What Causes Hyponatremia?

Patient Presentation
A 13-month-old female came to clinic with vomiting of stomach contents, diarrhea that was watery without blood or mucous that saturated her diaper, and fever to 100.5°F for 48 hours. She had been drinking reasonably well but over the past 12 hours had refused. Her last wet diaper was 8 hours ago. The past medical history was non-contributory and she had all of her vaccinations including seasonal influenza. The social history showed that she was an only child who attended daycare. The pertinent physical exam showed an ill-appearing female with an 800 gram weight loss, respiratory rate of 22, heart rate of 128 and temperature of 99.8°F. Her mucous membranes were tacky and her capillary refill was 3 seconds. Her abdominal examination showed increased bowel sounds.

The diagnosis of of gastroenteritis was made. The patient refused to drink anything in the office and had 1 emesis and 2 stools that were sent for culture and eventually showed norovirus. She was sent to the emergency room where she failed to improve and was admitted for 24 hours. Initially her laboratory evaluation showed a sodium of 131 mEq/L, chloride of 101 mEq/L and otherwise normal electrolytes and an unremarkable complete blood count that returned to normal after fluids.

The patient’s clinical course after she returned home found her to be improving with no vomiting, emesis or fever but 36 hours after discharge she began having copious rhinorrhea, increased eye tearing, coughing, lethargy and fever to 103F°. She had continued to drink and was having wet diapers every 4-6 hours and her weight was only 10 grams down from her normal weight. She however was very lethargic and would easily arouse but would instantly go to sleep again. Respiratory testing found her to have influenza A and she was admitted for observation and treatment. Laboratory testing at that time showed no bacterial pneumonia on chest radiograph but a plasma sodium of 130 mEq/L again. The patient was evaluated for recurrent hyponatremia including having normal aldosterone and thyroid testing. She was eventually diagnosed with SIADH presumably due to influenza after showing a urine sodium of 137 mEq/L, and urine osmolality of 966 mOsm/kg. She was started on fluid restriction initially and after another 48 hours of oseltamivir and fluid support, her electrolytes returned to normal and she was discharged to home. Three days later she followed up in outpatient clinic and was well. Her repeat electrolytes at that time were normal.

Normal kidneys regulate water balance to maintain a plasma osmolality of 275-290 mOsm/kg normally. Thirst and arginine vasopressin or antidiuretic hormone (ADH) are the primary regulators of plasma osmolality. ADH is made in the hypothalamus and released by the posterior pituitary gland. ADH acts on the kidney’s distal collecting duct to increase water reabsorption. ADH is appropriately released in hypovolemic states, such as dehydration caused by gastroenteritis. ADH has an ~10 minute half-life and therefore can respond to rapid changes in volume status. Sodium balance is regulated by aldosterone (as part of the renin-angiotensin system) causing sodium to be reabsorbed from the distal kidney tubules and secreting potassium and hydrogen. Atrial naturitic peptide is released from the atrium in hypervolemic states causing the kidney to excrete sodium and excessive water. In normal states, urine sodium is < 20 mmol/L.

Hyponatremia occurs when the body has a relative excess of free water relative to sodium. Rapid shifts in water can cause cellular damage particularly in the central nervous system (CNS). Normally, water and solutes pass through the cellular membrane to maintain homeostasis, but solutes generally pass slower than free water. Therefore with hyponatremia there is a relatively low amount of sodium and higher amount of water in the plasma with the opposite true for the cell. Therefore water will try to move into the cell to balance the intracellular and extracellular osmolality. The increased intracellular water volume can cause cellular damage or death especially in the CNS where it can cause cerebral edema and seizures. Rapid shifting of solutes and water usually causes more problems than shifts that occur over longer periods of time, when the body is able to compensate.

Hyponatremia signs and symptoms may be non-specific and insidious including headache, malaise, nausea, myalgia and decreased deep tendon reflexes when concentration is < 125-130 mEq/L. Mental status changes then usually develop with agitation, confusion, disorientation, depression, lethargy, psychosis, seizures, coma or death.

Correction of hyponatremia can cause additional problems such as cerebral edema if it occurs too quickly. Therefore depending on the causes, hyponatremia severity, and signs and symptoms, slow correction over several days may be needed. Hyponatremia is often associated with hypovolemia and may require 0.9% normal saline for initial repletion. This should stop ADH from being released. Intravenous fluids are usually then changed to hypotonic fluids such as 0.45 normal saline so as not to correct the sodium too quickly. Patients who are euvolemic or hypervolemic are usually treated by fluid restriction.

SIADH or syndrome of inappropriate antidiuretic hormone is ADH being triggered in inappropriate states of euvolemia or hypervolemia. In adults, malignancy and drugs are common causes. In pediatrics, infectious diseases of the CNS and respiratory systems are common along with head injuries. The differential diagnosis of SIADH includes:

  • Central nervous system problems
    • Infectious
      • Abscess
      • Meningitis
      • Encephalitis
      • Sepsis
    • Surgery/Trauma
      • Cerebrovascular accident
      • Head trauma
      • Surgical procedures
  • Pulmonary problems
    • Bronchiolitis
    • Pneumonia
    • Empyema
    • Aspergillosis
    • Tuberculosis
    • Chronic obstructive pulmonary disease
  • Malignancy
    • Leukemia
    • Lymphoma
    • Central nervous system
    • Lung – especially small cell in adults
    • Other organs
  • Drugs
    • Antineoplastic agents
    • Antiepileptics
    • Abuse drugs – MDMA, ectasy
    • Nonsteroidal anti-inflammatory drugs
    • Oral hypoglycemic agents
    • Phenothiazine
    • Tricyclic antidepressants
    • Selective serotonin uptake inhibitors

Learning Point
The differential diagnosis of hypoosmolar hyponatremia (note all will be hypoosmolar with plasma < 275 mOsm/kg) includes:

  • Hypo- or euvolemic and urine Osm < 100 mOsm/kg
    • Psychogenic polydipsia
    • Reset osmostat
    • Beer potomania
    • Water intoxication – enema, IV therapy
  • Hypo- or euvolemic and urine Osm > 100 mOsm/kg
    • Urine sodium < 20 mmol/L
      • Gastrointestinal losses
      • Skin loss
      • Cystic fibrosis
      • Third spacing such as ascites, burns
    • Urine sodium > 20 mmol/L
      • SIADH
      • Adrenal insufficiency
      • Congenital adrenal hyperplasia
      • Hypothyroidism
      • Salt-wasting syndromes
      • Renal losses
      • Urinary tract obstruction
  • Hypervolemic
    • Cirrhosis
    • Diuretic
    • Enteropathy
    • Heart failure
    • Nephrotic syndrome
    • Renal failure

Questions for Further Discussion
1. What causes hypernatremia? The differential diagnosis can be reviewed here.
2. What are indications for admission to the hospital for hyponatremia?
3. How is plasma osmolality calculated?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sodium, Norovirus Infections, and Flu.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lin M, Liu SJ, Lim IT. Lim Disorders of Water Imbalance. Emerg Med Clin North Am. 2005 Aug;23(3):749-770.

Arvanitis ML, Pasqual JL. External causes of metabolic disorders. Emerg Med Clin North Am. 2005 Aug;23(3):827-41, x.

Rivkees SA. Differentiating appropriate antidiuretic hormone secretion, inappropriate antidiuretic hormone secretion and cerebral salt wasting: the common, uncommon, and misnamed. Curr Opin Pediatr. 2008 Aug;20(4):448-52.

Lavagno C, Milani GP, Uestuener P, Simonetti GD, Casaulta C, Bianchetti MG, Fare PB, Lava SAG. Hyponatremia in children with acute respiratory infections: A reappraisal. Pediatr Pulmonol. 2017 Jul;52(7):962-967.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are Complications of Oropharyngeal Trauma?

Patient Presentation
A 9-year-old male came to the emergency room after he had purposefully stabbed himself in the mouth about 1 hour before. He said that he was “dared” to do it by some of his friends and had used a standard wooden pencil that was removed intact. He realized that he “didn’t poke himself very much” but he had been bleeding for a short time. The school officials had him suck on ice while his mother was contacted. She said that the bleeding had stopped when she arrived and he had not really complained of any pain, coughing, problems swallowing or talking. “He’s pretty much normal, but I saw blood back there and wanted to get it checked out,” she said. “It wasn’t very sharp, but I guess I shouldn’t have listened to my friends and did it,” he offered. He denied other trauma and said there was no pain unless he stuck his finger in the area of the injury. The past medical history showed the patient was taking stimulant medication for attention deficit disorder – combined type. He had a forearm fracture after a playground injury at age 7. His immunizations were current. The review of systems was negative.

The pertinent physical exam showed normal vital signs. He was quite active in the room talking animatedly about all the equipment. His general examination was normal. There was no external trauma noted to the face and neck. Just above the left tonsil on the tonsilar pillar was a 3-4 mm abrasion. Initially a small blood clot covered this area but by the end of the exam, it had fallen away and the base of the lesion was seen. There was no increased vascularity or edema to the area. Tongue blade inspection of the teeth, tongue, gingiva, buccal mucosa, palate, and uvula were normal. He had full range of motion in the temporomandibular joint. Cranial nerves were intake, and no pain was elicited with any maneuvers during the physical examination.

The diagnosis of a superficial soft palate injury was made. An otolaryngology resident was present in the emergency room seeing another patient and she also agreed that it was a superficial injury. The parent was educated about the potential complications of this type of injury and was to monitor the patient closely returning if any worrisome symptoms occurred. The patient was to followup in one week with his regular physician.

Oropharyngeal trauma is common and ranges from minor contusions to severe trauma of the head and neck. Sudden movement while having a foreign object in the mouth is a very common scenario with falls or collisions being common mechanisms. Common objects include toys, sticks, pens/pencils, chopsticks, toothbrushes, and popsicle sticks. Many of these injuries cause minimal problems such as a contusion to lips (i.e. “fat lip”).

In general, the more anterior the location the more common the injury and the less likely to have a severe injury (i.e. lips). Whereas posterior structures are more protected, but because of their location next to vital structures, the potential complications can be higher. Similarly, midline injuries tend to be less risk for complications than lateral injuries as lateral injuries are nearer to vital structures. Fortunately owing to the excellent blood supply to the oropharynx, most treated injuries are well-healed with good cosmetic and functional outcomes. High impact trauma (e.g. car accident), burns and animal bites are other types of trauma which do also cause injury to the oropharyngeal structures and are not discussed here.

General evaluation approach
The history should include mechanism of injury and if a foreign body caused the injury, if it was removed intact. A history of drooling, dysphonia, dysphagia, cough or obvious external swelling (possible subcutaneous emphysema) should increase the concern for complications. During the evaluation of oropharyngeal trauma, close inspection of the traumatized area and adjacent structures is important. This may necessitate local or general anesthesia. Evaluation for other injuries including dental occlusion, temporomandibular joint movement and for potential additional head and/or neck injury should be carried out. Cranial nerves should be evaluated. Carotid bruit evaluation is also performed as is appropriate. Use of computed tomography or computed tomography angiography may be needed to assist in evaluation and plan potential treatment especially if there is a concern for vascular injury. Non-accidental trauma should be considered if the history and injury seem discrepant or other injuries are noted. Similarly, psychiatric evaluation may be appropriate in the proper circumstances.

General treatment approach
Penetrating oral trauma management is controversial but often can be managed as an outpatient with good results. Irrigation, foreign body removal, hemostasis and debridement as needed should be the main general approach to treatment. Lacerations may communicate with adjacent spaces (e.g. through-and-through tear of oral gingival mucosa to the facial skin, or foreign body trauma that penetrates into potential neck spaces), so this must be considered when treating wounds. Exploration may be necessary and may necessitate local or general anesthesia. Use of prophylactic antibiotics in oropharyngeal trauma is controversial but if used, treatment for oral flora is appropriate. Rabies and tetanus vaccine status should be evaluated. External wound instructions and head injury instructions should be given as appropriate. Analgesic use (and antibiotic use) should be reviewed with the family. Patients should be instructed and encouraged to return to the emergency room for re-evaluation for bleeding, swelling, tenderness, increased pain or new pain, fever, increased secretions, difficulty swallowing or breathing, problems moving the neck or jaw or holding the head in an abnormal position, or if the family has any other concerns.

Contusions usually need only localized cooling to help vasoconstriction with resolution in a few days. Abrasions and lacerations are both considered infected wounds as the epithelium is damaged with superficial or deeper structures exposed. Antibiotics may be used, especially for large or more complicated injuries.

Frenula injuries often bleed copiously. Minor injury to the gingival frenulum may just need cold packs but suturing may be needed to control hemostasis. The lingual frenulum is injured less often but treated the same way. Injuries to the teeth or jaws usually requires evaluation and treatment planning by a dentist. Radiographs usually help with treatment planning. A tooth that is dislocated should be retained in position if possible. An avulsed tooth can be transported in the child’s or parent’s mouth for possible reimplantation. Alternatively, milk or water are other transport mediums. The tooth should not be manipulated but gently placed into the transportation device. Tongue lacerations often bleed copiously as they also have good blood supplies. They also usually heal quickly and well. Long or deep lacerations or those with a high risk of deformity (e.g. anterior split tongue) may require suturing with loose sutures as tighter sutures may cause tissue necrosis.

Buccal mucosa injuries are usually superficial but deeper or flap injuries may need additional treatment. Similarly gingival injuries may need additional evaluation and treatment. Salivary glands and Stensen’s duct may also need specific evaluation.

Injuries to the tonsils, uvula and palate are not very common and usually are due to sharp objects being placed into the mouth. Because of increased risk of potential complications, these locations may need additional evaluation (such as computed tomography or evaluation under general anesthesia) and/or treatment (additional suturing, hospitalization, etc.). Again like most oropharyngeal injuries, many of these can be treated with diligent inspection, foreign body removal, and hemostasis with appropriate evaluation by specialists and appropriate followup. Outpatient treatment requires careful instruction of the parents to return immediately if any red flag symptoms occur.

Learning Point
Foreign body injuries of the buccal mucosa, mouth floor, palate, and tongue usually occur when there is a object in the mouth and the child suddenly falls. These injuries are often unwitnessed. These should be inspected and palpated (which may require some type of anesthesia) to make sure the entire foreign object is removed. The external wound can belie deeper potential injury so it is important to carefully inspect the entire area surrounding the injury. Deeper injuries can be very difficult to identify and symptoms may occur over long periods of times as noted below. Imaging with computed tomography or computer tomographic angiography can be helpful for appropriate injuries.

Potential problems of penetrating oropharyngeal injuries includes:

  • Airway obstruction
  • Hemorrhage
  • Foreign body retention/obstruction
  • Subcutaneous emphasema
  • Infection – localized or in adjacent structures or spaces, and can cause severe infection such as abscess, mediastinitis, or sepsis. A review of deep neck infections can be found here.
  • Vascular injury to the internal carotid artery and internal jugular vein can cause dissection, thrombosis, and pseudoaneurysm

These potential problems can occur minutes to years after the trauma.

Questions for Further Discussion
1. What are indications for referral to an otolaryngologist for an oropharyngeal trauma?
2. What type of sutures are generally used for treatment of oropharyngeal trauma?
3. What are indications for hospitalization for oropharyngeal trauma?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Mouth Disorders and Foreign Bodies.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Marom T, Russo E, Ben-Yehuda Y, Roth Y. Oropharyngeal injuries in children. Pediatr Emerg Care. 2007 Dec;23(12):914-8.

Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma.
Pediatr Emerg Care. 2008 Mar;24(3):172-5.

Aremu SK, Makusid MM, Ibe IC. Oro-cranial penetrating pencil injury. Ann Saudi Med. 2012 Sep-Oct;32(5):534-6.

Lalitha RM, Ranganath K, Prasad K, Agrawal K, Perumal M. Potential danger of toothbrushes for children. J Investig Clin Dent. 2011 May;2(2):148-50.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Do You Fix A Broken Nail?

Patient Presentation
During some downtime in the pediatric clinic, a resident recounted that a 15-year-old female came to the emergency room because of a torn nail. “It really wasn’t too bad with only 2-3 mm of the nail bed area partially torn off by a door. It sort of delaminated along the nail edge but most of the nail was still there. There was little of the nail edge skin torn. She said it was painful because it would catch on something but mainly she wanted us to reattach it because she was going to the Homecoming dance in a couple of days,” he said. “So what did you do?” another resident asked. “We gave her 3 options. We could just trim the torn nail off. We could try to do a small repair using some superglue and tea bags, or we could put an adhesive bandage over it now and she could go to a manicurist the next day,” he explained. She chose the manicurist. We also recommended that she make sure to keep it clean and dry and watch for infection but there shouldn’t be much to worry about because the cut was at the nail edge and could be seen easily. It was kind of silly to be in the ER but it was different than seeing all the other colds and ear infections,” he finished.

Distal digits, especially of the hand, are important as they provide support for pinching and grip, give tactile sensation and contribute to cosmesis. Trauma to the distal digit and nailbed ranges from significant trauma with digital crush injuries or amputation to minor broken nails causing only annoyance. Most injuries especially in children involve the hand especially the middle finger. The dominant hand is more common if the child has a hand-preference. Usually they occur indoors especially being caused by being pinched by a door.

Significant trauma requires surgical intervention and may require specialty surgical intervention by a hand specialist. Survival rates for distal digital amputations with re-implantation vary based on several factors. A 2011 systematic review of fingertip amputations found an overall 86% survival rate. Clean-cut amputations had higher survival rates than crush or crush-avulsion amputations. Actual location along the fingertip was less of a factor, but vein repair in different areas had improved survival. Nerve repair did not make a difference and recovery was good “…because of the short distance the regenerating terminal branches of the purely sensory distal nerves have to travel to reach the distal targets.” The authors note, “…the phenomenon of adjacent and spontaneous neurotization may play a role especially in younger patients.” In this systematic review, 98% returned to work, 2-point discrimination averaged 7 mm (normal 2-8 on fingertips) and complications included nail deformity (23%) and pulp atrophy (14%). Appropriate followup for surgical patients is always needed. Distal tuft injuries usually are caused by a crush without neurovascular or ligamanetous injuries and are often treated conservatively with finger splinting in a functional position and appropriate surgical followup.

Nailbed injuries again are common. Often this may be a subungual hematoma that can be quite painful. Depending on the hematoma’s extent, patients may be monitored and treated conservatively with ice and pain medication until the acute swelling resolves. Others may need minor surgical intervention (usually trephination) to release the blood under the nail. Spontaneous decompression from the nailbed’s lateral nailfold also occurs. Patients should keep the area clean, dry, and monitor it closely for infection. Patients and families should also be warned about possible complications including infection.

In 2015, a Cochrane Collaboration systematic review found insufficient evidence to avoid or recommend use of adrenaline with lidocaine for digital nerve blocks that are usually used for outpatient surgical treatment. Less bleeding and prolonged anesthesia with adrenaline use was noted but the evidence quality was low. A 2010 study of 46 consecutive serious nailbed injuries requiring surgery in children for 6 months found that 44 needed general anesthesia as the children were quite young. Two-thirds used the replaced nail as a splint for the repair. Few complications occurred at followup (15-21 months later): 3 nailbed deformities and 1 with mild aching when the digit was pressed. A review of nailbed anatomy can be found here.

Learning Point
Torn or detached nails from the nailbed usually are treated with symptomatic care with attention to minimizing pain, preventing infection and preventing further injury. Detached nails may be sutured into place to splint the digit, provide protection to the nail bed and prevent infection. Soaking the area to keep it clean and remove accumulated secretions and debris is important and antibacterial cream or petroleum jelly also keeps the area moist. However the cream/jelly should still allow normal wound secretions to drain when present in the first few days after the trauma. Partially detached nails are again left in place often by securing with an adhesive bandage that can be changed often.

Broken or torn nails may cause no problems if they are distal to the nailbed. However they commonly do common catch the edge of the nailbed causing a minor open wound that is treated conservatively and heals within a few days. If the torn nail is more proximal it may be wise to try to repair the nail. Closing up the nail on top could potentially trap infectious material so the extent of the problem versus the risk of infection should be weighed. After cleaning the digit thoroughly, the distal nail should be trimmed and filed back to prevent it catching on something and tearing more. Nail repair kits are available and should be used as directed. Usually some thin paper-like material is glued in place to splint the nail tear. A small piece of a clean (non-used) tea bag is also commonly used as an alternative and other alternatives include coffee filter, clean handkerchief linen or silk. The material is cut to fit the area (including enough to overlap the free edge of the nail if appropriate). A small amount of cyanoacrylic glue is placed over the nail tear and around the area using a small applicator or brush. The tea-bag or other material is placed on top of the glue using tweezers, smoothed and held in place to dry. Placing the paper over the free edge of the nail may also give additional support to the nail. Another small amount of glue is smoothed on top of the material. Buffing of the nail and the repair (especially going in one direction) helps to eliminate ridges or edges that could catch and disrupt the repair. Applying a clean bandage over the area can help in the first few days to remind the patient to be careful of the repair. Patients should continue to monitor the area for signs of infection.

Questions for Further Discussion
1. How fast do nails grow? A review can be found here.
2. What are indications for evaluation by a hand surgeon?
3. What initial and ongoing professional training do manicurists and cosmetologists need for their professional degrees in your area?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Finger Injuries and Disorders, Hand Injuries and Disorders and Toe Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Pearce S, Colville RJ. Nailbed repair and patient satisfaction in children. Ann R Coll Surg Engl. 2010 Sep;92(6):483-5.

Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg. 2011 Sep;128(3):723-37.

Prabhakar H, Rath S, Kalaivani M, Bhanderi N. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database Syst Rev. 2015 Mar 19;(3):CD010645.

Torn or Detached Nail. C.S. Mott Children’s Hospital University of Michigan.
Available from the Internet at http://www.mottchildren.org/health-library/sig256776 (rev. 10/2016, cited 1/30/18).

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Problems are Caused by Non-Nutritive Sucking Habits?

Patient Presentation
A 4-year-old female came to clinic for upper respiratory tract symptoms. She had had green rhinorrhea for 3 days with a temperature maximum of 38.5°C. She had been pulling on her ears and her mother wanted her checked for a possible ear infection. She had not verbalized pain in her ears, throat or other places. Her mother denied any wheezing and there was minimal coughing. The past medical history showed impetigo and asthma. The social history revealed a difficult social situation with intermittent times of homelessness for the family and inconsistent health care.

The pertinent physical exam showed a happy female with normal vital signs and growth. She was sucking on a pacifier. HEENT showed copious rhinorrhea but normal tympanic membranes. Her oropharynx showed multiple caries and slightly protruding upper teeth. She had transmitted upper airway sounds to her lungs but no wheezing. She also was noted to have xerosis diffusely. The diagnosis of upper respiratory infection, caries and xerosis was made. The pediatrician discussed symptomatic treatment for the upper respiratory tract infection and xerosis. He also discussed oral hygiene, and with the help of the clinic social worker arranged for a dental appointment and transportation from the family’s temporary housing to the dentist. The patient’s clinical course over the next 4 months showed that she had been to the dentist and had started oral rehabilitation and restoration with some capping of her teeth. The family was still not as consistent as recommended with brushing her teeth and not giving her sweetened beverages in a sippy cup at night, but had stopped the pacifier use after the dentist had told them that her teeth were malaligned.

Facial growth is affected by the normal activities of breathing, sucking, chewing and swallowing. Sucking habits effects on facial structures “…depend[s] on the frequency, intensity and duration of the habits, the osteogenic development and the genetic endowment of the child.”

Breastfeeding assists normal development of the facial structures (mainly maxilla, mandible and dental arches) by proper muscle activity and tongue positions. With bottle, finger, or pacifier sucking, there is overuse of the chin and cheek muscles, underuse of the orbicular oris and masseter muscles, and malpositioning of the tongue which can impede proper facial growth.

Non-nutritive sucking (NNS) is a very common behavior in infants and young children. Prevalence varies “…based upon age, gender, ethnic origin, socioeconomic status, type of feeding, duration of breastfeeding, mother’s age, number of siblings and cultural level.” NNS objects such as pacifiers, thumb or fingers, or another external object such as blanket, or clothing are commonly used to help with self-soothing and for sleep. These may be used of other transitional objects (e.g. blankets, stuffed animals, etc.) which help with emotional regulation. However non-nutritive sucking habits (NNSH) can cause problems, mainly with dental malocclusion. Malocclusions can be seen in the deciduous teeth of even toddlers caused by NNSH. The American Academy of Pediatric Dentists recommends to cease the NNSH by age 3 stating “…professional evaluation has been recommended for children beyond the age of 3 years, with subsequent intervention to cease the habit initiated if indicated.”

“Malocclusion is the dental term for an improper bite relationship between the upper and lower teeth.” A basic description of the malocclusions is below along with planes of reference.

Vertical Relationship Problems

  • Frontal or vertical plane – plane running through the head perpendicular to the sagittal plane dividing the head in anterior and posterior halves.
    • Basically a plane from the top of the head to the bottom running through the ears. The face is separated from the back of the head by this plane.
    • Used to describe superior-inferior relationships
  • Overbite – the upper incisors overlap the lower incisors more than they should.
  • Open bite – the upper incisors do not overlap the lower incisors at all and there is an open space between them.

Transverse Relationship Problems

  • Transverse or horizontal plane – plane running through the head perpendicular to the sagittal and frontal planes dividing the head into upper and lower halves.
    • Basically a plane parallel to the ground running through the nose, across the top of the ears to the back of the head. The top of the head and eyes are separated from the lower part of the head and mouth by this plane.
    • Used to describe lateral or right-left relationships
  • Crossbites – a problem with the alignment of the upper and lower dental arches in the lateral plane. A tooth or teeth are located closer to the cheek or the tongue than they should be. These can be anterior or posterior.

Sagittal Relationship problems

  • Sagittal or median plane – plane running anterior to posterior dividing the head into right and left halves
    • Basically a plane running from the tip of the nose down the center of the head parallel with the spine. The left half of the head is separated from the right half of the head by this plane.
    • Used to describe anterior-posterior relationships
  • Retrognathic means the mandible and/or maxilla are positioned too far backward
  • Prognathic means the mandible and/or maxilla is positioned too far forward
  • Overjet – is when the anterior-posterior distances between upper incisors and lower incisors is increased.
    • Normally there is a small space between the upper incisors and lower incisors when the teeth are occluded that allows the teeth to overlap. An overjet is an increase in this space between the teeth and a reverse overjet or underjet is the opposite.

Learning Point
Malocclusions are very common with NNSH with just anterior overbite prevalence ranging from 15-84% in studies.
Pacifier use causes more problems in both anterior and posterior occlusions.
But as pacifier use is usually discontinued earlier than digit sucking, digit sucking can cause more longer term effects.
In one study at age 5 years the prevalence of malocclusion in deciduous teeth was 22% in the NNSH group verses 6.5% in the non-NNSH group. Anterior overbite is one of the most common malocclusions found in NNSH patients.

Digit sucking and nail biting also increases the risk of microbial exposure so potentially these children may have more infections. However there is data showing children with these habits are less likely to be atopic in childhood and adulthood suggesting this exposure is helpful to immune development.

Questions for Further Discussion
1. What are some techniques to stop NNSH?
2. Is there a correlation with NNSH and need for orthodontia in later life?
3. Is there a correlation with NNSH and dental caries or poor oral hygiene?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Behavior Disorder and Child Dental Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Academy of Pediatric Dentistry. Policy on Oral Habits. 2006. Available from the Internet at http://www.aapd.org/media/Policies_Guidelines/P_OralHabits.pdf (rev. 2006, cited 1/25/18).

Gallios, RG. Classification of Malocclusion. Slide set. Available from the Internet at http://www.columbia.edu/itc/hs/dental/D5300/Classification%20of%20Malocclusion%20GALLOIS%2006%20final_BW.pdf (cited 1/25/18).

Malocclusion. ToothIQ.com. Available from the Internet at https://www.toothiq.com/dental-diagnosis/malocclusion/ (rev. 2018, cited 1/25/18).

Isaacs D, Isaacs S. Transitional objects and thumb sucking. J Paediatr Child Health. 2014 Nov;50(11):845-6.

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Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa