PEDIATRIC DENTISTRY V 34 / NO 2 MAR / APR 12

Scientific Article
A Longitudinal Study of the Association Between Breast-feeding and Harmful Oral Habits
Suzely Adas Saliba Moimaz, DDS, PhD1 • Orlando Saliba, PhD2 • Luiz Fernando Lolli, MS, DDS, PhD3 • Cléa Adas Saliba Garbin, DDS, PhD4 •

Artênio José Ísper Garbin, DDS, PhD5 • Nemre Adas Saliba, DDS, PhD6

Abstract: Purpose: The purpose of this paper was to study the pattern of breast-feeding and harmful sucking habits (pacifier- and thumb-sucking) from
birth to 12-months-old. Methods: A prospective cohort study with 80 newborn infants and their mothers was conducted. A semi-structured questionnaire
on breast-feeding and pacifier- and thumb-sucking behavior was administered during monthly household visits. Data were analyzed using the chi-square
test. Results: Exclusive breast-feeding occurred in 50% of infants from birth while 69% of participants were completely weaned by 12-months-old.
Pacifier-sucking was more prevalent than thumb-sucking and was maintained at a higher rate than thumb-sucking throughout the study. The incidence
of thumb-sucking was highest between the third and sixth month of life. There was a significant association between a low rate of breast-feeding and
pacifier-sucking at the 12-month visit (chi-square=5.29; P<.05). Thumb-sucking did not significantly correlate with breast-feeding behavior. Conclusion:
The rate of exclusive breast-feeding was lower than that recommended by the World Health Organization. More than half the infants had a pacifier-
and /or thumb-sucking habit during the study, and the incidence of breast-feeding was lower in those who used a pacifier. (Pediatr Dent 2012;34:117-21)
Received June 3, 2010 | Last Revision September 4, 2010 | Accepted September 12, 2010

KEYWORDS: ORAL HABITS, BREAST-FEEDING, PACIFIER USE, THUMB-SUCKING

The economical, ecological, and psychological advantages of
breast-feeding, which include reduction of child mortality, pro-
viding healthy nutrition, and development of the immune sys-
tem, are globally accepted.1 In addition, breast-feeding has been
shown to promote the health of the stomatognathic system, al-
lowing the establishment of nasal breathing and the prevention
of the development of detrimental habits, which contributes to
the normal development of the craniofacial complex. 1,2 For
these advantages, the World Health Organization (WHO) 4
recommends exclusive breast-feeding until 6-months-old, with
supplementary breast-feeding for the first 2 or more years of life.
Some studies have indicated the importance of sucking
during breast-feeding in the promotion of the proper develop-
ment of the oral cavity and its annexes. Mobility, strength,
posture, and the development of breathing, chewing, swallow-
ing, and phonetics, in addition to a reduction in non-nutritive
sucking habits, have been attributed to breast-feeding.5-7 Oral
behaviors can be classified into normal and harmful habits.
Normal behavior, like breast-feeding, contributes to the estab-
lishment of normal occlusion and favors facial growth while
harmful sucking habits may be a risk factor in the development
of oral and dental anomalies.8-10
Of all sucking habits, pacifier-sucking is most common
among children.11,12 Pacifier use has been shown to be associa-
ted with a decrease in sucking behavior at the mother’s breast.13
It is also likely that the variety of pacifier nipples leads to infant
Drs.1Moimaz, 2O. Saliba, and 6N. Saliba are full professors and Drs. 4C. Garbin and 5A.
Garbin are associate professors, all in the Department of Pediatric and Social Dentistry
Universidade Estadual Paulista, Aracatuba, São Paulo, Brazil; 3Dr. Lolli is a professor
in the Faculdade Ingá and Universidade Estadual de Maringá, Maringá, Paraná, Brazil.
Correspond with Dr. Lolli at profdrluizfernando@gmail.com
confusion, and is ultimately detrimental to the breast-feeding
process.14 Prior studies investigating the association between
sucking habits and breast-feeding have mostly used a cross-
sectional approach with few studies using a longitudinal design.
The purpose of the present study was to describe, based on
questionnaires administered over a 12-month period, the pat-
tern of breast-feeding and potentially harmful sucking habits
(pacifier- and thumb-sucking) of newborn babies and to inves-
tigate a possible association between these factors.
Methods
The present study was a prospective cohort study conducted
with 80 infants between 0 and 12- months-old, residing in São
Paulo State, Brazil. This study was approved by the Committee
of Ethics in Human Research of the Faculty of Dentistry of
Araçatuba, Universidade Estadual Paulista Júlio de Mesquita
Filho (UNESP), São Paulo State University, Aracatuba, São
Paulo, Brazil.
A total of 120 pregnant women from a government health
center were contacted. Women who provided informed consent
(n=80) were included in the study, while 40 women chose not
to participate. Recruitment of participants, monitoring, and
data collection occurred between July 2007 and November 2008.
A previously validated, semi-structured questionnaire on
type of feeding (bottle vs breast) and thumb- and pacifier-
sucking habits was used to collect data. In addition, maternal
and family characteristics were recorded, including age, marital
status, education, employment, type of delivery, family income,
and presence of previous children.
After birth, monthly home visits were conducted for the
first 6 months, followed by an additional visit at 12 months post
birth. There were not many monthly visits from the sixth to the
twelfth month following birth, because most mothers returned

BRE AST-FEEDING AND HARMFUL ORAL HABITS 117

PEDIATRIC DENTISTRY V 34 / NO 2 MAR / APR 12

to work and children were enrolled in day care centers, Table 1. MATERNAL AND FAMILY CHARACTERISTICS OF INFANTS DURING A 1-YEAR PERIOD IN
making the access more difficult. During the initial THE NORTHWESTERN REGION OF THE STATE OF SÃO PAULO, BRAZIL, IN 2009 (N=80)
home visit, mothers answered questions pertaining to
Maternal and n Pacifier-sucking Thumb-sucking
maternal and family variables. During the initial visit family profile
and all subsequent visits, data on infant feeding behavior Fourth Fifth 12th Fourth Fifth 12th
  month month month month month month
were collected. Feeding behavior was recorded accord-
ing to WHO criteria. Exclusive breast-feeding was re- Gestational age (years)              
corded in cases where the infant consumed only breast ≤20 16 6 9 6 8 8 3
>20 64 30 30 28 26 13 9
milk; predominant breast-feeding was recorded in cases
where breast milk was the primary nutrition with the Marital status
Resides with partner 63 29 29 29 30 23 10
addition of other liquids; supplementary breast-feeding
Does not reside 17 7 10 5 4 6 2
was recorded for infants who consumed solid foods in with partner
addition to breast milk; and finally, artificial feeding Family income (month)
was recorded for infants who were completely weaned < $258 19 8 9 6 3 7 3
from the breast. $258-$516 32 13 16 13 14 10 8
At all visits, each mother was asked to report on > $516 29 15 14 15 17 12 1
the thumb-sucking and/or pacifier-sucking habits of Education (years)
her infant. All data were collected by a single researcher. 0-8 25 14 13 12 5 9 2
The data were entered into spreadsheets. A nonpara- 8-11 49 20 26 19 27 17 9
> 11 6 1 0 3 2 3 1
metric chi-square test with a 5% significance level was
used to assess the association between breast-feeding Maternal employment
patterns and thumb-/pacifier-sucking. An addition Works 41 17 20 15 23 15 4
Does not work 39 19 19 19 11 14 8
analysis was carried out to assess the relationship be-
Delivery type
tween the presence of sucking habits and maternal and
Vaginal 54 23 25 23 25 17 7
family variables. For statistical purposes, breast-feeding Cesarean 26 13 14 11 9 12 5
behavior was categorized as either maternal breast-
No. of children
feeding (exclusive, predominant, or complementary
0 37 15 18 15 12 13 4
breast-feeding) or artificial feeding (the absence of breast ≥1 43 26 21 19 22 16 8
milk). Statistical analyses were made with Bioestat 5.0
software.15

Results
Maternal variables and family living conditions of participants
are shown in Table 1. There was a predominance of women over
20-years-old (n=64) living with a partner (n=63) and having an
average family income of $700 ($387 US dollars) per month
(n=32). Most mothers (n=41) had a job to help support
their families. Most women attended school for a period of
8 to 11 years (n=49), time enough to finish the 8-year basic
cycle in Brazil (at the time of collecting the data). Only 6
women had completed high school. There was a predominance
of natural labor, and most women had already been mothers.
Figure 1 shows the pattern of breast-feeding and
nonbreast-feeding sucking behavior of infants over the study’s
12-month period. Only 50% of infants were breast-fed ex-
clusively for the first month, and none were exclusively breast-
fed at 6-months-old. In general, as time went by, there was a
decrease in the ‘exclusive’ and ‘predominant’ breast-feeding
forms. The “complementary” breast-feeding way registered a
peak between the third and sixth month. Different from the
‘exclusive’ and ‘predominant’ breast-feeding, the ‘artificial’
option became more common as time went by.
Figure 2 shows that more than half of the infants surveyed
(65%) used a pacifier, sucked their thumb, or did both at some
point during the study. Pacifier-sucking (~28%) was slightly
more common than thumb-sucking (~21%). Besides being
more common, pacifier-sucking lasted longer, whereas thumb-
sucking showed prevalence between the third and sixth
month. Although not shown on Figure 2, just 1 child showed
concomitantly thumb- and pacifier-sucking during the study
period.
Table 2 shows that there was a significantly higher inci-
dence of pacifier sucking in infants who did not breast-feed vs
infants who were breast-fed, regardless of how often (exclusive,
predominant, and complementary were grouped together) at
12-months-old (chi-square=5.29; P<.05). More specifically,
from the 34 children on pacifiers, 29 were being artificially
nursed  and only 5 were breast-fed. Although not statistical-
ly significant at earlier time points, this trend was observed
throughout the course of the study. By contrast, thumb-sucking
was not significantly associated with breast-feeding behavior
(Table 3).
Discussion
Most study participants were over 20-years-old (80%) and
living with a partner (married or living with boyfriend/fiancé)
(80%). The average family income was approximately $700
($388 US dollars) per month. Over half of the participants
(54%) had other children, and approximately 50% worked
outside the home. Most births were vaginal (~68%). Prevalence
of thumb- and pacifier-sucking was not significantly associated
with any demographic variables. These results agree with Kron-
borg and Vaeth,16 who also found no association between
pacifier-sucking habits and social and demographic variables.
Moimaz et al.,17 however, found that both thumb- and pacifier-
sucking habits were associated with a mother’s marital status.
Specifically, the presence of parents was positively associated
with a higher prevalence of sucking habits. Furthermore, an-
other study18 discovered an association between pacifier-sucking
and teenage mothers, mothers with lower educational levels,

118 BRE AST-FEEDING AND HARMFUL ORAL HABITS

 PEDIATRIC DENTISTRY V 34 / NO 2 MAR / APR 12

Table 2. ASSOCIATION OF THE PREVALENCE OF PACIFIER-SUCKING AND BREAST-FEEDING BEHAVIOR DURING THE
FIRST YEAR OF LIFE AMONG INFANTS FROM THE NORTHWESTERN REGION OF THE STATE OF SÃO PAULO,
BRAZIL, 2009 (CHI-SQUARE=5,29; P<.05)*
Breast-feeding pattern Pacifier-sucking
1 month
st
2 month
nd
3 month
rd
4th month 5th month 6th month 12th month
n % n % n % n % n % n % n %

Maternal Exclusive 10 13 7 8 5 6 1 1 0 0 0 0 0 0
breast-feeding Predominant 6 7 14 16 18 23 14 16 18 23 0 0 0 0
Complementary 7 8 3 4 4 4 8 8 5 4 12 16 5 4
Artificial feeding 1 1 6 7 8 10 13 14 16 20 23 28 29* 34

* Chi-square=5.29; P<.05).

lower income, and residents in public housing, while the op-
posite was observed for thumb-sucking behavior.
The feeding habits of the 80 infants followed in the pre-
sent study did not adhere to the WHO recommendation4 in
that only 50% of infants were breast-fed exclusively for the first
month, and none were exclusively breast-fed at 6-months-old.
Moreover, at 12-months-old, 69% of the infants studied had
been completely weaned from the breast (Figure 1). In a study
conducted in the northwestern region of the state of São Paulo,
Brazil,19 a slightly higher prevalence of exclusive breast-feeding
was recorded (~76% at 6-months-old and 22% at 12-months-
old). A survey conducted in Iran20 found a breast-feeding rate
of over 90% during the first year of life, while exclusive breast-
feeding during the first month was low (44%). In the United
States, approximately 73% of mothers begin breast-feeding
in the immediate postpartum period, but only approximately
39% continue for the first 6 months and 20% continue breast-
feeding for the first year.21
A study of 94 developing countries22 found that the average
prevalence of exclusive breast-feeding in infants younger than
6-months-old was 39% and the rate of the absence of breast-
feeding was approximately 6%. These findings suggest that,
despite the known benefits of breast-feeding, there is a low
prevalence of the practice, especially of exclusive breast-feeding,
in several regions of the world.
More than half the infants surveyed (65%) used a pacifier,
sucked their thumb, or did both at some point during the
study. Pacifier-sucking (~28%) was slightly more common than
thumb-sucking (~21%). In addition, pacifier-sucking was more
constant through the analysis period. The thumb-sucking habit
was most frequent between the third and sixth months of life
(Figure 2). These findings agree with Mendes et al., 23 who
found thumb-sucking to be less common (~10%) than the use
of a pacifier (53%).
Pacifier use is widespread due to the known calming and
comforting effects on infants. 24 Prior studies have shown an
association between pacifier use and early weaning. Cause and
effect of this relationship, however, has not been established. 25
One hypothesis for the relationship between pacifier use and
early weaning is that the introduction of a pacifier can lead to
breast-feeding difficulties for the mother.25 In addition, pacifier
use has been discouraged due to potentially harmful effects on
the teeth and speech, such as occlusal modifications and harm-
ful alterations in breathing, chewing, swallowing, and speaking
functions.26
The American Academy of Pediatrics highlights the pros
and cons of using pacifiers. Among the positive has been the
calming effect of this enhancement and the contribution to sud-
den death syndrome reduction in infants. Drawbacks include
interference with breast-feeding, increased risk of colds that
children develop because pacifiers touch another objects, and
dental malocclusion induction.27
A recent review in the databases shows that professional
opinions about the use of pacifiers are controversial. These
opinions depend on factors that professionals, including psy-
chologists, dentists, speech pathologists, pediatricians, and in-
fectious disease experts, focus on. Dentists, for example, typically
give more attention to the impact of pacifier-sucking on teeth.
Psychologists and pediatricians, on the other hand, often con-
sider pacifier use as a soothing panacea.28
The present longitudinal study not only collected data on
the prevalence of sucking habits, but also chronologically fol-
lowed the adoption, maintenance, and removal of these habits
throughout the first year of life. Interestingly, we found that
when the pacifier was introduced during the first month of life
(n=24), the habit was partiality maintained throughout the
study period (n=6). In other words, only 25% of infants who
were given a pacifier during the first month of life still used a
pacifier at 12-months-old. When the pacifier was introduced
during the third month of life (the most common time for its
introduction), however, this habit was maintained until the
end of the study period. The acquisition of thumb-sucking was
greatest between the second and fourth month of life. Unlike
pacifier-sucking, however, there was a decrease in the prevalence
of the habit from the fourth month of life onward. Further-
more, none of the infants who started thumb-sucking during
the first month maintained the habit for the entire study pe-
riod. In this study, only 19 infants used a pacifier and sucked
their thumb.
There was a significantly higher incidence of pacifier-
sucking among 12-month-old infants who did vs did not
breast-feed, regardless of breast-feeding frequency (exclusive,
predominant, and complementary were grouped together;
chi-square=5.29; P<.05). Although not statistically significant
at earlier time points, this trend was observed throughout the
course of the study (Table 2). By contrast, thumb-sucking was
not significantly associated with breast-feeding behavior (Table
3). Our longitudinal results on sucking behavior and breast-
feeding agree with previous cross-sectional studies. One prior
study 17 found a negative correlation between breast-feeding

BRE AST-FEEDING AND HARMFUL ORAL HABITS 119

PEDIATRIC DENTISTRY V 34 / NO 2 MAR / APR 12

Table 3. ASSOCIATION OF THE PREVALENCE OF THUMB-SUCKING AND BREAST-FEEDING BEHAVIOR DURING THE FIRST
YEAR OF LIFE AMONG INFANTS FROM THE NORTHWESTERN REGION OF THE STATE OF SÃO PAULO, BRAZIL, 2009
Breast-feeding pattern Thumb-sucking
1st month 2nd month 3rd month 4th month 5th month 6th month 12th month
n % n % n % n n % n % n % n

Maternal Exclusive 6 7 2 3 1 1 1 1 0 0 0 0 0 0
breast-feeding Predominant 2 3 4 4 8 10 6 6 1 1 0 0 0 0
Complementary 1 1 4 4 10 13 13 11 15 18 10 13 3 3
Artificial feeding 0 0 1 1 4 4 14 11 13 14 11 13 9 11

Total 9 11 11 18 23 28 34 44 29 34 21 25 12 14

and pacifier-sucking, with no relationship between breast- Conclusions

feeding and thumb-sucking behavior. Research by Leite
Cavalcanti et al.,29 found that 80% of the artificially fed chil-
dren in their study had 1 or more harmful oral habits, while
the rate of harmful oral habits in breast-fed children was only
approximately 18%. Furthermore, these authors found that
infants who breast-fed for a period of 6 months or less showed
a higher frequency of malocclusion (~82%) vs those who were
breast-fed for 19 months or more (~46%). In another study
by Kroeff de Souza et al.,10 it was shown that infants who were
never breast-fed or who had a combination of breast-feeding
and artificial feeding before 3-months-old were approximately
7 times more likely to develop sucking habits than infants
who were breast-fed exclusively until 3 or 6-months-old.
In a study conducted in Iran 30 the prevalence of breast-
feeding was lower for infants who used pacifiers (30%) vs those
who did not (64%). Furthermore, the early breast-feeding ces-
sation was lower among infants who did not use pacifiers.
Benis24 suggested that pacifier use may be an early indicator of
breast-feeding trouble or may signify the absence of a motiva-
tion to breast-feed. Moreover, others have indicated that pacifier
use is associated with a shorter duration of exclusive breast-
feeding and have suggested that this behavior should be avoided
in the first weeks after birth by mothers who wish to breast-
feed.16 In a systematic review by O’Connor et al.,13 it was noted
that most studies have shown a link between breast-feeding
and a lower rate of pacifier use, and these results suggest the
practice of breast-feeding as a protective function.
Each thumb- and pacifier-sucking situation must be ad-
dressed by private practitioners in patient counseling. Parents
should assess the sucking’s cost-benefits to their children in
accordance with the reality in which the children live and the
risks to which they are exposed.23,28
In summary, previous research on breast-feeding and pa-
cifier use has determined that: 1) pacifier use appears to cause
or be a determinant of weaning and 2) the use of pacifiers is
seen as a consequence or indicative of problems in the practice
of breast-feeding.25 The question of whether the pacifier is a
determinant of weaning or an alternative for situations where
weaning occurs for other reasons is still unanswered. Future
research should more thoroughly focus on this cause-effect
relationship.
Based on this study’s results, the following conclusions can be
made:
1. The duration of breast-feeding in the present study
was shorter than that recommended by the World
Health Organization.
2. More than half of study participants reported a poten-
tially harmful sucking habit, with pacifier-sucking
more prevalent than thumb-sucking.
3. A minority of infants maintained a potentially harm-
ful sucking habit for the full 12 months of the study.
4. At 12 months old, there was a significantly negative
correlation between breast-feeding behavior and paci-
fier use.
5. There was no association between thumb-sucking and
breast-feeding.
Acknowledgments
The authors wish to thank Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior (CAPES) for Ph.D scholarship
and Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP) for research support.
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