The Saudi Dental Journal (2010) 22, 77–82

King Saud University

The Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

ORIGINAL ARTICLE

Attitudes of Saudi mothers towards prolonged

non-nutritive sucking habits in children
Al Johara A. Al-Hussyeen

Division of Pediatric Dentistry, Department of Preventive Dental Sciences, P.O. Box 60169, Riyadh 11545, Saudi Arabia

Received 14 April 2009; revised 26 May 2009; accepted 30 May 2009

Available online 6 February 2010

KEYWORDS Abstract Objectives: The purpose of the present study was to evaluate Saudi mothers’ attitude
Attitudes; towards non-nutritive sucking habits by their children and report the methods they used to stop
Non-nutritive sucking habits these habits.
Methods: Across-sectional study involved 181 mothers of preschool children currently engaged
in non-nutritive sucking habits (digit and pacifier) were studied. The information was obtained from
a self-administered questionnaire completed by the mothers.
Results: The majority of mothers (69.1%) were from high socio-economic families, (77%) had
university or higher education and more than half of them (58.6%) were employed. About 75%
of the children were pacifier users, and 25% of them habitually sucked their digits. Nearly half
of the mothers (43.5%) thought that the reason of acquiring the habit was because their children
cried a lot at night. The majority of studied mothers (88.7%) considered sucking a harmful habit
to their children’ teeth, and 69.1% never accepted the sucking habit. High percentage (80.8%) of
mothers tried to intervene with these habits and 61.0% of them tried their intervention when chil-
dren were one year old or less. Most proposed reasons for mothers’ intervention with sucking habits
were their concerns that the habit might continue until the child become older (53.3%) followed by
their concern that the habit might affect their children’s permanent teeth (45.3%). The methods

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1013-9052 ª 2010 King Saud University. All rights reserved. Peer-

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78 Al Johara A. Al-Hussyeen

used by mothers were mostly non-invasive procedures which included restricting the use of pacifier
to specific times in the day (63.0%), followed by reinforcement of positive behaviors and using
rewards (26.0%). None of the mothers sought advice from pediatrician while only one mother
(0.6%) consulted a dentist about sucking habits.
Conclusion: This study shows that Saudi mothers are concerned about sucking habits and recog-
nized the harmful effect on their children. These mothers, however, are in great need for education
about ways of preventing the habits in the first place as well as professional advice and help in treat-
ment cessation of already established habits.
ª 2010 King Saud University. All rights reserved.

1. Introduction
The ability of infant to swallow and suck is one of the manifes-
tation that showed the well-developed circum oral and intra
oral muscular activity of the new born child (Larsson and
Dahlin, 1985). Although many babies attempt to suck their fin-
gers or dummies occasionally, sucking can only be considered
as a habit if it has continued for several months after birth
(Larsson and Dahlin, 1985; Uwaezuoke et al., 2003). Non-
nutritive sucking habits may be acquired through the repeti-
tion actions of parents used to calm the emotional need of
the child which eventually developed a strong attachment be-
tween the child and the sucking object (Larsson and Dahlin,
1985; Uwaezuoke et al., 2003; Salah, 2007; Paredes and Pare-
des, 2005; Degan and Puppin-Rontani, 2004). Several studies
evaluated the etiological factors responsible in the initiation
of non-nutritive sucking habits and suggested some situations
that may stimulate digit sucking habits including; fatigue,
boredom, excitement, hunger, fear, physical, emotional stress
and insufficient satisfaction of sucking need in infancy (Salah,
2007; Paredes and Paredes, 2005). The proposed explanation
of acquirement of this habit is that sucking may provide hap-
piness and sense of security during difficult times to the child
(Salah, 2007; Al-Jobair and Al-Emran, 2004; Ayer and Gale,
1970; Sears and Wise, 1950; Hanna, 1967). Most dummy suck-
ers were found to have broken the habit during their earlier
years, while digit suckers continued the habit beyond five years
(Kharbanda et al., 2003). The prolonged practice of non-nutri-
tive sucking habits beyond the preschool age, have been impli-
cated as an important environmental etiological factors
associated with the development of malocclusion including in-
creased open bite, over jet and cross bite (Larsson and Dahlin,
1985; Salah, 2007; Al-Jobair and Al-Emran, 2004; Katz et al.,
2004). In addition to accidental ingestion of harmful sub-
stances and digital deformation associated with digit sucking
habit. Several studies evaluated the negative effect of sucking
habits on the social and emotional development, learning pro-
cess, and impact on the speech ability of the child (Al-Jobair
and Al-Emran, 2004; Ayer and Gale, 1970; Van Norman,
1997). Disruptive behavior and lack of interaction and com-
munication skills has also been reported as the child become
older and enrolled in the school (Salah, 2007; Al-Jobair and
Al-Emran, 2004; Van Norman, 1997; Van Norman, 2001). A
review of the literature reveals that the prevalence of sucking
habits varies from one population to another (Larsson and
Dahlin, 1985; Uwaezuoke et al., 2003; Salah, 2007; Paredes
and Paredes, 2005; Degan and Puppin-Rontani, 2004; Al-Job-
air and Al-Emran, 2004). Pacifier-sucking habits increased by
a prevalence of 75% to 79% in industrialized western countries
in recent decades (Larsson and Dahlin, 1985; Svedymr, 1979;
Zadik et al., 1977; Moore, 1996). The prevalence of both digit
and dummy sucking habits has been reported to be 48.36% in
Saudi Arabia (Farsi and Salama, 1997). Most studies concen-
trated on prevalence, adverse effects, management and factors
that were believed to influence the occurrence of sucking habits
(Larsson and Dahlin, 1985; Uwaezuoke et al., 2003; Paredes
and Paredes, 2005; Van Norman, 1997). Little concentration
has been given to investigate mothers’ attitudes toward suck-
ing habits. Mother is the person responsible for the child rear-
ing and is an important factor in elimination of this habit. It is
assumed that attitudes towards sucking habits vary from one
population to another according to the deference in culture,
beliefs and awareness, as well as socio-economic status. The
aims of this study were to investigate the attitude of the Saudi
mothers toward sucking habits and their attempts to eliminate
this behavior in their children.
2. Subjects and methods
The research protocol was approved by College of Dentistry
Research Center, King Saud University and Ministry of Edu-
cation, Saudi Arabia. It involved cross sectional study con-
ducted in 8 kindergartens which were randomly selected to
represent different academic zones in Riyadh City. Data of
the present study were collected as part of another investiga-
tion assessing the prevalence of non-nutritive sucking habits,
contributing factors and effect on deciduous dentition. One
hundred and eighty-one Saudi mothers of preschool children
(age range from 3 to 6 years old) with non-nutritive sucking
habits participated in this study by completing a questionnaire.
Before the start of the study and to insure the clarity of ques-
tionnaire items, it was pretested and appropriate modifications
were made accordingly. The self-administered Arabic ques-
tionnaire included questions about the child’s age, sex, sucking
habits (digit or pacifier), mother’s education, occupation, fam-
ily socio-economic status, mother’s attitude towards the habit,
views why her child acquired the habit, mother’s attempts to
break the sucking habits, the reason for her intervention and
whether she had sought medical or dental advice. Socio-eco-
nomic status of the family was estimated by father’s occupa-
tion. It was divided into three groups: professionals (doctors,
dentists) and businessmen as high socio-economic status, gov-
ernmental (military, technical workers) as middle socio-eco-
nomic status, and manual (tradesmen, farmers) and unskilled
(itinerant workers, unemployed) as low socio-economic status
(Al-Shammary et al., 1991). The data were collected, entered
the computer and analyzed using the Statistical Package for
the Social Sciences (SPSS version 13) program. Frequency dis-
tribution was used for descriptive analysis. Chi-square test was
Attitudes of Saudi mothers towards prolongednon-nutritive sucking habits in children 79

utilized to evaluate differences between the variables. The sig- ways available for them and only 10.1% of mothers thought
nificant level was set at 0.05. that this habit occurred because her child was hungry.
About half of mothers (47%) described their children’ per-
3. Results sonalities as easily irritable, 29.3% calm, 21.5% normal and
only 2.2% were introverted.
Tables 1 and 2 showed that the majority of mothers (69.1%) in The majority of studied mothers (88.7%) considered suck-
this study were from families of high socio-economic status ing a harmful habit, while 69.1% never accepted the habit,
(77%) were university graduates or higher education and more 26.5% accepted the habit until the child become 2–3 years
than half of them (58.6%) were employed. High percentage of old and 4.4% found it acceptable until the age of 4 years.
children (46.4%) was 5 years old and about 56% of them were High percentage (80.8%) of mothers tried to intervene with
girls. Among the children with non-nutritive sucking habits, the sucking habits, and 61.0% of them tried their intervention
135 (74.6%) were pacifier users, and 46 (25.4%) habitually when their children were one year or less, 35.5% when their
sucked their digits. children were between 2 and 3 years old, and very few
Table 3 presents the reasons of acquiring sucking habits in (3.5%) tried when children were 4 years or older.
mothers’ opinion. About half the mothers (43.5%) thought Table 4 presents mothers’ reasons to intervene with the
that the reason of acquiring the habit was because their chil- sucking habits. High proportion of mothers (53.3%) were
dren always cried at night, 27.6% because pacifiers were al- afraid that the habit might continue until the child become old-
er, followed by 45.3% of mothers were afraid that it might af-
fect their children’s permanent teeth, and 4.1% of mothers
mention different other reasons such as effect on speech,
Table 1 Descriptive distribution of the mothers involved in
throat problems, microbial transmission, or afraid that other
the present study (N = 181).*
kids might make fun of their children.
Variables Number Percentage Table 5 shows the different methods used by mothers to
Level of education break the sucking habits among their children. More than half
High school or less 41.0 23.0 of mothers (63.0%) tried to interrupt the use of pacifier by
University or higher education 137 77.0 changing the used brand or restricted its use to specific times
Employment status in the day, followed by reinforcement of positive behaviors
Employed 106 58.6 and use of reward and encouragement (26.0%). Results also
Unemployed 75 41.4 indicated that none of the mothers consulted their children’s
pediatrician and only one mother (0.6%) sought dentist advice
Socio-economic status\
who suggested the use of motivational methods.
High 125 69.1
Medium 48 26.5 Although all mothers had tried one or more of the methods
Low 8 4.4 mentioned in Table 5, high percentage of mothers reported
*
Some mothers did not answer all questions.

Table 4 Mothers’ reasons to intervene with their children’

sucking habits.*
Table 2 Age and gender distribution of children practicing Reasons Number Percentage
the non-nutritive sucking habits (N = 181). Habit might continue until the 97 53.3
Variables Number Percentage child become older
Habit might affect child’s permanent teeth 82 45.3
Child’s age in year
Habit might affect child’s primary teeth 70 38.7
3 20 11.1 Habit might affect child’s appetite 44 24.3
4 59 32.6
Others 7 4.1
5 84 46.4
*
6 18 9.9 Some mothers selected more than one answer.

Gender
Boys 80 44.2
Girls 101 55.8
Table 5 Techniques used by mothers to stop the non-nutritive
sucking habits in their children.*
Techniques Number Percentage
Table 3 Mothers’ opinions about reasons for having the Interrupting the use of pacifier 114 63.0
sucking habits.* Reinforcement (reward) 47 26.0
Wrapping the hand or tape application 22 12.2
Reasons Number Percentage
to the digit
Crying a lot at night 74 43.5 Placing unpleasant flavor substances 14 7.7
Pacifier is always available to him 47 27.6 on the pacifier or digit
Misses mother or close relative 32 18.8 Seeking dentist advice 1 0.6
Being hungry 17 10.1 Seeking pediatric advice 0 0
* *
Some mothers did not answer all questions. Some mothers selected more than one answer.
80 Al Johara A. Al-Hussyeen

Table 6 Association between mothers’ education, employment, socio- economic status and their attitudes towards the non-nutritive
sucking habits (N = 181).
Variable Economic status Employment status Education level
High Medium Low Employed Unemployed High school University or higher
N = 125% N = 48% N = 8% N = 106% N = 75% or less N = 41% education N = 137%
Sucking habit is harmful to child’s teeth
Yes 91.1 83.3 85.7 86.7 91.9 87.5 89.1
No 8.9 16.7 14.3 13.3 8.1 12.5 10.9
Habit acceptance
Never 66.1 56.2 57.2 69.8 68.0 73.2* 68.6
Until 2 years of age 29.0 33.3 28.5 25.5 28.0 17.0 29.2
Until 4 years of age 6.5 10.4 14.3 4.7 4.0 9.8 2.2
Mothers’ attempt to intervene
Tried 93.5 97.9 85.7 81.6 79.7 77.5 82.2
Did not try 6.5 2.1 14.3 18.4 20.3 22.5 17.8
Child’s age when 1st tried to intervene
One year or less 62.1 56.3 66.7 58.3 61.0 61.3 58.6
2–3 years old 33.4 37.4 33.3 38.1 28.8 29.1 36.0
4 years or older 3.5 4.3 0 3.6 10.2 9.6 5.4
Seeking pediatric advice – – – – – – –
Seeking dentist advice 0.6 – – 0.6 – – 0.6
*
P < 0.05 using chi-square test.

that the used methods had only small effect on eliminating the
pacifier-sucking habit in their children, while no effect hap-
pened in the children with digit habit.
Association between mothers’ attitude towards non-nutri-
tive sucking habits and some variables such as mothers’ level
of educational, occupational and economic status is presented
in Table 6. A high proportion of mothers recognized the harm-
ful effect of non-nutritive sucking habits, but no significant
relationships were found between mother’s recognition of the
harmful effect of the sucking habits and their education,
employment, or economic status. A significant statistical dif-
ference was found in the relationship between mother’s educa-
tional level and her acceptance to the sucking habits. Seventy-
three percent of mothers with high school or less were found to
be more concerned about the habit than the more highly edu-
cated mothers (P = 0.045). No significant difference, however,
was detected between mothers in different economic or occu-
pational status and their acceptance to the sucking habits.
High percentage of mothers tried to stop the habit, but no
statistical significant differences was found between mother’s
attempts and studied variables i.e., educational levels, employ-
ment and economic status.
Most mothers started their attempts to break the sucking
habits when their children were one year or less. No relation-
ship, however, was found between child’s age when habits
intervention was first tried and mothers’ educational levels,
employment and economic status.
None of the studied mothers had attempted to consult a
pediatrician about sucking habits, while only one employed
mother who had university or higher education and belong
to high family economic status sought dental advice.
4. Discussion
Review of the literature revealed that the prevalence of sucking
habits is affected by child rearing practices and that it range
vary in different populations (Johnson and Larson, 1993; Cur-
zon, 1974; Traisman and Traisman, 1958). The same studies
showed that parents usually introduce the pacifier to their chil-
dren early in infancy mostly to calm them and keep them
asleep at night.
The present study showed that more than three quarter of
the children were pacifier users and this is in agreement with
the aforementioned studies. Half of the mothers in the present
study thought that crying at night was the most important
reason for acquiring non-nutritive sucking habits. This
finding is in agreement with Bowden and Orth (1966) and Pau-
nio et al. (1993) who stated that parents often rely on pacifiers
to calm their children, and not to provide an extra suction
experience.
The current study results indicated that 69% of mothers
never tolerated the non-nutritive sucking habits and none of
them accepted the habit after the age of four. These findings
are in agreement with previous studies which indicated that
sucking habit was a normal behavior until the age of four (Sal-
ah, 2007; Al-Jobair and Al-Emran, 2004; Van Norman, 1997).
In the present study, the proportion of mothers who did not
accept the sucking habits among their children was higher than
that reported by Al-Jobair and Al-Emran (2004) in Saudi Ara-
bia. This difference might be attributed to the difference in the
socio-demographic characteristics between the two samples.
Interestingly, results indicated a highly significant relationship
between mothers’ acceptance of sucking habits and their level
of education, more proportion of mothers with high school or
less reported that they never tolerated the sucking habits com-
pared to those with higher education. This finding is in contra-
diction with the findings of other studies (Salah, 2007; Al-
Jobair and Al-Emran, 2004) who found no association be-
tween mothers’ level of education and their acceptance of the
sucking habits. Possibly mothers with high school education
or less spend more time with their children because they are
not engaged with activities outside their homes.
Attitudes of Saudi mothers towards prolongednon-nutritive sucking habits in children
The harmful effect of non-nutritive sucking habits to the
child’s dentition was recognized by the majority of mothers
(88.7%) in this study. This is comparable with Al-Jobair and
Al-Emran (2004) findings and higher than that reported by
Salah (2007) and Vadiakas et al. (1998). This finding suggested
that mothers noticed the adverse effects of prolonged sucking
habits on their children’s teeth. Numerous studies documented
the occurrence of malocclusion with the development of open-
bite, increased overjet and posterior cross bite in deciduous
dentition (Vadiakas et al., 1998; Charchut et al., 2003; Viggi-
ano et al., 2004). Studies also documented that occlusal dys-
functions can have severe implications on children’s general
health as well as self steam (O’Brien et al., 2007; Petersen,
2003).
About 80% of mothers had tried to break the sucking hab-
its and about 60% of them started their attempts when their
children were one year old or less. This finding is comparable
to that reported by Salah (2007) and, Al-Jobair and Al-Emran
(2004) and higher than Vadiakas et al. (1998) findings who re-
ported that only 71% of mothers in their sample had tried to
break the habit.
The methods used by mothers in the present study to break
the sucking habits were mostly non-invasive procedures which
included interruption the use of pacifier (63%) by changing the
brand or restricted its use to specific times per day followed by
reinforcement of positive behavior and rewarding the child
(26%). This was followed by wrapping the hand or tape appli-
cation to the digit, or by placing unpleasant flavor substances
on pacifier or digit.
Using non-invasive procedures to break sucking habits has
been reported in previous studies (Salah, 2007; Degan and Pup-
pin-Rontani, 2004; Al-Jobair and Al-Emran, 2004; Vadiakas
et al., 1998). Mothers in the present study, however, reported
little success in the elimination of pacifier habits and absolutely
no effect on the digit habit by using their attempted methods.
This finding is in agreement with above mentioned studies
who reported little effectiveness of using these methods in com-
parison to professional intervention. A surprising finding in this
study is to find that counseling medical or dental professional
was not popular at all among the study sample. This contra-
dicts with previous studies (Salah, 2007; Degan and Puppin-
Rontani, 2004; Al-Jobair and Al-Emran, 2004; Vadiakas
et al., 1998). Degan and Puppin-Rontani (2004) reported that
professionals’ explanations to the children with non-nutritive
sucking habits achieved the best result in eliminating the habit
among their study sample. The children in the present study
were 3–6 years old who visited the well-child clinics several
times for physical check up and routine vaccination. In addi-
tion, it is assumed that by this age, they must visit their dentist
for checkup or dental treatment. This indicates that both den-
tists and pediatrician were not providing mothers with the nec-
essary information about the sucking habits nor offering help in
treatment techniques. This finding necessitates the need for
health education. The medical and dental experts must include
investigation about non-nutritive sucking habits in their exam-
ination charts and provide mothers with information about
dental and psychological deleterious effect of the habit to their
children as well as treatment cessation techniques. In addition,
realizing the important role that mothers play in families, they
determine many behaviors that children may develop in their
future. Education on the prevention of oral diseases including
oral habits should be provided to the pregnant women to insure
81
better oral health status for children. Literature reveals that
during pregnancy, women are more ready to receive and accept
information and assume responsibilities (Rothwell et al., 1987;
Gomez and Weber, 2001).
This study shows that the Saudi mothers are concerned
about sucking habits and recognized the harmful effect on
their children; they are in great need for education about ways
of preventing the habits in the first place as well as professional
advice and help in treatment cessation of already established
habits.
5. Conclusions
 In mothers’ opinion, children’s crying at night was the most
proposed reason for acquiring sucking habits.
 High proportion of studied mothers were aware of the
harmful effect of non-nutritive sucking habits on their chil-
dren’ teeth and had attempted to break it early in their chil-
dren’s lives.
 The methods that had been tried among mothers to stop the
habit mostly were non-invasive procedures.
 Consulting medical or dental professionals about sucking
habit was not popular way among the study sample.
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