Behavior: Biting by a toddler

Q: I am a pediatric nurse practitioner practicing in a hospital-affiliated outpatient facility. A parent recently placed her 18-month-old son in daycare for the first time. He was previously cared for by his maternal grandmother at home. Private daycare was chosen for educational and socialization purposes. The parent states that the child is in jeopardy of losing his placement there because of bad behavior. It seems as though the child has been biting the other children. Could you advise me as to what behavioral modification would be best for this parent to institute?

A: Pediatricians frequently hear about biting among infants and toddlers. Most toddlers pass through a biting stage, but this behavior in a group childcare setting may be stressful for parents and other child care individuals.

Many parents recognize the first "bites" when breastfed babies with new teeth "bite" their mother while feeding. This type of biting usually resolves quickly, following the mother's startle and removal of the infant. The next most common time for biting follows the first birthday. Children in this stage of development strive for independence, and their developmental progression with walking and self-feeding leads to the awareness that they can control their own actions. Compounding this is the emergence of new teeth, which are painful and partially soothed by pressure/biting. The third peak in biting occurs in the second year of life, when they strive for autonomy and begin the process of learning to manage frustrations and anger.

In a child with a language delay, referral for speech and language evaluation may lead to a placement with developmentally-matched children. A child who is experiencing teething pain should be given a soothing, safe object for biting, and in some cases, a mild analgesic. Other children respond to acute and chronic stressors (changes at home, new siblings, fatigue, hunger, etc.) with disruptive behaviors, including biting. Stressors should be minimized when possible until the biting subsides.

In this case, a suggestion can be made that the patient's grandmother continue a part-time caregiver role. Or she might attend the daycare for a few hours to aid in the child's transition to the new environment. The response of parents and child care personnel during or after a bite is important to a successful outcome. Like other aggressive acts, a firm and clear, "No biting" should be directed to the child. Depending on the situation, the caregiver may also add, "We use words, not teeth." The child should be given examples of how words are used in conflict situations-"I don't like that" or "I was playing with that toy."

Although it is important for the parent of a "biter" to be aware of the offense, the name of the biter should not be released to the "bitten" child's family, to prevent conflict between families. The child who was bit should be given sympathy and then evaluated for skin breakage, while physically separated from the biter in the form of a "time out."

The hours and days after a biting episode are opportunities to reinforce anti-biting messages. "What could you do next time you feel [insert emotion]? What do we use our teeth for? Did it hurt when your friend bit you? Should we bite our friends? Why not?" These are questions that should stimulate a conversation about biting. In addition, parents can redirect a toddler when rising frustration results in biting by anticipating the biting behavior with a calm voice ("No biting").

A referral to a consultant should be considered if biting persists for longer than a few months, when either a language delay or global developmental delay is associated with biting, in families where there is chronic stress in the home, or in a child who is older than 3 years.

DR. IRELAND is a fellow of developmental-behavioral pediatrics at the University of California, San Diego.

DR. STEIN is a professor of pediatrics at the University of California, San Diego.

The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.