GUIDELINES FOR PARENTS

Thumb-sucking, Temper Tantrums, and PICA

Thumb-sucking

Q1. We thought that he would leave it after some time. Now my child is 3 years old, but his habit is the same. Why does my child still do thumbsucking?

Thumb-sucking is self-soothing. This behavior of infancy and early childhood is not of any harm.

Q2. No other children in my family have this habit. Its my child who has this problem?

Thumb-sucking is neither manifestation of abnormal behavior nor a disorder in a 3-year-old child. Its very common in children below age of 4 years, but it does not run in genes.

Q3. Apart from doing it for selfsoothing, could there be other reasons for thumb-sucking in children?

If it persists beyond 4 years of age, it could be habitual or due to psychological reasons. The reasons include emotional insecurities, loneliness,neglect, overcontrolling parents, etc. Children who are not self-confident enough resort to thumb-sucking. Moreover if a child wants to parental attention (bcoz of new sibling) may also develop this habit.

Q4. I have seen many parents giving pacifiers to their babies to avoid thumb-sucking. Should I try to introduce pacifier to get rid of thumbsucking in my child?

I will not advise that. Pacifiers might increase the risk of infections say ear infection by adding germs to your baby’s mouth. Long time use of pacifiers may also cause to dental deformities. .30

Q5. Doctor, we have tried many things at home as suggested by my mother and other relatives to get rid of this problem. We have tried so many things say scolding,forcibly taking out his thumb from mouth, applying bitter substances, plastering of thumb, etc. But, all these attempts are of no use. Now you are the last hope. Please help us.

Have patience. Your child is only 3 years old. Punishing or scolding the child never going to help. And at times, it may even worsen the situation. Child may become more aggressive or rebellious and may develop behavioral problems in later life. And he fails to understand why my parents are doing all these things to me.

Q6. Sir, many of my relatives and friends have scared me by saying that thumb-sucking may deform my child’s teeth and face. What problems is he likely to face in future if he does not leave this habit?

Thumb-sucking beyond 5 years may be associated with sequelae (Dental malocclusion with open bitssde or under bite, paronychia, and social and psychological issues)

Q7. I am very scared after knowing the serious complications which may happen to my child. I was taking this problem very lightly. Please educate me at what age we have to intervene?

Most of the children give up this habit by the age of 4 years. If a child persists in thumb-sucking beyond the age of 4 years, we need to intervene. Developmentally, beyond the age of 4 years, you may reason with the child and obtain his cooperation in working on giving up a bad habit. You may plan on various activities and games which involve the use of hands such as drawing, craft, painting, etc.

Q8. What else can we do for the bigger children who continue to do thumb-sucking?

Intervention should be preceded by 1 month moratorium on parental attention. Many a times, it is successful.

• Habit Monitoring: Monitoring of habits allows parents and child to keep record of progress and that provides basis for delivery of motivational incentives. Make charts of progress and record daily.
• Motivation rewards and incentives: Praise the child for substitute behavior.
• Sensory feedback: Application of noxious, bitter nail polish which is applied over the nails only. It can be used two-to-three times a day. Child must be aware of about what are you applying. Most of the children improvise in around 2 weeks and do not require further intervention.

Q9. If some complications occur, whom should we consult?

Dentist opinion and intervention is a must, if there are malocclusion and abnormal facial features. Orthodontic appliances for correction are needed. Orthopedic help in the form of thumb guard, hand-stopper, palatal arch, and palatal crib may be worth a trial. In very resistant cases, fixed intraoral antithumb-sucking devices may be used, though very rare.

DO NOTs OF THUMB-SUCKING

• DO NOT intervene till 4 years of age.
• DO NOT use force to stop thumb-sucking like tying the limbs and slapping the hands.
• DO NOT use aversion techniques such as dipping the hands in unpleasant-tasting substances as it may lead to frustration and rarely poisoning.
• DO NOT delay any further in the treatment, if there is any dental malocclusion or abnormal facial growth.

Temper Tantrums

Q1. My 2-year-old daughter does not listen to us at all. Whenever her demands are not fulfilled, she starts crying and hitting around. What is it?

Your daughter is showing temper tantrums. Temper tantrums are just way higher than anger or demanding behavior. A temper tantrum is a behavioral response characterized by extreme anger & frustration. The child will express her frustration by excessive crying, screaming, and violent body motions such as throwing things, falling to the floor, or banging her limbs or head against the floor.

Q2. I have seen the children of my friends in the same age group. They do not have such a problem. Why does my child have this problem? Are we not parenting her well?

Please do not doubt your parenting. Temper tantrums (also called “acting-out”) are part of natural behavior during early childhood days. As children grow and develop, they begin to think themselves as seperate entities from their parents. Beacause of which, they begin to try to get some independence. Occasionally, children may throw some tantrum to get attention from parents/caregivers or to manipulate the situation according to their wants. Tantrums are also worsened as a result of a child’s limited vocabulary which impedes their ability to express themselves effectively. Certain conditions such as being exhausted, hungry, or sick may worsen a tantrum or increase their frequency. Please be assured that it is not at all a sign of bad parenting.

Q3. If we fulfill her demand every time, will it help in avoiding these episodes?

As a parent, you may think that giving in to the child’s tantrum is a tempting option. However, this could be counterproductive. It might make her believe that she can get everything she wanted by simply throwing a tantrum. It is equally very important to follow some rules and maintain disciplined behavior. She has to obey these rules with willingness. It can only be possible once you discuss the problem when she is cool, calm, and ready to understand what is said by you.

Q4. Can you do something to reduce the duration of the tantrum episode?

A temper tantrum is an attention-seeking behavior. There is only one way by which you may minimize length and severity of the tantrum is to ignore behavior of the child whenever she throws a tantrum. Keeping her alone in a room provided the child safety and she not behaves in a destructive manner, may work because there would be no one to react to the behavior. But she may still persistent with her tantrum. In such case, do not react or talk until the behavior stops. Once the episode ends, gently discuss the issue, justify your behavior reaction, and give the right options.

Q5. How to manage the child during a tantrum episode?

It is important to remember to keep your cool and stay calm when responding to a tantrum. when she is throwing a temper tantrum, is not the right time to try and convince logically or make her understand. It helps to remember that tantrums are normal. Shouting and/or hitting the child will worsen the situation only. When responding, do not change the rules that were set before or accept child’s unreasonable demands. Maintain a quiet and peaceful atmosphere in order to contain the amount of stress that you face. Try to make an environment in which both child and you feel better suited for bringing the tantrum to a resolution. When tantrum thrown away from home, take the child to a quiet place like car or a toilet. Ensure the child’s safety until the tantrum subside.

Q6. Can you do something when a child is about to show a temper tantrum? Are there any signs which indicate that child is going to have a tantrum episode?

Yes, it may be possible to mitigate an episode by being alert to certain danger signs, especially fatigue, hunger, and irritability. You may have to change your plans and give the child the food, rest, or change of place and scene. Gentle distraction by engaging the child in playful activities that amuse her may also work.

Q7. Are there any medications that help?

It is important to keep in mind that temper tantrums are benign. Prevention is the best antidote to frequent and recurrent temper tantrums.Only thing that helps is to pay attention to common triggers such as hunger, fatigue, illness, or injury may help. In rare cases, medication may help in management of associated extreme behavior such as breath-holding or aggression. Iron therapy has been found to be helpful in reducing the frequency and severity of breath-holding events in children with iron deficiency.

Q8. How can we prevent tantrums?

The acronym C.A.L.M may help with remembering how to prevent a temper tantrum.

• Communicate well: Children pick up a lot through the means of social learning. Parents must set a precedent for the children to emulate by modeling excellent communication skills and they must avoid getting into arguments or shouting in front of children. Toddlers may also benefit from being presented with facial expression of feelings (such as angry face, sad face and happy face) and allow them to pick the face that best describes their emotions. It is also essential to teach older children how to use their words to express their emotions.
• Attend to the child’s needs: Make sure that you are providing positive attention to the child such as reading to her, playing games with her, and including her in routine activities such as cooking and cleaning. It may also be useful to let her play with age-appropriate toys in order to take her mind off of undesirable objects. Maintain age appropriate expectations of your child’s behavior.
• Let the child share her feelings: Try to minimize the use of the word “no”. In a condition that does not cause a health or safety issue, its alright to let the child make their own choice that may not goes with your preferred alternatives, for eg wearing mismatched clothes.
• Make sleep-times and meal a part of regular schedules: In case, the toddler is away from home or misses her scheduled meal-times, keep healthy snacks such as fruits or crackers at hand.

Q9. What to do if a tantrum starts in a public place?

Children become overstimulated or tire more easily in busy public spaces such as malls, public functions, etc.They use the tantrum to regain parental attention when they are busy somewhere else. Despite their understandable embarrassment, parents have to treat public tantrum in essentially same way as they treat one at home. Whenever possible, they ought to take the kid to the car or another private space to avoid inconvenience to others and attracting any unwelcome attention.

Q10. Till what age will my child continue to show temper tantrums? Is it likely that these will hamper my child’s development?

The onset of temper tantrum usually occurs between 12 and 18 months of age. With passage of time, children learn to identify feelings, name their emotions, and utilize positive means of coping with negative emotions as they grow older. Temper tantrums become less frequent after the age of 4 years.They are a part of normal childhood development and the child usually stops them by the time he reaches school-going age. There are no long-term side effects on development or behavior.

PICA

Q1. My 8-month-old son puts his toys into his mouth. I am worried. Will this become a habit for him in future?

This is no cause for concern, as all toddlers have this habit, which is often called mouthing. This is regular and common phenomenon and is normal behaviour of toddlers to assess the edibility of any substance they found while playing around. If this continues beyond 2 yrs of age, we may suspect an eating disorder known as “pica”, and then a medical consultation may be warranted.

Q2. What is “Pica”?

“Pica” is basically an eating disorder. Usually, a person eats only standard edible items such as fruits, bread, milk, etc. The child having PICA eats nonedible items such as soap wool, clay,chalk paint, earth, ashes, etc. If this process has lasted for over a month, then condition is medically termed as “Pica”.

Q3. Does pica occur only in children?

No. It can occur throughout lifetime. But it occurs most commonly in childhood.

Q4. Which children are more likely to have this eating disorder?

Children with malnutrition, specific nutritional deficiencies (e.g. calcium, zinc, and iron), and children who are facing neglect or are in poor family environment are more likely to be affected. It is found more common in children with autism, intellectual disability and schizophrenia. Therefore, a proper assessment of the child is very important.

Q5. How can I confirm that my child suffers from pica?

There is no confirmatory test such as a blood test or X-ray, etc. The diagnosis is made on certain criteria. These include:

• The child must have been eating these non-nutritive non-food items for over a month.
• The eating is not normal for the child’s age and development level (it might be a normal for an infant or toddler to put items in mouth that come to its grasp). A minimum age of 2 years is mentioned for the same reason.
• The eating should not be associated with any culturally accepted practice, which is considered normal in the social context of the child (just as a pregnant lady may have peculiar taste cravings).

Q6. How long is this habit likely to continue?

Pica mostly disappears by teenage. Sometimes, it may persist in adolescence age too.

Q7. My cousin lives in Ghana, and she says mud-eating is a common practice there particularly in pregnant women?

This is called “Geophagia”. It is actually associated with pregnancy and is considered normal for them. This is accepted in some rural communities in Africa as a normal cultural practice.

Q8. My colleague’s 13-year-old daughter scrapes off paint from the walls and chews that. What should they do?

This will require a good evaluation of the child. Deficiencies of iron, vitamin D, calcium, and zinc need to be excluded. Behavioral and psychological assessment have to be done, and relevant intervention and counseling may be required. In many cases, counseling helps.

Q9. Are there any medicines or specific treatment for this condition?

Any deficiency disorders, particularly iron deficiency must be treated and any mental issues evaluated and treated likewise. Any family issues such as parental discordance, etc. should also be addressed.

Q10. What can I, as a mother, do to help my child get rid of this habit?

Apart from following your pediatrician’s advice, please give your child good nutritious food from your regular family bowl. You can avoid any negative impacts on the child’s brain and psyche (parents arguing, family shouting at each other, uttering bad words about others in their absence). The family environment needs to be healthy for proper mental development of the child.

Q11. Is there any possibility of any serious issues developing out of this habit, if it cannot be prevented or controlled?

Usually “pica” in itself does not create any serious problems. However, children with pica are at increased risk of lead poisoning (caused by paint eating), worm infestations (mud or feces eating), iron deficiency anemia, etc. All these will have to be treated appropriately.Few children have the habit of tearing and eating their own hair. These hair may entangle and get stuck somewhere in the stomach or lower down in the alimentary canal, which may require treatment including surgery to take out the ball of hairs (Trichobezoar)