Pediatric Educational Intervention May Reduce Prolonged Bottle Use

From MedscapeCME Clinical

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

July 13, 2010 — A simple educational intervention administered during a health maintenance visit reduces prolonged bottle use by 60% but does not reduce iron depletion at age 2 years, according to the results of a study reported online July 12 in Pediatrics.

"Observational studies suggest associations between prolonged bottle-feeding, excessive milk intake, and iron deficiency," write Jonathon L. Maguire, MD, MSc, from the University of Toronto in Ontario, Canada, and colleagues. "The [American Academy of Pediatrics] recommends complete bottle-weaning by 15 months, but many parents bottle-feed much longer. No evidence-based interventions exist to promote timely bottle-weaning."

The objective of this pragmatic, randomized trial was to assess the effect of an office-based, educational intervention for parents of 9-month-old children on reducing bottle use and iron depletion at age 2 years. During a routine health maintenance visit between January 2006 and January 2007, a total of 251 healthy, 9-month-old infants were randomly assigned to an intervention group (n = 129) or to a control group (n = 122).

In the intervention group, parents were introduced to a 1-week protocol designed to wean their child from bottle-feeding. The intervention could be administered in less than 5 minutes. Parents were given a sippy cup and taught how to use it to transition their child from the bottle, and they were also counseled regarding the risks for continued bottle use, including tooth decay, iron depletion, and poorer school performance. Study outcomes were iron depletion, defined as serum ferritin levels of 10 μg/L or less, and bottle use at age 2 years.

Follow-up rate was 81%, with 201 children monitored to age 2 years. In the intervention group, children began drinking from 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 age 2 years (15 [15%] of 102 children vs 39 [40%] of 99 children; P = .0004) vs the control group. However, the 2 groups were not significantly different at age 2 years in rates of iron depletion (10 [10%] of 102 children vs 13 [13%] of 99 children; P = .42) and in milk intake of more than 16 oz (16 [16%] of 102 children vs 17 [17%] of 99 children; P = .7).

"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," the study authors write.

Limitations of this study include possibly insufficient power to show a reduction in iron depletion resulting from earlier bottle-weaning, risk for contamination between groups, and follow-up limited to age 2 years.

"Additional studies are needed to determine whether decreasing prolonged bottle use could lead to a reduction in iron depletion in higher-risk populations, as well as other proposed consequences of prolonged bottle-feeding, including bottle-related caries, otitis media, and behavior problems," the study authors conclude.

This study was supported by a grant-in-aid from the Danone Institute of Canada. The Pediatric Outcomes Research Team is supported by a grant from the Hospital for Sick Children Foundation. Dr. Maguire was supported by a Canadian Institutes of Health Research fellowship. The other study authors have disclosed no relevant financial relationships.

Pediatrics. Published online July 12, 2010.
Clinical Context

The American Academy of Pediatrics recommends that children be weaned off bottle feeding by age 15 months. There is an association between bottle feeding beyond ages 15 to 18 months and excessive milk intake and iron deficiency from observational studies. However, pediatricians do not routinely counsel parents to wean their children off bottles after age 15 months.

This is a prospective randomized study to compare rates of iron depletion and feeding behaviors with vs without an educational intervention for parents at a 9-month routine health maintenance visit.