Rev Súde Públic 2013;47(1) Originl Articles Lisine Mrtins d Silveir I Leil Suer Prde I Aneline Mri Ruedell II Influence of brestfeeding on children's orl skills Léris Slete Bonfnti Heffner III Angel Regin Mciel Weinmnn III ABSTRACT OBJECTIVE: The objective of this study ws to investigte the influence of orl hbits nd brestfeeding on the orl skills of children. METHODS: Cross-sectionl study evluted the orl skills of 125 nine-monthold-children born t term, belonging to Mcro-Midwest region of Rio Grnde do Sul between August 2010 nd Mrch 2011. Vribles included evluting orl skills nd informtion on brestfeeding nd wening. The results were nlyzed using simple nd multiple logistic regression. RESULTS: Brestfeeding positively influenced the cquisition of orl skills sucking t nine months of ge (OR 3.1, 95%CI 1.2;8.3) nd using pcifier hd negtive effect (OR 0.1, 95%CI 0.03;0.6). CONCLUSIONS: It ws found tht brestfeeding contributed to mture orofcil s it improved the bility of orl suction. Pcifier use ws shown to ffect the functioning of the stomtognthic system. This should be mde cler to prents nd the use of pcifiers during infncy should be voided. DESCRIPTORS: Infnt. Brest Feeding. Sucking Behvior. Pcifiers, dverse effects. Mouth, growth & development. Stomtognthic System, growth & development. Cross-Sectionl Studies. I Progrm de Pós-Grdução dos Distúrbios d Comunicção Humn. Curso de Fonoudiologi. Universidde Federl de Snt Mri. Snt Mri, RS, Brsil II Curso de Fisioterpi. Centro de Ciêncis Biológics e d Súde. Universidde Estdul do Oeste do Prná. Cscvel, PR, Brsil III Deprtmento de Peditri e Puericultur. Curso de Medicin. Universidde Federl de Snt Mri. Snt Mri, RS, Brsil Correspondence: Lisine Mrtins d Silveir Centro de Ciêncis d Súde, Deprtmento de Peditri e Puericultur Av. Rorim, 1000 Prédio 26 Sl 1319 Cmpus d UFSM Cmobi 97105-900 Snt Mri, RS, Brsil E-mil: slisine@hotmil.com Received: 2/3/2012 Approved: 7/23/2012 Article vilble from: www.scielo.br/rsp
Influence of brestfeeding nd skills in children Silveir LM et l INTRODUCTION Developing dequte orl skills, defined s motor orl response during feeding, is fundmentl to the child. 18 Problems in moving the structures of functions of the stomtognthic system during brest feeding or when other food is offered my compromise not only development of the child s orl motor skills but lso hve serious repercussions on child nutrition. 2,17 Brestfeeding is the focus of studies of multi-professionl interest for their nutritionl nd immunologicl vlue nd for stimulting physicl contct between mother nd child, which contributes to the child s biopsychosocil development. 1,4 The intense musculr ctivity it provides promotes crniofcil development. This promotes proper lip closure in repose, stimultes physiologicl correction of mndibulr retrognthi nd correctly positions the tongue in the pltl region of the centrl incisors. 5 These benefits explin why mothers re recommended to brestfeed exclusively during the first six months of life. 6,19 After this period, it becomes necessry to grdully introduce complementry foods in order to meet the child s nutritionl needs. 12,17 Complementry foods should be given using spoon, glss or cup for purees nd liquids respectively. 3,16,17 At first, the child will use sucking motion with the cup, s it hs grown used to doing previously but, s use is encourged by the prents, the child will begin to cquire the bility to sip liquids. It msters the use of this utensil round the ge of nine months. 3,14 It is expected tht children will cquire the bility to use spoon round eight months, when they should be cpble of removing food from it with their two lips. 16 Although the onset of chewing movements occurs t round six months, the bility to chew with mndibulr rottion nd lterliztion of the tongue is observed from 7-8 months. 14 During its first yer of life, the child is exposed to other utensils in ddition to cups nd spoons which do not hve nutritive function, such s pcifiers nd teething rings. Helthy bbies show the need to suck, which my be stisfied in nutritive (brest or bottle feeding) nd non-nutritive form (pcifiers nd thumb sucking). s re usully given to the child to llevite symptoms relted to teething, which begins t round six months. 15 Frequent expressions of the teething stge re irritbility, incresed dribbling, fever, dirrhe, reduced ppetite, sleeping less, incresed thumb nd finger sucking nd frequently plcing the hnd to the mouth nd chewing on objects, mong others. 8,15 No studies on children s orl skills nd relted fctors were found in the literture. The im of this study ws to ssess the influence orl hbits (pcifiers, teething rings nd other objects) nd brestfeeding hd on children s orl skills. METHODS This ws trnsversl study with 125 nine-month-old children in the centrl region of the stte of Rio Grnde do Sul, Southern Brzil, between August 2010 nd Mrch 2011. The children were selected from public nd privte child cre fcilities nd helth cre centers Children born t full term, helthy nd ged between eight months nd one dy nd nine months nd 29 dys were included in the study. Neurologicl disorders, crniofcil deformities, genetic syndromes nd sensory disorders (visul nd uditory) were criteri for exclusion. The convenience smple hd 90% confidence level, with sttisticl power of 80%, reltive risk of 1.5 for the rtio of exposed/not exposed 1.1. The vribles for the study were obtined from the children s records (weight, length nd gesttionl ge t birth, Apgr score nd current weight), from questionnire completed by the prents or gurdins (with informtion on: brestfeeding, complementry feeding nd orl hbits (pcifiers, teething rings or other objects) nd from tool to ssess orl skills. The tool used, which relibility nd concept hd been previously vlidted, consisted of 11 items, in which orl skills were ssessed during sucking (t the brest or the bottle), when using cup, using spoon nd when chewing solid foods. Ech item hd score of 0, 1 or 2 ccording to whether the skill ws bsent, occsionlly present or consistently present respectively (Tble 01). The mximum score for sucking ws 6, for using cup, 8, for using spoon, 2 nd for chewing, 6. Scores of 5-6 for sucking, 7-8 for using cup, 2 for using spoon nd 5-6 for chewing were considered to be dequte orl skills. The tool ws dministered by speech therpist, with trining nd experience in the re of child orl motricity. The child s typicl food ws given to them by fmily member, using their own utensils. Simple nd multiple logistic regression nlysis ws crried out in order to nlyze the contribution of brestfeeding nd orl hbits (independent vribles) for the presence of dequte orl skills (dependent vrible). Vrible with p < 0.20 in the simple nlysis were included in the finl model. P < 0.05 ws considered to be sttisticlly significnt difference. The dt were inputted into Excel nd nlyzed using Stt 10 softwre. Silveir LM. Hbiliddes oris em crinçs: vlidção de instrumento e influênci dos hábitos oris e do leitmento mterno [dissertção de mestrdo]. Snt Mri: Centro de Ciêncis d Súde d Universidde Federl de Snt Mri; 2011.
Rev Súde Públic 2013;47(1) Tble 1. Protocol ssessing orl skills in children ged eight to ten months. Snt Mri, Southern Brzil, 2011. Orl skills in children Skill during sucking t the brest/bottle Score 1. Movement rising nd lowering the tongue nd jw 2. Lbil closure during nutritive sucking 3. No lek during nutritive sucking Skills using cup Score 4. Antero-posterior movement of the tongue when using the cup 5. Movement of the mndible when using the cup 6. Sipping liquid 7. No spilling when using the cup Skill t tking food from the spoon Score 8. Both lips used to tke food from the spoon Skills t chewing 9. Movement rising nd lowering the tongue 10. Sidewys movement of the tongue nd jw Score 11. Rottionl movements of the jw The study ws pproved by Universidde Federl de Snt Mri Ethicl Reserch Committee (Report nº 01550243.000-09). Prents greed to tke prt nd signed consent forms. RESULTS Of the children who took prt, 43.2% were boys nd 56.8% girls. They hd men ge of nine months (stndrd devition sd: 0.8) nd weighed 8,910 (sd: 1,697) grms. As regrds their orl hbits: 64.0% used pcifier, 66.4% teething ring nd 62.4% hd n orl hbit with some other object. Of the children, 54.4% were brestfeeding, 60.8% used cup (men strting ge four months), 100% used spoon (men strting ge five months) nd solid food ws included in the diets of 96% (men strting ge six months). Adequte orl skills were observed in 82.4% of the children for sucking, 8.8% for using cup, 65% for using spoon nd 80.8% for chewing. Adequte orl skills for sucking were observed in 89.7% of the children who were brestfed nd in 95.5% of those who did not pcifier, with sttisticlly significnt difference when compred with those who were not brestfed nd those who used pcifier (Tble 2). Brestfeeding ment tht the child s chnce of hving dequte orl skills for sucking incresed by 3.1 times (OR = 3.1; 95%CI 1.2;8.3) in the simple logistic nlysis. Using pcifier ws negtively ssocited (p < 0.01), decresing the chnce of developing this skill dequtely (OR = 0.1; 95%CI 0.03;0.6). The orl hbit of introducing other objects into the mouth ws shown to be positively ssocited (p < 0.02) with using cup in the simple regression nlysis, incresing the chnce of the child demonstrting dequte orl skills by 6.6 times (OR = 6.6; 95%CI 1.3; 33.5) (Tble 3). Tble 2. Adequte orl skills for sucking (score 5 or 6) t nine months, ccording to the vribles: brestfeeding nd orl hbits. Snt Mri, Southern Brzil, 2011. Vrible Adequte orl skills for sucking Brestfeeding 125 Absent 57 42 73.7 1 Present 68 61 89.7 3.1 1.2;8.3 0.02 Orl hbits Pcifier 125 Absent 45 43 95.5 1 Present 80 60 75 0.1 0.03;0.6 0.01 Absent 42 35 83.3 1 Present 83 68 81.9 0.9 0.3;2.4 0.84 Absent 47 42 89.4 1 Present 78 61 78.2 0.4 0.14;1.24 0.12 p < 0,05 two proportions test
Influence of brestfeeding nd skills in children Silveir LM et l Tble 3. Adequte orl skills for using cup (score seven or eight) ged nine months, ccording to the vribles: brestfeeding nd orl hbits. Snt Mri, Southern Brzil, 2011. Vrible Adequte orl skills for using cup Brestfeeding 125 Absent 57 6 10.5 1 Present 68 5 7.3 0.9 0.24;3.72 0.94 Orl hbits 125 Pcifier Absent 45 5 11.1 1 Present 80 6 7.5 1.4 0.37;5.75 0.59 Absent 42 1 2.3 1 Present 83 10 12 2.6 0.67;10.51 0.16 Absent 47 6 12.7 1 Present 78 5 6.4 6.6 1.31;33.5 0.02 p < 0.05 two proportions test Tble 4. Adequte orl bility for using spoon (score 2) t nine months, ccording to vribles: brestfeeding nd orl hbits. Snt Mri, Southern Brzil, 2011. Vrible Score 2 Brestfeeding 124 Absent 57 37 64.9 1 0.63;2.92 0.42 Present 67 48 71.6 1.36 Orl hbits 124 Pcifier Absent 45 29 64.4 1 0.61;2.93 0.45 Present 79 56 70.9 1.34 Absent 42 32 76.2 1 0.24;1.32 0.19 Present 82 53 64.6 0.57 Absent 47 35 74.5 1 0.28;1.4 0.26 Present 78 50 64.1 0.6 p < 0,05 two proportions test Adequte orl skills for using spoon nd for chewing were not ssocited with brestfeeding or orl hbits (Tbles 4 nd 5). The results of the finl model of the multiple logistic regression nlysis re shown in tble 5. For sucking, using pcifier is the only vrible which is included in the finl model (p < 0.04), i.e. using pcifier is negtively ssocited with orl skills for sucking. For using cup, the orl hbit of putting other objects in the mouth (p < 0.02) ws positively ssocited (OR = 6.71; 95%CI 1.29;34.84) (Tble 06). DISCUSSION Brestfeeding contributed positively to the development of orl skills for sucking, wheres using pcifier negtively influenced these skills. The hbit of putting objects in the mouth encourged orl skills for using cup. Developing dequte orl skills in child, in ddition to the nutritionl spect being importnt, lso plys n importnt prt in cquiring speech. Eting hbits, s well s other common hbits developed during childhood, my ffect the development of the stomtognthic system. 7 Brestfeeding is primordil, s the intense
Rev Súde Públic 2013;47(1) Tble 5. Adequte orl skills for chewing (score 5 or 6) t nine months, ccording to the vribles: brestfeeding nd orl hbits. Snt Mri, Southern Brzil, 2011. Vrible Score 5-6 Brestfeeding 124 Absent 57 46 80.7 1 0.37;36.2 0.26 Present 67 55 82 3.6 Orl hbits 124 Pcifier Absent 45 37 82.2 1 0.35;2.38 0.86 Present 79 64 81 0.9 Absent 42 34 81 1 0.4;2.72 0.91 Present 82 67 81.7 1.0 Absent 47 40 85.1 1 0.25;1.76 0.41 Present 77 61 79.2 0.66 p < 0,05 two proportions test Tble 6. Multiple logistic regression model including independent vribles which were significnt in the simple nlysis (p < 0.20), in reltion to dequte orl skills. Snt Mri, Southern Brzil, 2011. Adequte orl skills Vrible Sucking Cup OR 95%CI p OR 95%CI p Brestfeeding 1.93 0.67;5.53 0.2 - - - Orl hbits Pcifier 0.19 0.04;0.96 0.04 - - - - - - 2.79 0.67;11.54 0.15 0.49 0.16;1.40 0.2 6.82 1.33;34.88 0.02 musculr ctivity involved promotes dequte growth nd crniofcil mturtion. 5,9,10,13 In this study, higher percentge of dequte orl skills were observed in the group of children who hd been brestfed. In contrst, other orl hbits frequently developed in childhood, especilly in the first yer, cn compromise the child s motor-orl development nd their brething pttern nd hve negtive effect on the development of orl skills. This is the cse with the pcifier, use of which during the first yer my cuse chnges in the movement of the periorl muscles, minly the tongue, ltering its position in repose. 7 Pcifiers my lso be responsible for erly wening nd contribute to the introduction of the bottle, which is ssocited with lower number of sucks thn the brest. This leds to less work for the periorl musculture, which compromises the motor-orl development of the fce. 1 The influence of the pcifier on the stomtognthic system, especilly on the orl skill of sucking, ws observed in this study. The hbit of using pcifier increses the risk of compromising the orl skill of sucking. Using cup nd chewing skills were evluted in reltion to brestfeeding nd the presence of orl hbits. The guidnce given to prents is tht cups should be introduced from round six months, t the strt of wening, initilly to give wter or fruit juice. b When the child first strts to use cup it trnsfers the hbit of sucking to this new utensil. 14 When the liquid reches the mouth, the child tries to stbilize the jw, sticking out the tongue, before swllowing. 18 At round nine months the child begins to hve the bility to complete sequence of up to three sips, move the cup wy nd interrupt the flow of liquid, in order to brethe. In this study the cup ws introduced, on verge, t four months nd 8.8% of the children demonstrted dequte orl skills during its b Ministério d Súde, Secretri de Polítics de Súde, Coordenção Gerl d Polític de Alimentção e Nutrição. Gui limentr pr crinçs menores de dois nos. Brsíli (DF); 2002. (Série A. Norms e Mnuis Técnicos, 107).
Influence of brestfeeding nd skills in children Silveir LM et l use. A similr result, showing less efficiency using the cup, ws observed in children ged between six nd nine months, compred to group ged between 10 nd 12 months. 3 The orl hbit of putting other objects in the mouth positively influenced, i.e., contributed to, dequte orl skills when using cup. Bringing the hnds to the mouth, for exmple, is present from the intr-uterine stge. Between the 17 th nd 20 th week of pregnncy the fetus cn be observed mking hnd to fce movements nd t round the 28 th nd 31 st weeks more complex movements of finger sucking occur, lthough coordintion only occurs t round the 34 th or 35 th week. 11 At four months, when orl reflexes re inhibited, the child begins to put objects into its mouth, seeking to explore the orl cvity better. 11 From six months, when teething strts, the tendency for the child to introduce objects nd teething rings into the mouth cn be observed. It is common for prents to give such objects with the im of relieving the child s nxiety nd irritbility. 15 These fctors, nd the orl hbits which they led to my eventully positively ffect the cquisition of the orl skills necessry for their use. However, the findings of this study clerly show the need to clrify nd disseminte to prents nd crers the importnce of introducing cup use into the child s feeding routine. All of the children used spoon nd the mjority were being fed solid food. These results re in greement with Ministry of Helth recommendtions b tht complementry food should begin to be introduced from the ge of six months. Although the children ssessed were using the spoon, 35% did not demonstrte dequte skills in its use. Although brestfeeding is considered essentil for good development of orofcil structures nd functions, the multiple logistic regression nlysis showed tht the hbit of using pcifier ws vrible ssocited (lbeit negtively) with developing dequte orl skills for suction. This finding reinforces the ide tht pcifiers lter the function of the stomtognthic system, signifying tht this should be explined to prents long with the recommendtion they not be used. At nine months, children do not hve dequte orl skills to use cups, even though this period of emotionl development corresponds to the orl stge, in which the hbit of putting objects in the mouth is common. However, the presence of these hbits contribute to developing the orl skill of using the cup. Fmilies need to encourge their use more when strting to wen. REFERENCES 1. Albuquerque SSL, Durte RC, Cvlcnti AL, Beltrão EM. A influênci do pdrão de leitmento no desenvolvimento de hábitos de sucção não nutritivos n primeir infânci. Cienc Sude Coletiv. 2010;15(2):371-8. DOI:10.1590/S1413-81232010000200012 2. Alves CRJ, Tudell E. Comportmento motor orl: bses ntômics e fisiológics pr intervenção. Tems Desenvolv. 2001;10(56):34-40. 3. Alves MC, Arújo VC, Guedes ZCF. Hbiliddes n utilizção dos utensílios copo e cnudo por lctentes de 6 12 meses de idde. Fono Atul. 2005;8(33):4-10. 4. Antunes LS, Antunes LAA, Corvino MPF, Mi LC. Ammentção nturl como fonte de prevenção em súde. Cienc Sude Coletiv. 2008;13(1):103-9. DOI:10.1590/S1413-81232008000100015 5. Crrscoz KC, Possobon RF, Tomit LM, Mores ABB. Conseqüêncis do uso d mmdeir pr o desenvolvimento orofcil em crinçs inicilmente mmentds o peito. J Peditr (Rio J). 2006;82(5):395-7. DOI:10.1590/S0021-75572006000600015 6. Csgrnde L, Ferreir FV, Hhn D, Unfer DT, Prtzel JR. Aleitmento nturl e rtificil e o desenvolvimento do sistem estomtognático. Rev Fc Odontol Porto Alegre. 2008;49(2):11-7. 7. Cstilho SD, Roch MAM. Uso de chupet: históri e visão multidisciplinr. J Peditr (Rio J). 2009;85(6):480-9. DOI:10.1590/S0021-75572009000600003 8. Frco Junior IM, Del Duc FF, Ros FM, Poletto VC. Conhecimentos e conduts de médicos peditrs com relção à erupção dentári. Rev Pul Peditr. 2008;26(3):258-64. DOI:10.1590/S0103-05822008000300010 9. Gomes CF, Trezz EMC, Murde ECM, Pdovni, CR. Avlição eletromiográfic com eletrodos de cptção de superfície dos músculos msseter, temporl e bucindor de lctentes em situção de leitmento nturl e rtificil. J Peditr (Rio J.). 2006;82(2):103-9. DOI:10.2223/JPED.1456 10. Leite-Cvlcnti A, Medeiros-Bezerr PK, Mour C. Aleitmento nturl, leitmento rtficil, hábitos de sucção e mloclusões em pré-escolres brsileiros. Rev Slud Public. 2007;9(2)194-204. DOI:10.1590/S0124-00642007000200004 11. Medeiros AMC. A existênci de sistem sensório-motor integrdo em recém-nscidos humnos. Psicologi USP. 2007;18(2):11-33. DOI:10.1590/S0103-65642007000200002 12. Modesto SP, Devincenzi MU, Sigulem DM. Prátics limentres e estdo nutricionl de crinçs no segundo semestre de vid tendids n rede públic de súde. Rev Nutr. 2007;20(4):405-15. DOI:10.1590/S1415-52732007000400008 13. Neiv FCB, Cttoni DM, Rmos JLA, Issler H. Desmme precoce: implicções pr o desenvolvimento motor- orl. J Peditr (Rio J.). 2003;79(1):7-12. DOI:10.1590/S0021-75572003000100004
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