Prolonged bottle feeding in a cohort of children: does it affect caloric intake and dietary composition?

Age of Bottle Cessation and BMI-for-Age Percentile among Children Aged Thirty-Six Months Participating in WIC

Background: Children's age at bottle weaning typically ranges from 12 to 24 months. The recommended age of bottle weaning varies. The American Academy of Pediatrics recommends weaning by 12 months; The American Academy of Pediatric Dentistry recommends 12-15 months; The US Department of Agriculture recommends 18 months. Prolonged bottle use is associated with dental caries, iron-deficiency anemia, and child overweight or obesity. We examined factors associated with age of bottle cessation, and the association between age of bottle cessation and BMI-for-age percentile at age 36 months among Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants. Methods: Data were from the WIC Infant and Toddler Feeding Practices Study-2 (ITFPS-2). The ITFPS-2, a longitudinal study of WIC participants (mothers and their children) began in 2013. We used Cox proportional hazards models to identify factors associated with bottle cessation and multivariate linear regression to examine the association between age of bottle cessation and BMI. Results: About 34% of children used a bottle longer than 12 months, and 13% longer than 18 months. Bottle cessation at older ages was associated with Hispanic ethnicity, multiparity, low income, low education, higher caregiver weight, and not initiating breastfeeding. The adjusted children's BMI-for-age percentile at age 36 months increased by 0.47 for each additional month of bottle use. Conclusion: Prolonged bottle use was associated with increased children's BMI-for-age percentile. Future research is warranted to determine the optimal age to recommend bottle cessation for WIC participants.

Is High Milk Intake Good for Children's Health? A National Population-Based Observational Cohort Study

Milk is widely considered as a beneficial product for growing children. This study was designed to describe the milk consumption status of Korean children aged 30–36 months and to investigate its association with the risk of obesity and iron deficiency anemia (IDA). This nationwide administrative study used data from the Korean national health insurance system and child health screening examinations for children born in 2008 and 2009. In total, 425,583 children were included, and they were divided into three groups based on daily milk consumption: low milk group (do not drink or drink <200 mL milk per day, n = 139,659), reference group (drink 200–499 mL milk per day, n = 255,670), and high milk group (drink ≥500 mL milk per day, n = 30,254). After adjusting variable confounding factors, the consumption of a large amount of milk of ≥500 mL per day at the age of 30–36 months was associated with an increased risk of obesity at the age of 42–72 months and IDA after the age of 30 months. These results may provide partial evidence for dietary guidelines for milk consumption in children that are conducive to health.

The influence of malocclusion, sucking habits and dental caries in the masticatory function of preschool children

The aim of this study was to evaluate the association of malocclusion, nutritive and non-nutritive sucking habits and dental caries in the masticatory function of preschool children. A cross-sectional study was conducted with a sample of 384 children aged 3-5 years. A single examiner calibrated for oral clinical examinations performed all the evaluations (kappa > 0.82). Presence of malocclusion was recorded using Foster and Hamilton criteria. The number of masticatory units and of posterior teeth cavitated by dental caries was also recorded. The parents answered a questionnaire in the form of an interview, addressing questions about the child's nutritive and non-nutritive sucking habits. The masticatory function was evaluated using Optocal test material, and was based on the median particle size in the masticatory performance, on the swallowing threshold, and on the number of masticatory cycles during the swallowing threshold. Data analysis involved simple and multiple linear regression analyses, and the confidence level adopted was 95%. The sample consisted of 206 children in the malocclusion group and 178 in the non-malocclusion group. In the multiple regression analysis, the masticatory performance was associated with age (p = 0.025), bottle feeding (p = 0.004), presence of malocclusion (p = 0.048) and number of cavitated posterior teeth (p = 0.030). The swallowing threshold was associated with age (p = 0.025), bottle feeding (p = 0.001) and posterior malocclusion (p = 0.017). The number of masticatory cycles during the swallowing threshold was associated with the number of cavitated posterior teeth (p = 0.001). In conclusion, posterior malocclusion, bottle feeding and dental caries may interfere in the masticatory function of preschool children.

Quantifying the Impact of Common Feeding Interventions on Nutritive Sucking Performance Using a Commercially Available Smart Bottle

An estimated 25% to 40% of infants experience difficulties with learning to breast- or bottle-feed. Yet, guidelines and evidence-based support for common feeding practices are limited. The objective of this case report was to quantify the impact of feeding interventions on nutritive sucking performance after discharge in an outpatient setting. This observational case series involved 2 infants. To determine the impact of cumulative interventions, pre- and postintervention effect sizes were calculated. Sucking performance metrics of interest included nipple movement peak sucking amplitude, duration, frequency, and smoothness. Interventions included positional changes and changes in nipple flow rate, among others. For both infants, cumulative interventions had the greatest impact on suck frequency; postintervention, infants were able to increase their rate of nutritive sucking per burst. Other aspects of sucking performance were differentially impacted for each baby. Researchers agree that neonatal and infant feeding has been understudied and that the evidence for common interventions needs to be strengthened. We have demonstrated the implementation of readily available technology that can be used to quantify the direct impact of any intervention on actual sucking performance. In doing so, we can individualize care to support skill development and improve outcomes for infants at risk for ongoing feeding challenges.

Bottle milk feeding and its association with food group consumption, growth and socio-demographic characteristics in Chinese young children

It is recommended that infants from the age of 12 months should be weaned from bottles. However, an overwhelming proportion of young children were still using bottle after the recommended age of bottle-weaning. This cross-sectional study examined the association between utensils for milk drinking and food group consumption, growth and socio-demographic characteristics among young children. Data from the Survey of Infant and Young Child Feeding in Hong Kong were analyzed for 649 children aged 18-48 months old. Dietary outcomes were obtained via 3-day dietary records, while utensils for milk drinking and socio-demographic characteristics were collected from a self-developed questionnaire. Length/height and weight of the children were measured by the nurses. Results showed that daily consumption of formula milk was significantly greater among bottle users or bottle plus cup users than non-bottle users (p < 0.05). Exclusive bottle users had significantly lower intakes of meat and meat alternatives than bottle plus cup users for the 18 to 24-month group (p = 0.001) and lower intakes of fruits than non-bottle users in the 48-month group (p = 0.015). BMI z-score was significantly higher for exclusive bottle users than non-bottle users, even after adjusting for socio-economic factors and child's age (p = 0.006). The results showed that the milk drinking utensil was associated with the amount of formula milk and food group consumption as well as BMI z-score. There is a need to actively discourage prolonged bottle use in order to help young children develop good dietary habits. © 2016 John Wiley & Sons Ltd.

Iron deficiency in young children: a risk marker for early childhood caries

Aim:

Evaluate the coexistence of iron deficiency and early childhood caries.

Evaluate whether iron deficiency can be considered as a risk marker for early childhood caries.

Estimate the incidence of iron deficiency in children with early childhood caries.

To evaluate and compare the iron status of children with and without severe early childhood caries.

Materials and methods: Sixty children of age 2 to 6 years in whom blood investigations are advised by pediatricians are selected for the study and are divided into early childhood caries (ECC) and control groups according to the def index. After obtaining the informed consent from parent, blood investigations are carried out in these children for the estimation of iron status.

Results: All the values depicting the iron status are found to be decreased in the clinical trial group (ECC group) and they are statistically significant.

Conclusion: Iron deficiency is observed definitely in children having ECC.

How to cite this article: Koppal PI, Sakri MR, Akkareddy B, Hinduja DM, Gangolli RA, Patil BC. Iron Deficiency in Young Children: A Risk Marker for Early Childhood Caries. Int J Clin Pediatr Dent 2013;6(1):1-6.

The relationship between cow's milk and stores of vitamin D and iron in early childhood

OBJECTIVE

To examine the association between cow's milk intake on both vitamin D and iron stores in healthy urban preschoolers.

METHODS

Healthy children 2 to 5 years of age were recruited from December 2008 through December 2010 through the TARGet Kids! practice-based research network. Cow's milk intake was measured by parental report. Vitamin D and iron stores were measured by using serum 25-hydroxyvitamin D and ferritin. Bivariate multivariable linear regression was used to examine the effect of cow's milk intake simultaneously on 25-hydroxyvitamin D and serum ferritin. Analyses were stratified by important clinical variables including skin pigmentation, bottle feeding, vitamin D supplementation, and season.

RESULTS

Among 1311 children, increasing cow's milk consumption was associated with decreasing serum ferritin (P < .0001) and increasing 25-hydroxyvitamin D (P ≤ .0001). Two cups (500 mL) of cow's milk per day maintained 25-hydroxyvitamin D >75 nmol/L with minimal negative effect on serum ferritin for most children. Children with darker skin pigmentation not receiving vitamin D supplementation during the winter required 3 to 4 cups of cow's milk per day to maintain 25-hydroxyvitamin D >75 nmol/L. Cow's milk intake among children using a bottle did not increase 25-hydroxyvitamin D and resulted in more dramatic decreases in serum ferritin.

CONCLUSIONS

There is a trade-off between increasing 25-hydroxyvitamin D and decreasing serum ferritin with increasing milk intake. Two cups of cow's milk per day appears sufficient to maintain healthy vitamin D and iron stores for most children. Wintertime vitamin D supplementation was particularly important among children with darker skin pigmentation.

Cup introduction, drink type and vitamin supplementation in preterm babies at 11-25 months

BACKGROUND

  To avoid adverse effects of prolonged bottle use, the recommendations are that full-term babies are introduced to cups from 6 months and discouraged bottles from 12 months old. There are no recommendations for preterm babies. In the UK, the Department of Heath recommends the introduction of vitamin supplements, alongside the transition from formula to cow's milk. The present study aimed to determine age of cup introduction in a group of preterm babies, identify drinks offered from bottles versus cups and the types of cups used, and establish the prevalence and appropriateness of vitamin supplementation.

METHODS

  A validated postal questionnaire was sent to the parents of 369 babies born <34 weeks of gestation at Queen Charlottes Neonatal Unit; 104 sent in 2003 and 265 sent in 2004-2005. The questionnaire was sent when the babies were calculated to be between 12 and 18 months (all ages stated are uncorrected). A separate questionnaire was sent for each baby from multiple pregnancies.

RESULTS

  The questionnaire return rate was 46% (n = 169). Length of gestation (P < 0.001), hospital stay (P = 0.009), birth weight (P = 0.002) and maternal age (P < 0.001) were significantly greater and more mothers were of European origin (P = 0.036) for those babies for whom questionnaires were returned compared to nonresponders. Infant gender did not differ. Fifty-seven percent had been introduced to a cup before 12 months, distribution was: 58% (n = 53) of singletons, 54% (n = 37) of twins and 67% (n = 6) of triplets. This rose to 80% before 13 months. Thirteen percent (n = 22) had not started drinking from a cup and 17% (n = 29) only used cups at the time of the questionnaire. Cow's milk had been introduced to 69% (n = 117) of all babies and 32% (n = 54) were still on formula (10 on both and eight were on neither; hence, the figures do not sum to 100%). Cow's milk was drunk from bottles by 56% (n = 95) and formula by 31% (n = 52). A significantly greater proportion of twins and triplets were drinking cow's milk compared to singletons [80% (n = 62) versus 60% (n = 55) P = 0.005] and significantly fewer were drinking formula [22% (n = 17) versus 40% (n = 37) P = 0.012]. Water was the drink most commonly given from a cup (80%) (n = 135) followed by juice, which was given to 64% (n = 108). Juice drinks were given by bottle in 16% (n = 27). Fifty-two percent (n = 88) used a 'spill-proof' cup some of the time. Vitamins were given as recommended in 18% (n = 31), given even though not recommended in 12% (n = 20), not given but recommended in 49% (n = 83) and appropriately not given in 21% (n = 35). A greater percentage of twins and triplets, compared to singletons, were not commenced on vitamins, even though they were no longer drinking formula.

CONCLUSIONS

  The present study reports baseline data on cup introduction in preterm babies both from singleton and multiple births. The data suggest that education about appropriate bottle drinks, timing of cup introduction, suitable cups and the correct use of vitamin drops is required. However, because the profile of responders differed from nonresponders, these results may not be applicable to all preterm babies.

Office-based intervention to reduce bottle use among toddlers: TARGet Kids! Pragmatic, randomized trial

OBJECTIVE

The goal was to determine whether an office-based, educational intervention for parents of 9-month-old children could reduce bottle use and iron depletion at 2 years of age.

METHODS

Between January 2006 and 2007, 251 healthy, 9-month-old infants attending a routine health maintenance visit were assigned randomly to intervention or control groups. Parents in the intervention group were introduced to a 1-week protocol to wean their children from the bottle. Iron depletion (ferritin levels of <10 microg/L) and bottle use at 2 years were assessed.

RESULTS

A total of 201 children were monitored to 2 years of age (follow-up rate: 81%). Rates of iron depletion (10 [10%] of 102 children vs 13 [13%] of 99 children; P = .42) and milk consumption of >16 oz (16 [16%] of 102 children vs 17 [17%] of 99 children; P = .7) were not significantly different between the 2 groups at 2 years of age. However, children in the intervention group started using a cup 3 months earlier (9 vs 12 months; P = .001), were weaned from the bottle 4 months earlier (12 vs 16 months; P = .004), and were more than one-half as likely to be using a bottle at 2 years of age (15 [15%] of 102 children vs 39 [40%] of 99 children; P = .0004).

CONCLUSIONS

This simple intervention administered during a health maintenance visit did not result in a decrease in iron depletion at 2 years of age but did result in a 60% reduction in prolonged bottle use.

Inappropriate bottle use: an early risk for overweight? Literature review and pilot data for a bottle-weaning trial

Identifying early risk factors for childhood obesity is critical, as weight in infancy and early childhood tracks to later periods. Continued bottle use - primarily from excess milk intake - is emerging as a potential risk factor for early childhood overweight. Over three fourths of US infants drink from bottles beyond the recommended weaning age of 12 months, and two thirds of UK infants use a bottle at 18 months. This paper is divided into three parts. Part 1 reviews the literature on beverage intake, weight and bottle use in young children. Part II describes pilot data on milk bottle use and weight in 12-60-month-olds, collected prior to a randomized controlled (RCT) trial of a bottle-weaning intervention. Median daily milk bottle consumption at 12 months was 5.0 (interquartile range = 3-6). Among 12-36-month-olds, current users were significantly more likely to be >95th% weight-for-height (19% vs. 0%, P < 0.02), and more were >85% weight-for-height (27% vs. 11%, P < 0.11), vs. non-users. In contrast, current bottle use was not associated with either overweight or obesity in 37-60-month-olds. Part III describes the RCT, begun in fall 2008. It is enrolling 464 parent/12-month-old dyads from a nutrition assistance programme for low-income families. Children's bottle use, anthropometrics, dietary intake and nutrient density (via 24 h recall) are assessed quarterly through 24 months of age. For the intervention, site nutritionists employ a project-developed, visually attractive flip chart. An observational study nested within the RCT will describe dietary changes during this period of feeding transitions.

Reasons for prolonged bottle-feeding and iron deficiency among Mexican-American toddlers: an ethnographic study

OBJECTIVE

Several studies have shown that prolonged bottle-feeding is associated with iron deficiency. Mexican-American toddlers are the racial/ethnic group at greatest risk for prolonged bottle-feeding and iron deficiency, yet no studies have examined reasons for prolonged bottle-feeding in Mexican-American toddlers. The objective of this study was to assess infant feeding beliefs, knowledge, and behaviors among Mexican-American parents.

METHODS

Ethnographic interviews were conducted of parents of Mexican-American toddlers 15 to 48 months old at 3 community sites. A 31-question moderator's guide addressed 4 domains: knowledge and cultural beliefs; sources of nutritional information; anticipatory guidance; and suggestions for ways to change infant feeding practices. Interviews were audiotaped, transcribed, and analyzed using grounded theory.

RESULTS

Thirty-nine parents were interviewed; the mean parental age was 29 years, and mean child age, 2.2 years. Parents cited convenience as a reason for prolonged bottle-feeding, and believed that they should give toddlers as much milk as they want. Many parents lacked essential knowledge regarding infant feeding practices and iron deficiency, including when to stop bottle-feeding, health problems caused by prolonged bottle-feeding, the quantity of milk to give a child >1 year old, and iron deficiency as a complication of prolonged bottle-feeding. Parents reported not receiving enough education from physicians, and they supported educational interventions on healthy infant feeding practices, including refrigerator magnet charts, videos, brochures, and teaching by physicians.

CONCLUSIONS

Parents of Mexican-American toddlers often are unaware of the adverse consequences of prolonged bottle-feeding and developmental problems associated with iron deficiency. Parents supported educational interventions, including videos, brochures, and refrigerator magnet charts on healthy infant feeding practices.

Randomized controlled trial of bottle weaning intervention: a pilot study

Inappropriate baby bottle use is associated with tooth decay, anemia, and overweight, and it may adversely affect dietary patterns. Parents often do not follow guidance to wean by 18 months of life. We piloted a brief, counseling-based weaning intervention in an urban WIC agency among primarily Hispanic parent/toddler dyads. At baseline (n = 48), toddlers consumed a mean 4.7 bottles/day. At follow-up (n = 39), the intervention group consumed fewer mean bottles/day than controls (0.09 vs 2.0 bottles/day, P < .045). Half the toddlers in the experimental group and one third of the control groups weaned completely. Parents of weaned children were satisfied with the outcome.

Is late bottle-weaning associated with overweight in young children? Analysis of NHANES III data

To determine whether age of bottle-weaning is associated with overweight in young children, National Health and Nutrition Examination Survey III data for 3027 children aged 3-5 years were analyzed. The main outcome measure, the child's body mass index (BMI), was measured as: <85%, 85-95%, >95%. Mean bottle-weaning age was 18.78 months. After adjustment for potential confounders, each additional month of bottle use corresponded to a 3% increase in the odds of being in a higher BMI category (95% CI 0.0099-0.0535). Prolonged bottle use in young children is associated with increased risk of overweight. From a preventive medicine standpoint, decreasing exposure to this potential risk for childhood overweight is indicated.

Breastfeeding, food choices, restrictive diets, and nutritional fads

In the past year, a number of studies were published that illustrated the importance of dietary choices at all ages and singled out pediatricians as useful and vociferous advocates for healthy nutrition in children. Obesity continues to top the list as a major threat to the health of children and adults worldwide and is increasingly being recognized as a direct result of inappropriate nutritional intake. Parental misperceptions and misinformation about their children's diets beginning in infancy and stretching into the college-age years may represent prime targets for pediatricians ready and able to provide guidance. There are more reasons than ever to encourage breastfeeding and more formal studies to help direct the various stages of transition to adult eating habits after infancy. On the other hand, parents must be encouraged to take a well-balanced and reasonable approach to their children's food choices, lest we see increasing evidence of unnecessary nutritional deficiencies.