ELSEVIER Early Human Development 47 (1997) 1-9

Neonatal sucking behaviour and its development

until 14 months

Kazuko Iwayamaa’*, Mariko Eishimab

aChikushi Jogakuen Junior College, 2-12-I Ishizaka, Dazaifu City, Fukuoka 818-01, Japan
bSt. Mary’s Hospital, Fukuoka, Japan

Received 20 December 1995; revised 22 February 1996; accepted 12 April 1996

Abstract

A fiberscopesupportedby a holder, devised by one of the authors, was used to film neonatal
sucking behaviour and its development from birth to 14 months of life. The subjects were 57
low-risk full term infants. Present observations detect a developmental course of the sucking
behaviour. The main changes are: (a) the bell shape produced by the peristaltic tongue
movements is quite high in the neonatal period, decreasesin height considerably during the
third month and almost disappearsby the tenth month of life. (b) The depth of the cavity
produced by the peristaltic tongue movementsincreasesfrom the third month until the eighth
month and decreasesafter this time. (c) The wrapping by the root of the tongue at the tip of the
nipple gradually weakensduring the first month and almost disappearsaround the sixth month
of life. (d) The neonatal pattern disappearsand the pattern for older infants appears in one
sucking episode in the same infant during the second and third month after birth. There are
individual differences in the period of actual change but it usually appearsduring the third
month.

Keywords: Sucking behaviour; Developmental change; Newborn infant; Fourteen-month

infant; Low-risk full term infant; Audio-visual aids

1. Introduction

The main purpose of this research was to observe and analyze the neonatal sucking
behaviour in natural conditions and its development, using a fiberscope with a

*Corresponding author.

037%3782/97/$17.00 Copyright 0 1997 Elsevier Science Ireland Ltd. All rights reserved
PIZ SO378-3782(96)01750-I
2 K. Iwayama, M. Eishima I Early Human Development 47 (1997) l-9

modification of previously reported technique [ 131.The results of the present study

might be helpful in understanding the characteristics of sucking in infants and may
provide data for better understanding of the underlying neural mechanisms.
A major developmental change was found during the second and third months of
life. To find the reasonswhy the change occurs in this period, we need more research
comparing full term infants and preterm infants.

2. Subjects and methods

2.1. Subjects

Fifty-seven full term infants (29 boys and 28 girls) were selected. They were
followed longitudinally until 14 months of life. The number of infants decreasedat
each age for various reasons:the moving of families of the subjects to other towns;
the inconvenience for parents of bringing their babies to the place where the filming
was carried out; health conditions of the subjectsand so on. The numbers of subjects
were 44 at the first month, 26 at the second month, 24 at the third month, 23 at the
sixth month, 18 at the eighth month, 15 at the tenth month and 12 at the fourteenth
month of life.
Selection criteria for subjects were the same as for the previous study [13] except
for feeding types. An almost equal number of breast-fed and bottle-fed infants were
selected.
The recording was carried out on the fifth day and at the beginning of the first,
second, third, sixth, eighth, tenth, and fourteenth month of life. It was carried out
before the usual nursing time when the baby was awake and seemedhungry.

2.2. Techniques of Jilming

The sucking movements inside the mouth were filmed using a fiberscope (hard
type, 4 mm in diameter) supportedby a holder made from a nursing bottle. A hole is
punctured in the bottom of the bottle. A rubber plug prevents this hole from leaking
when the bottle is filled with liquid. A cylinder is inserted into the bottle and fixed to
the opening of the bottle. There are three holes in the bottom of the cylinder. One is
for the fiberscope and the other two are for water and air. The fiberscope is fixed at
two points. One point is fixed by the rubber plug at the bottom of the bottle, and the
other point is fixed to a hole in the bottom of the cylinder. The fiberscope is then
inserted into the holes. Thus, the same focal point can be maintained. This nursing
bottle is made from opaque materials, so that infants cannot seethe fiberscopeinside
the bottle and for an infant it is similar to a common nursing bottle. The fiberscopeis
connected to a video deck. The bottle, nipple, frame, cylinder, plug and fiberscope
can be dismantled and sterilized easily.
Two types of nipple were used. One was the round type (12 mm in diameter) made
from hard silicone rubber with a small hole at the tip. The other was a flat type (15
mm in width) made from soft rubber with a small hole. The hole sizes of both nipples
 K. Iwayama, M. Eishima I Early Human Development 47 (1997) l-9 3

were almost the same.Water dripped at a rate of about 4 min per 10 ml (from 100 ml
to 90 ml) from the hole when the bottle was inverted. All infants were given 5%
sucrose in water at the same temperature as a usual feed.
Ethical permission for the research was granted by the appropriate hospital
con.un&&e and the parents of dte R&@&S gave their consent after having been
informed Af the purpose and the me&r& of the study.

3. Results

Figs. 1-14.

3.1. Lips

When a nipple touches a part of the lips, the lips open as a reaction and the inside
surface adheresto the base of the nipple. Fifty-one out of 57 infants (89.5%) in the
neonatal period and 39 out of 44 infants (88.6%) in the first month showed this
pattern.
As development progresses,infants open their mouths, not as a reaction to the
touching of the lips by the nipple, but mainly when they want to suck. Twenty out of
26 infants (76.9%) in the second month and most infants after the third month
showed this opening of the mouth before sucking.

3.2. The tip of the tongue

Before an infant starts to suck, the tongue protrudes beyond the lower gum and
then protrudes and retracts repeatedly, trying to draw the nipple into the mouth.
Forty-five out of 57 infants (78.9%) in the neonatal period showed these movements.
After the first month, the movements vary between individuals.

3.3. The front part of the tongue

When the infant starts to suck, the front part of the tongue pushes down strongly.
Thirty-nine out of 57 infants (68.4%) showed this motion in the neonatal period.
After the first month, this is no longer evident.

3.4. The root of the tongue

In the case of a round nipple, the root of the tongue comes up and wraps around
the tip of the nipple (Fig. 2). During the neonatal period the root of the tongue
worked well in 40 out of 57 infants (70.2%). However, this pattern gradually
weakened during the first month and almost disappearedaround the sixth month of
life (Fig. 8).
In the caseof a flat nipple made from soft rubber, the situation is different. The tip
4 K. Iwayama, M. Eishima I Early Human Development 47 (1997) l-9

Developmental changes of the sucking patterns

2 nd month 6 th month

I I Photo 1 / Photo 3

I I Photo 2 Photo 4 Photo 6 / Photo 8 1

t T t
t I 1 I
Similar patterns Similar patterns
Fig. 1. The under side of the nipple is pushedup to the palate during the peristaltic tongue movements.
Fig. 2. The tongue is pulled down during the peristaltic tongue movements.We cannot see the throat
becausethe root of the tongue comes up to the palate.
Pig. 3. The tongue shows a similar pattern for neonates.Note the time code appearson the upper part of
the photos. The third number from the left shows the seconds.These times show that the same infant
changed the way of sucking after 4 s during the same sucking series.
Fig. 4. The tongue shows a similar pattern for neonates.Note the time code appearson the upper part of
the photos. The third number from the left shows the seconds.These times show that the same infant
changed the way of sucking after 4 s during the same sucking series.
Fig. 5. The tongue shows a similar pattern for older infants. Note the time code appearson the upper part
of the photos. The third number from the left shows the seconds.These times show that the same infant
changed the way of sucking after 4 s during the same sucking series.
Fig. 6. The tongue showsa similar pattern for older infants. Note the time code appearson the upper part
of the photos. The third number from the left shows the seconds.These times show that the same infant
changed the way of sucking after 4 s during the same sucking series.
Note the time code appears on the upper part of the photos. The third number from the Left shows the
seconds.These times show that the same infant changed the way of sucking after 4 secondsduring the
same sucking series.
Photo 3. 05:03:55:00
Photo 4. 05:03&5:16
Photo 5. 05:03:59:09
Photo 6. 05:03:59:22
Fig. 7. The per%altic tongue movements are becoming weak.
Fig. 8. The tongue is pulled down more widely than during the neonatal period. We can see the throat
becausethe root of the tongue does not come up to the palate.

of the nipple collapses when the tongue pushesit up to the hard palate. The shapeof
the root of the tongue at the tip of the nipple differs according to the shape and
material of the nipple, but the tongue takes the samerole to fill in the spaceat the tip
 K. lwayama, M. Eishima / Early Human Development 47 (19971 l-9

Photo 10 Photo 12 Photo 14

Fig. 9. When the tongue comes up, the tongue is flat.
Fig. 10. When the tongue is pulled down, the tongue makes a U- or V-shape.
Fig. 11. The sucking movements show up-and-down movements like biting.
Fig. 12. The mouth does not open wide.
Fig. 13. The mouth shows open-and-shutmotions and the tongue does not move.
Fig. 14. The lips adhere firmly to the nipple.

of the nipple. In this way the tongue makes it easier to produce negative pressure
inside the mouth.

3.5 The central line of the tongue

During the first few months of life, the tongue movementsare not up and down nor
are they forward and backward movementsof the whole tongue in one cycle. The tip
of the tongue stays in the flat position and does not come up to squeeze the nipple.
Peristaltic tongue movements occur along the central line of the tongue (Fig. 1 and
Fig. 2). The bell shapeof the tongue along the central line moves from the front part
to the root, changing the points of pushing up (Fig. l), and the cavity of the tongue
then moves from the root to the front part changing the points of pulling down (Fig.
2).
The bell shapeof the tongue during the peristaltic movements is characteristic for
younger infants. The peristaltic tongue movements were seen during the neonatal
period in all infants (lOO%), during the first month in 43 out of 44 infants (97.7%)
and during the second month in 25 out of 26 infants (96.2%). The amplitude of the
bell shape becomes lower from the third month of life onwards (Figs. 7, 9) and
almost disappearsaround the 10th month of life (Figs. 11, 13).
The amplitude of the cavity deepensfrom the thiid month until the eighth month
(Figs. 8, 10). Twenty-three out of 24 infants (95.8%) in the third month, 22 out of 23
infants (95.7%) in the sixth month and 13 out of 18 infants (72.2%) in the eighth
month showed deep cavity movements.These gradually weaken thereafter (Figs. 12.
14).
6 K. Iwayama, M. Eishima I Early Human Development 47 (1997) 1-9

The tongue movementsthen changeto a motion similar to that when an adult sucks
from a straw, that is without moving the tongue (Fig. 13 and Fig. 14). Individual
differences are found in the timing of changes in the sucking patterns.

3.6. Movements of the jaw and cheeks

When the lower jaw pulls down, the cheeks are pulled inwards and when the lower
jaw comes up, the cheeks return to a flat position. These movements get wider and
more powerful from the third month through the eighth month after birth. After this,
they become weaker. Twenty out of 23 infants (87.0%) in the sixth month showed
very powerful jaw movements.

3.7. Coexistence of two sucking patterns

During the second and third months of life, two patterns appear in the same
episodeof sucking. One is the neonatal pattern with peristaltic movements(Fig. 3 and
Fig. 4) and the other is the pattern of older infants with up and down movements
without peristaltic tongue movementsand without the root of the tongue coming up to
the tip of the nipple (Fig. 5 and Fig. 6). One burst shows the neonatal pattern (Fig. 3
and Fig. 4) and the next burst shows the pattern for older infants (Fig. 5 and Fig. 6).
This happens in the transformation period of the sucking pattern. This phenomenon
may occur for a very short period only. However, it was successfully recorded on
video in five out of 26 (19.2%) infants in the second month and three out of 24
infants (12.5%) in the third month.

4. Discussion

Many studies have been carried out on the analysis of sucking such as on the
relationship with swallowing and breathing 161,heart.rate [ 1l], [20], sucking rhythm
[15], sucking pressure [19], [22], milk intake [7] and wakefulness [lS].
Oral performance was analysed by Ardran et al. [l], [2] by X-ray cinefilms.
However, the hazards of X-rays have restricted the use of this technique. The
technique of ultrasound has now been introduced in this researchfield [5], [28], [30].
It is useful for taking pictures of the movements inside the mouth from several
angles, during breast-feeding or bottle-feeding. However, a probe may disturb
sucking, especially in older infants. The instrument may feel strange to them and
sucking may be influenced as a result. During observations it is important to maintain
normal conditions within the usual feeding situation. In the present study, a natural
situation very similar to that of the usual feeding situation was maintained with the
help of the new technique.
Human infants can discriminate between water and sweet tastes [3], [9] or the fat
content of milk [23] even a few days after birth Many of the differences in sucking
movementscould be attributed to the amount of liquid delivery from the nipple 141,
1131,[21]. Infants showed very successful sucking patterns when using nipples with
 K. hayama, M. Eishima / Early Human Development 47 (1997) I-9 :

small holes, and the same infants showed very poor and irregular movements when
using nipples with large holes [13]. Christensen et al. [8] found that the sucking
movements differ according to the diameter of the nipple. Gunther [14] reported on
the adaptation of infants to different shapesof maternal nipple. Thus, infants show
very adaptable movements for several conditions.
The observations in the present study show that the sucking behaviou is very
complex even during the neonatal period. de Vries et al. [lo] reported that movements
of the young fetus appear to be specific and recognizable patterns, rather than
uncoordinated and random. The neurological mechanism in newborn and young
infants may be more adaptable and complicated than was previously believed.
As for developmental changes in oral performance, Harris [16] stated that the
characteristic pattern of neonatal sucking differs from the more mature sueking
action. The former combines both positive pressure (expression) and negative
pressure(suction) components,whereas the latter is almost entirely a function of the
ability to generatenegative pressureor suction. DiVitto and Goldberg [ 121found that,
with increasing age, infants spend more time sucking and less time pausing.
Someresearchersdid not consider the differences in sucking among the subjectsin
relation to the months after birth. For instance, Smith et al. 1281stated that most of
the infants appearedto rely less on undulant tongue motion and more on up and duwn
piston-like movements of the mandible, tongue and hyoid. According to the present
study, undulant motion of the tongue works well in the neonatal period but weakens
with age. In older infants the vacuum related to the enlarged oral cavity is more
powerful than in the neonatal period. The subjectsin Smith’s study [28] were infants
aged 60-120 days. The sucking patterns of their subjects were similar to those of the
older infants in the present study.
Concerning the period of the developmental change, Kron et al. [ 171reported that
changes in sucking behaviour were found between the second and third day of life.
The results of Pollitt et al. [24] show that nutritive sucking efficiency changes and
improves in the first month of life. Prechtl [26], [27] found a period of major
transformation of several motor and sensory functions to be occurring at the end of
the second and beginning of the third month of life. The present data add a new
aspect to his description, namely the change in sucking pattern which also occurs at
this age range.
The infants in the present study were carefully selectedfor neurological [25] and
obstetrical optimality as well as suitable socioeconomic background [29], so the
common patterns among these subjects showed better oral performance. These
samples will be used as ideal models.
Further research can be carried out comparing these samples with the sucking of
preterm infants or infants who have sucking problems.

5. Addendum

Video films recorded by the present method with an English narration are available
for those who are interested in the sucking behaviour.
8 K. Iwayama, M. Eishima I Early Human Development 47 (1997) 1-9

Acknowledgments

The authors wish to express their gratitude to Dr Heinz Prechtl, Dr Christa

Einspieler, Dr Yunosuke Ogawa, Dr Martin Richards, Dr Bert Touwen, Dr Ursula
Haberfellner, Dr Juhichiro Naito, Dr Akiyuki Ogawa, Dr Sadariki Shirataki and Dr
Yukuo Konishi for their valuable comments. Thanks are also due to Dr David
Harvey, Dr Deborah Rosenblatt, Dr Takeo Hashimoto, Head of Midwifery, Yumiko
Kihara and the staff of their Hospitals. Special thanks are due to the parents and
babies whose help and cooperation made this research possible.

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