thumb, a correctly shaped soother has less impact on jaw development and is also an easier habit to break. 99

CONCLUSION If the soother is used responsibly and taken away early enough, no permanent malocclusions or negative influences on orofacial structures and speech development are to be expected. Only where an intensive soother habit is retained beyond the age of three years can it result in permanent detrimental effects on tooth positioning and jaw development. Knowledge of responsible soother use is therefore an important message for all parents.

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE SOOTHER AND PARENTS – INTERESTING FACTS FOR PARENTS Although the scientific community are now in agreement that the controlled use of a soother can have numerous benefits, many parents initially refuse to give their child a soother. Among other things, because they believe it is an object that is primarily intended to quiet the baby, or because they are afraid of malformation of the teeth or jaw. Mothers often change their originally negative attitude over time. The majority of mothers – 69% – offer their child a soother as early as the first week of life due to the need to calm their baby. 95% of those who do not do so, do it because their baby refuses the soother.

100

Parents who opt to use a soother do so primarily to meet the neonatal need for non-nutritive sucking or as an alternative to thumb-sucking. 101

HOW DO I OFFER A SOOTHER TO A CHILD FOR THE FIRST TIME? •• In the first few days, the soother should be used consciously. •• The soother should only be offered, not forced on the child. If the soother is pushed into the mouth, this may trigger a defensive reaction or the gag reflex. •• First, gently touch the corners of the mouth or the cheek to trigger the rooting reflex. •• Carefully place the soother on the lower lip and the front third of the tongue; bring the baby’s hands up to its face. The sucking reflex will be triggered. •• Because the newborn is unaccustomed to the soother, it first has to learn how to suck it. It may use its tongue to explore the soother. What may look like a rejection or pushing the soother out, is perhaps just an attempt to explore the foreign object more closely. (Source: Dr. Corinne Mathys Zulauf, certified Speech Therapist, federally certified Dentist)

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

RESPONSIBLE USE OF A SOOTHER – EXPERT RECOMMENDATIONS The most important recommendation by professionals concerning the soother is: “The soother should be used intelligently and responsibly”. 102

There are many suggestions and important recom-

It is also undisputed that the soother – particularly

mendations to be taken into consideration when

after years of intensive frequent sucking – may be

using a soother. These include:

responsible for various dental problems. Many profes-

•• Give the child the soother between feeding or

sional associations and experts have addressed the

meal times when it is not hungry; this reduces

possible disadvantages and have made recom-

any interference with normal eating times.

mendations on how the negative consequences

•• The soother may have a calming effect before the afternoon nap time or bedtime. •• Very small children may need a care provider who helps them find the soother if it falls out of their mouth. Older children are usually able to find the soother themselves. •• When a child cries or screams, it is important that you try to hold and cuddle it. Soothers should not replace the bond with the care provider. •• A soother should not be put into the baby’s mouth every time it cries. Generally, the soother serves to satisfy the need for non-nutritive sucking. When a child is agitated or stressed,

can be prevented. Some of their current recommendations can be found in the following section: •• Information on the safe and appropriate use of soothers should be an element of the routine check-ups for newborns, infants and children. •• Unless further studies produce clearer results on adverse effects, soother use should be recognised as the parents’ choice, based on the needs of their newborn, infant or child. •• The early use of a soother may be an indication of possible breastfeeding problems. •• In infants and children with chronic recurrent

it may be that additional sucking gives it

otitis media it may be favorable to limit the use

reassurance. A care provider can also provide

of a soother.

this reassurance by holding, talking, singing to or playing with the child.

103

•• The use of soothers should not be routinely discouraged, as current data suggests there can be a reduced risk of SIDS when a soother is used. •• Soothers should continue to be used in neonatal intensive care units for non-nutritive sucking and for the calming of preterm babies or sick infants. 104

•• It is recommended that the soother be replaced after the child has suffered an infectious disease. 105

CONCLUSION Based on the current status of scientific knowledge, the following recommendations can be made: Soothers can have a pain-relieving effect and may reduce the risk of sudden infant death syndrome in the first year of life. There is no clear evidence that a reasonable and planned use of a soother shortens the duration of breastfeeding. Providing a soother can prevent thumb-sucking. The soother should be washed regularly and examined for signs of wear and tear such as cracks and holes. The soother should only be offered to breastfed babies when breastfeeding has become established. Prolonged soother use (more than six hours a day) can lead to malocclusion. It is therefore important to limit soother use and to wean the child from the soother by the fourth year of age at the latest. The soother should not be dipped in sugar solutions, honey or fruit juices. This could lead to caries. 106

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

WHAT IS THE RIGHT SOOTHER SIZE? One aspect that should be addressed in the field of paediatrics is the (physical, chemical and immunological) safety of soother use. Numerous studies have described the possibility of swallowing or choking caused by small parts of the soother coming loose or by cords attached to the soother, as well as the possibility of injury to the oral mucosa or the nasal base when children fall with a soother in their mouths. It is therefore recommended that soothers be compatible in shape and size with the mouth of the child (varying depending on age: younger or older than six months). The support for the lips should be slightly concave towards the mouth and provided with holes in the shield for ventilation. The area near the base of the nose should have a curve to ensure a good lip sealing. 107 A soother should allow for the growth of the facial skeleton and be adapted accordingly. The shield should not be too small to prevent it from being placed into the mouth and swallowed. The shaft of

TIPS FOR REDUCING SOOTHER USE • Keep the soother out of sight, and from the beginning onwards give it to the child only at specific times – for instance, only to help it get to sleep.

the teat, which sits between the teeth, should exert as

• Be consistent.

little pressure as possible to prevent malocclusions in

• Avoid uncontrolled, spontaneous soother use

the front area or minimise them in the event of excessive use. The teat should be soft and flexible, with an appropriate width and a minimal shaft thickness and teat volume. In some soothers, the transition point sits inconveniently between the teeth, which can lead to an anterior open bite in the milk teeth and an open mouth position. To ensure that tooth and jaw development is not mechanically impaired and that the teeth are able to erupt unobstructed, no object should lie as a foreign object for a prolonged period between or on the teeth. The tongue, which is a very powerful muscle, is also deflected and restricted in its function by soother- and thumb-sucking. The tongue should be able to move freely; it should lie partly against the upper jaw when in the resting position and thus in its function, in interplay with the cheeks, lips and mastication muscles, supporting the natural growth processes. 108, 109

during the day. • Encourage careful dental care. Introduce adult oral activities, such as the use of a toothbrush and dental floss. • Find alternatives to the soother with which the child can soothe itself, such as its favourite toy (soft toy animal or blanket). • Limit use of the soother in the transition between the development phases. When the child starts to crawl is a good time to reduce access to the soother. • When a soother is lost or damaged, decide if it is time not to buy a new soother. • Limit duration of use and opportunities for use, e.g. only at home or bedtime. • Distraction. • Do not allow the child to speak with a soother in its mouth. • Slowly reduce soother time. The child does not have to go ‘cold turkey’. Children tend to respond positively to a gradual change. 114, 115

WHEN IS THE RIGHT TIME TO BREAK THE SOOTHER HABIT? All experts agree that parents should be informed as comprehensively as possible about the possible effects of soother-sucking. They do not necessarily agree on an exact time when children should give up their soothers. Children should stop using pacifiers by age 2, according to the American Academy of General Dentistry. “Up until the age of 2, any alignment problem with the teeth or the developing bone is usually corrected within a 6-month period after pacifier use is stopped. Prolonged pacifier use and thumb-sucking can cause problems with the proper growth of the mouth, alignment of the teeth and changes in the shape of the roof of the mouth.” (Matranga 2007, Pacifiers have negative and positive effects). In contrast, the American Dental Association, the American Academy of Paediatric Dentistry and the European Academy of Paediatric Dentistry recommend children be weaned off a soother by the fourth year of age at the latest. 110, 111, 112 For most experts, it is appropriate to give the soother from 2 months of age until the end of the second year. At the age of two to four years, it is recommended that its use be gradually reduced. Often, rigid rules are not compatible with the reality. A child’s individual stage of development, its state of health, the socio-economic background of the parents and many other personal factors must be taken into account. Sick or stressed children may still feel a profound need to suck at 5 or even 6 years old. If it is not possible to fully wean the child off the soother, it is important to at least clearly limit its use. 113

CONCLUSION From the very beginning, it is important that the baby receives a soother only when it exhibits a genuine need to suck. The soother should remain in the child’s mouth only until the need to suck has been satisfied. The child’s crying may also be an expression of a different need and it can also be comforted in other ways than soother use. Most experts consider it normal for children to have a soother from the second month of age until the end of the second year. After the second year, it is recommended that parents gradually limit the use of a soother and start the process of weaning the child from its use. Parents should be given information on the deliberate and responsible use of the soother.

TIPS TIPS FOR WEANING A CHILD OFF THE SOOTHER •• With advanced tooth eruption and with an increasingly varied diet, parents can start limiting soother use around the age of 12-18 months. •• It is best to choose a time when the child will not be affected by other stress factors, such as a journey, moving or adjusting to the birth of a sibling. •• A child should never be forced to give up its soother with threats of punishment. •• If it is proving difficult to wean the child off the soother, talking with a paediatrician may be helpful. •• Distraction such as cuddling, playing, talking etc. is sometimes useful. •• When the child gives up the soother, the care provider should support and praise it. •• When the child is ready to give up the soother, it can send the soother on a trip by balloon or boat or have a “going away” party. Parents can use their fantasy. •• Perhaps the child is willing to exchange the soother for a gift? •• Prepare the farewell with an appropriate children’s book. •• A step-by-step approach is helpful. Keep the soother always in the same place, for example in the bed, where the child can use it to satisfy its need to suck. The soother then stays in the bed, the child is not allowed to take it with it.

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

bibi® HAPPINESS SOOTHER GENERATION The bibi ® soother generation ‘Happiness’ was developed together with an interdisciplinary team of experts. Ergonomic considerations played an important role in the design of the ErgoComfort shield and teat of the bibi ® Happiness soother.

ERGONOMIC DESIGN CRITERIA In order to effectively fulfil the basic functions of a soother and reduce any known health risks, bibi ® has worked with experts to develop advanced ergonomic design criteria for shields and teats. In the resting state and during the child’s natural

In the resting state and during the child’s natural

sucking movements, the shield of the soother should:

sucking movements, the teat of the soother should:

•• Absorb the sucking forces during sucking and

•• Absorb the sucking forces and to a

distribute the remaining forces evenly over

certain extent pass them on to the shield

the outer mouth region (lips and other facial

(counterpressure on the lips).

muscles). •• Provide a support surface for the lips and allow

volume, surface friction) to transfer the tongue

the formation of a vacuum when the mouth is

movements to the soother, without pushing the

closed.

tongue aside.

•• In the resting position and during movements

•• Allow the suspension of the lower jaw when at

within the normal range of motion, not interfere

rest, with the alveolar processes or rather the

with either the nose or the chin (no pressure

teeth coming as close together as possible in

points on the chin and the nasal septum,

the resting state and during natural sucking and

allowing good range of movement of the lower

sucking movements (narrow shaft).

jaw). •• Have no exposed or protruding edges or contact

•• To a certain extent absorb the sucking and pulling forces of the tongue and the lower jaw.

surfaces, so that the soother cannot be pulled

Sufficient pressure should also be applied by

out by simple movements, such as light contact

the tongue against the alveolar processes to

within the normal range of motion of the arms.

promote natural growth of the upper jaw. 116

•• Prevent the soother from accidentally entering the child’s oesophagus. •• Have air holes, allowing the baby to continue to receive air, in the event that the soother obstructs the airway.

•• Give the tongue sufficient resistance (surface,

THE PLANNING bibi ÂŽ Happiness Natural and Dental soothers are the result of a close collaboration of speech therapists, midwives, lactation consultant and motherhood consultants, dentists, doctors and orthodontists. A large-scale survey revealed the following requirements, which have been implemented accordingly:

1. Reduced volume 2. Flatter soother teat 3. Softer and more flexible teat 4. Thinner shaft 5. A slight curvature of the shield 6. Length and width of the soother teat based on anthropometric data and thus adapted to the size of the developing mouth

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

THE IMPLEMENTATION bibi ® Happiness soothers support the oral development of newborns and infants and offer the right soother for each stage of development and age. They have been ergonomically developed so that the teat takes up a minimum amount of space in the mouth, allowing for an increased free movement of the tongue. The new symmetrical, oval shape of the Natural teat is similar to a mother’s nipple. It provides an ideal level of sucking comfort and is quickly accepted by breastfeeding newborns and babies. The proven Dental shape has been re-designed and now conforms with the latest scientific recommendations for the healthy and natural development of jaw and palate.

ERGOCOMFORT SHIELD

bibi® HAPPINESS SOOTHER TEAT

• Ergonomically adapted to the infant’s and

• Flexible for maximum sucking comfort. This is

child’s face. • Curvature and radius are balanced in such a way to eliminate any pressure points. • Secure and strong attachment of the teat for high pull resistance. • Two different shield forms– symmetrical and asymmetrical. • Improved adjustments for optimal fit to the nose and chin. • Larger ‘air flow’ holes for greater safety and more air circulation. • Improved material quality: less weight, softer feel. • SensoPearls ®: provide tactile stimulation. They have a similar effect like the Montgomery glands on the breast during lactation. They help to protect the skin by allowing a better air exchange between the shield and skin. • New knob and ring shape.

important for the healthy development of the baby’s mouth. • Less volume in the baby’s mouth, due to the optimal teat geometry which is adapted to the baby’s growing stage. • The improved teat geometry has been ergonomically developed to take up less space in the oral cavity, allowing an increased movement of the tongue. This is important because it supports the natural development of the hard tissue (palate shape, jaw growth) and the orofacial soft tissue (primary functions, speaking). • Symmetrical (Natural) and asymmetrical (Dental): both forms enable natural sucking movements. • Secure attachment edge for maximum pull resistance. • Increased wall thickness at the usual biting points. • 4 different sizes: ergonomic adaptation to the oral cavity as the baby grows. • The engraved size tattoo on the inside of the teat makes it easy to identify the soother size which helps the parents to repurchase the correct size needed.

DENTAL TEAT FORM

NATURAL TEAT FORM

• Improved and optimized dental teat form.

• Improved and optimised symmetrical teat

• Flatter and wider - less volume.

shape.

• Longer shaft: more space for jaw and teeth.

• Flatter, wider - less volume.

• Thinner shaft: minimises pressure on the teeth,

• Longer shaft: more space for the jaw and teeth.

facilitating the resting position of the lower jaw.

• Thinner shaft: minimises pressure on the teeth,

• The concave part on the lower front side of the

facilitates the resting position of the lower jaw.

teat allows additional tongue movement. • Flat asymmetrical teat supports the natural development of the palate and jaw as well as speech development.

• Eases the transition from nutritive to non-nutritive sucking. • Flat symmetrical teat with a shape that feels familiar to breastfed babies.

NEWBORN TEAT FORMS • bibi ® Newborn Natural and Dental soothers are especially suitable for the needs of newborns. • Extra small and light-weight. • Suitable for infants born up to two months before their due date. Ideal in the hospital for premature infants. • The teat forms have been ergonomically developed to take up a minimal amount of space in the mouth, allowing free movement of the tongue. This is important for the natural development of the palate and jaw and also for a natural speech development. • The shields have been ergonomically adapted to the delicate face of the newborn.

The distance between lips, chin and nose grows very rapidly in the first two months of life. Around 2 months of age, one can change to the next size of the bibi ® Happiness soother .

THE SOOTHER FROM A SCIENTIFIC PERSPECTIVE

GLOSSARY Anterior-posterior

Guthrie test

This is a positional and directional description of the

The Guthrie test is a screening test done on a drop of

anatomy. ‘Anterior’ denotes lying nearer the front,

blood taken from the heel of a neonate between the

‘posterior’ lying to the back.

4th and 7th day of life. It is part of neonate screenings and serves to aid in the early detection of congenital

Anthropometry

metabolic and hormonal diseases.

Anthropometry is the study of human body measurements especially on a comparative basis. Anthro-

Habit

pometry is used primarily in ergonomics for the design

Habit means practice, learned thing, acquired

of work equipment in the workplace, vehicles and

custom. In medicine and pharmacology, we also

other articles of daily use in order to improve comfort,

speak of habituation, referring to the progressive

health, safety and productivity.

adaptation of the human body to increasingly higher doses, for instance of stimulants. Something that it

Cavum oris proprium

does often or regularily.

Cavum oris proprium refers to the main cavity of the oral cavity (cavum oris) and denotes the space inside

Haemodynamic

the rows of teeth.

Haemodynamics describes the blood flow in the blood vessels. This is dependent on various factors,

Concave

such as the elasticity of the vessels or the composition

From the Latin concavus – hollowed out, curved

of the blood.

inwards. Denotes a curvature inwards. Intracranial Dorsal displacement

Intracranial means ‘inside the skull’. The term is used

Dorsal is a positional description and indicates that

for structures or processes that are inside the cranial

something is behind. In the case of a dorsal displace-

cavity, which is in the cavity formed by the cranial

ment, there is a shifting of a tissue towards the back.

bones.

Dysgnathia

Larynx

An abnormality that extends beyond the teeth and

The larynx forms the entrance to the trachea. It

includes the maxilla and/or mandible.

protects the trachea from food aspiration. The larynx is also involved in voice production and commonly

Endogenous

called the voice box. Through muscle tension, the

Endogenous means originating from within, existing

arytenoid cartilage in the larynx can be rotated,

within the body. The opposite of endogenous is

causing the vocal cords to tense or relax, which is

exogenous.

essential for phonation.

Eustachian tube

Lateral

The Eustachian tube, also known as the auditory tube,

Lateral is a directional description of the anatomy. It

is one of a pair of tube-like connections, about 3.5

means ‘sideways’.

centimetres long in adults, between the middle ear and the nasopharynx. An air pressure equalisation

Libido

can occur via the auditory tubes, so that the pressure

In psychoanalysis, the term libido refers to the psycho-

in the middle ear is adjusted to that in the nasopha-

logical driving force of sexuality and love. It includes

ryngeal zone and thus to the external pressure.

both the desire for sensual and physical pleasure and the need for personal affection and security.

Gastrointestinal reflux The word gastrointestinal is made up of the Latin ‘gaster’ – stomach and ‘intestinum’ – intestine, and means ‘relating to the gastrointestinal tract’. ‘Reflux’ means backflow. What is meant here is throwing up or spitting – thus, a flowing back of stomach contents into the oesophagus.

Occlusion

Somatic / visceral swallowing

Occlusion refers to the closure of a hollow organ, for

In visceral (infantile) swallowing, the tongue push-

instance, a vessel or a body passage. The occlusion

es between the rows of teeth during swallowing. By

may be caused by the body’s own tissue or delib-

the age of four at the latest, this swallowing process

erately carried out by a doctor using instruments as

should be replaced by the somatic (adult) swallowing

part of a surgical procedure (e.g. vascular clamp).

pattern. In this pattern, the tongue lies in the oral cavi-

In dentistry, any contact between the teeth of the

ty during swallowing with closed rows of teeth.

upper and lower jaws is referred to as occlusion. Stereognosis Ontogenetic

Stereognosis is the ability to recognise objects and/or

Ontogenesis or ontogeny is the origination and devel-

distinguish them from one another. Depending on the

opment of an organism. In biology, the term denotes

sensory organ involved, we speak of manual (with the

the development of the individual organism from the

hand), visual (with the eyes) or oral (with the mouth)

fertilised ovum to the mature form.

stereognosis.

Orofacial

Visceral swallowing (see Somatic swallowing)

The word orofacial is made up of the Latin ‘os’, refer-

ring to the mouth, and ‘facies’ for the face. Orofacial therefore means ‘relating to the mouth and face’. Prevalence Prevalence is a key indicator of health and pathology. It reveals how many people of a particular group are affected by a particular disease. Proprioceptors Proprioceptors are found in muscles, joints and tendons. They are jointly responsible for the perception of one’s own body in space. The proprioceptors provide information on muscle tension, muscle length, joint position and movements to the cerebellum and the cerebral cortex, where this information is processed unconsciously. Recurrence Recurrence means a relapse, which can mean the reappearance of an illness, a mental disorder or its symptoms following a treatment that was temporarily successful. Sagittal In anatomy, a sagittal plane designates a section extending from the head to the pelvis and from the back to the abdomen. The corresponding adjective is ‘sagittal’ and corresponds to the meaning ‘proceeding from front to back’.

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