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Prolonged baby bottle feeding: a health risk factor.

Deysi is a 2-year-old girl who lives with her parents in a one-bedroom apartment. Her mother and father work outside of the home, approximately 10 hours/day. Child care is provided by a network of women who include licensed home-based providers and a variety of friends and extended family members. On most evenings, Deysi's father picks her up from the child care site and gives her a fresh bottle of chocolate-flavored milk for the 45-minute trip home. She usually fails asleep while drinking it. Deysi's parents see this routine as a comfort for their daughter that usually results in a most welcomed, quiet ear ride home at the end of a busy day.

Documenting the Clinical Encounter

Chief Complaint: Cold symptoms x 3 d, concern about possible ear infection.

Historian: Mother, reliable.


Present History: Cough, runny nose, unusually fussy, rubbing ears 3 or 4 times in past 3 days. Denies fever, wheeze, or changes in activity level, appetite, or fluid intake. Denies diarrhea, vomiting, and rash.

Meds: None.

Allergies: None known.

Immunization Status: Up-to-date.

Past History: BOM x 3 (ages 8, 12, and 18 months).

Development: Says about 50 words, mother understands her speech and reports no apparent hearing difficulty at home.

Family History: Mother-asthma, controlled with medication, MGM-diabetes treated with medication.

Social/Cultural Issues: Both parents work. Multiple babysitters. Watches about 4-6 hours TV/day, often sips from bottle (milk or juice) while viewing, no ETS or known sick exposures.

Nutrition: Eats fruits, vegetables, and meat daily; eats "all offered" foods, drinks 12 oz milk from bottle and 24 oz from cup/day. All milk flavored with chocolate powder. Drinks 12 oz/d juice from bottle. Falls asleep in car and bed with bottle.

Physical Examination

General: Alert, smiling girl in NAD and drinking brown liquid from B oz. bottle.

Vital Signs: Temp: 97[degrees]F (t), HR: 105 RR: 30, Wt. 13 kg (75th percentile), 83 cm (25th percentile), Pain Score: 0.

Eyes: Clear, no discharge or injection.

Ears: TM's pink-grey, non-bulging, visible landmarks.

Nose: Clear to yellow, copious discharge.

Mouth/Throat/Neck: Brown discoloration on posterior surface of both maxillary central incisors, o/p with no erythema, exudates, or lesions; no palpable lymph nodes.

Cardio: RRR, no murmurs.

Chest/Lungs: CTA bilaterally, no wheeze or adventitious sounds, no retractions.


* Viral URI

* Probable Baby Bottle Tooth Decay

* Possible Iron Deficiency Anemia

* Risk for Obesity


1. Reassure: No ear infection observed today.

2. Advise: Cough and cold care, including increase po fluids; careful handwashing among family members; and monitor for worsening of symptoms, including fever, breathing difficulty, or other changes. If they occur, call triage nurse.

3. Advise: Discontinue use of baby bottle; provide Home Care instruction Sheet; discontinue chocolate powder in milk; reduce juice to 4 oz/day.

4. Labs: H and H to assess for iron deficiency anemia (IDA). Will call family with results.

5. Refer to pediatric dentist for evaluation.

6. Return in 1 month for weight check and evaluation of progress in d/c bottle use. Address issue of excessive TV viewing.

Maintaining Continuity of Care

Prolonged baby bottle use (beyond 12 months of age) is a common feeding practice that is often accompanied by recumbent feeding at nap or night time sleep. Kaste and Gift (1995) reported that 19.9% of U.S. children at age 2 years use a baby bottle at bedtime with contents other than water. In their review of the 1991 National Health Interview data set, they found that 9.3% of 3 year olds continued to use a bottle. Further, prolonged bottle use was most often associated with Hispanic ethnicity, poverty, urban residence, and low parental education levels. A more recent community-based study found that 40% of 2 year olds continued to use a bottle as did 16% of 3 year olds, and 8% of 4 year olds. In this smaller study (N - 191), the significant contributing factor for late bottle weaning was mothers' return to work. Their findings were derived from a sample of children with middle class, well-educated parents (Hammer, Bryson, & Agras, 1999).

A systematic review of published research on prolonged baby bottle use yielded several studies that confirmed a significant association between prolonged bottle feeding and/or bottle feeding at sleep time and the incidence of Baby Bottle Tooth Decay (BBTD). For example, an Irish study of 5-year old children (N = 636) found that the presence of caries was significantly related to a history of taking a bottle to bed (Creedon, & O'Mullane, 2001). An Australian study of 3,375 4-to-6-year-old children found that the presence of early childhood caries (the presence of caries on at least one primary tooth in children under 6 years of age) was significantly associated with past infant feeding practices, including both sweetened bottle contents and going to sleep with the bottle (Hallett & O'Rourke, 2002). In the U.S., a study of 120 Hispanic families supported the findings of these international studies. In this research, the practice of going to sleep with the bottle was found to be significantly associated with early childhood caries (Huntington, Kim, & Hughes 2002).

In addition to BBTD, the review yielded studies that demonstrate additional pediatric morbidities associated with prolonged bottle use. A few studies warn that prolonged bottle use increases the risks associated with iron deficiency anemia and obesity, which the Agency for Heathcare Research and Quality (AHRQ, 2003) confirms are on the rise among American children. In a small study (N = 34), Lampe and Velez (1997) compared two groups of 18-month-old toddlers, those who were still bottle fed and those who were weaned from the bottle at 12 months of age. They found that prolonged bottle use was associated with drinking significantly more milk (mean daily intake 26.3 ounces vs. 16.1 ounces) and lower mean iron stores as measured by levels of serum ferritin concentration. The later difference was not, however, statistically significant. Building on this research, Bonuck and Kahn (2002) surveyed 95 caregivers of predominantly Black and Hispanic children aged 18-56 months (average 36 months) about the practice of prolonged bottle feedings. Two-thirds of the children reportedly received daily bottles of milk or sweet liquids, with the number of bottles per day ranging from 2 to 10. Their bottle use was found to be significantly associated with iron-deficiency anemia and obesity. The authors point out that iron deficiency anemia in infancy and early childhood has been associated with delayed mental and psychomotor development and long-term behavioral disturbances. The health sequelae for childhood obesity, including increased risks for diabetes, cancer, and cardiovascular disease, are well-documented.

In addition to significant associations found with tooth decay, iron deficiency anemia, and obesity, prolonged bottle feeding and/or recumbent bottle feeding have also been associated with wheezing in early childhood. Celedon and colleagues (2002) followed a cohort of 448 children with a parental history of atopy from birth through 5 years of age. They found that the risk of recurrent wheezing and asthma at 5 years of age increased significantly with the increased incidence of bottle feeding in the bed or crib before sleep during the first year of life. In a previous study, these researchers had also shown that parental report of bottle feeding a child in the bed or crib at sleep time was associated with an increased risk of wheezing during the first year of life (Celed6n, Litonjua, Weiss, & Gold, 1999).

As a practice guideline to prevent dental caries and related pediatric morbidities, the Bright Futures program recommends that anticipatory guidance for infants include the introduction of the cup for drinking water and juice at approximately 6 months of age, initial weaning from the bottle at 9 months of age, and complete weaning by 12 months (Casamassimo, 1996). In addition, children between 1 and 4 years of age should not drink more than 16 ounces per day of milk or 4 ounces per day of juice (Story, Holt, & Sotfka, 2000). The American Academy of Pediatrics Committee on Nutrition has recommended that children should not go to sleep with bottles (AAP, 1998). The American Academy of Pediatric Dentistry has recommended that an infant oral health evaluation should be performed within 6 months of the eruption of the primary tooth but no later than 12 months of age (AAPD, 1999).

>From the viewpoint of nurses who examine children in primary care settings, the history of baby bottle use and the physical examination can provide important clues. In particular, Beaulieu and DuFour (2000) point out that evidence suggestive of BBTD is the presence of a dull, white band of demineralized enamel along the gingival margin, usually found on the central incisors. Often all 4 maxillary anterior teeth are involved simultaneously. The white band is a marker for a rapidly progressing process that leads to overt caries.

The white band signals the destruction of tooth enamel that is subsequently replaced by yellow or brown areas of decay. The pathological process for BBTD includes the presence of Streptococcus mutans. This is a bacteria that may occur in infant saliva. It facilitates the conversion of the sugar in fermentable carbohydrate liquids, such as milk, formula, and juice to an acid that, in turn, penetrates the protective layer of enamel on affected teeth. The identification of early demineralization requires immediate referral for a pediatric dental exam to prevent long-term sequelae.

In summary, the review of current literature indicates that prolonged baby bottle use, as illustrated in the case of 2-year old Deysi, is a health risk factor for several pediatric morbidities. The Home Care Information forms that follow are designed to serve as a teaching aid when addressing this important clinical problem with parents.


Agency for Healthcare Research and Quality (2003). Prolonged bottle feeding of young children may lead to childhood obesity and iron deficiency anemia. Research Activities, 270, 6.

American Academy of Pediatric Dentistry (1999). Oral health policies. Pediatric Dentistry, 21, 18-37 (http://www.aapd. org).

American Academy of Pediatrics, Committee on Nutrition (1998). Pediatric nutrition handbook, 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Beaulieu, E., & DuFour, L A. (2000). Early childhood caries: How you can help preserve teeth for life. Consultant,40(6), 1129-?.

Bonuck, K.A., & Kahn, R. (2002). Prolonged bottle use and its association with irondeficiency anemia and overweight: A preliminary study. Clinical Pediatrics, 41, 603-607.

Casamassimo, P. (1996). Bright futures in practice: Oral health. Arlington, VA: National Center for Education in Maternal and Child Health.

Celedon, J.C, Litonjua, A. A., Ryan, L., Weiss, S.T., Gold, D.R. (2002). Bottle feeding in the bed or crib before sleep time and wheezing in early childhood. Pediatrics, 110(6), e77.

Celedon, J.C, Litonjua, A. A., Weiss, S.T., Gold, D.R. (1999). Day care attendance in the first year of life and illnesses of the upper and lower respiratory tract in children with familial history of atopy. Pediatrics, 104(3), 495-500.

Creedon, M.I., & O'Mullane, D.M. (2001). Factors affecting caries levels amonst 5-year old children in County Kerry, Ireland. Community Dental Health, 18(2), 72-78.

Harlett, K.B., & O'Rourke, P.K. (2002). Early childhood caries and infant feeding practice. Community Dental Health, 19(4), 237-242.

Hammer, L. D., Bryson, S., & Agras, W. S. (1999). Development of feeding practices during the first 5 years of life. Archives of Pediatric and Adolescent Medicine, 153, 189-194.

Huntington, N.L, Kim, I.J., & Hughes, C.V. (2002). Caries risk factors for Hispanic children affected by early childhood caries. Pediatric Dentistry,24(6), 536542.

Kaste, L.M., & Gift, H.C. (1995). Inappropriate bottle feeding: Status of Healthy People 2000 objective. Archives of Pediatric and Adolescent Medicine, 149, 786-791.

Lampe, J.B., & Velez, N. (1997). The effect of prolonged bottle feeding on cow's milk intake and iron stores at 18 months of age. Clinical Pediatrics, 36, 569-572.

Story, M., Holt, K., & Sofka, D. (Eds.) (2000). Bright Futures in Practice: Nutrition (2nd ed.). Bethesda, MD: Department of Health and Human Services, Health Resources and Services Administration.

Kathleen E Gaffney, PhD, RN-CS, F/PNP, is Professor, College of Nursing and Health Science George Mason University, Fairfax, VA.

Margie A. Farrar-Simpson, MSN, RN-CS, PNP, is Patient Care Director, Inova Pediatric Center Inova Fairfax Hospital for Children, Falls Church, VA.

Delicia Claure, RN, BSN, is Management Coordinator, Inova Pediatric Center, Inova Fairfax Hospital for Children, Falls Church, VA.

Gloria Davila, Interpreter/Translator, is Volunteer, Inova Pediatric Center, Inova Fairfax Hospital for Children, Fails Church, VA.

In today's primary health care environment, clinical encounters are increasingly time-limited. Focused assessments, evidence-based plans for immediate and home-based care, as well as succinct but comprehensive documentation of pediatric visits must all be completed within just a few minutes. This column presents sample documentation for typical clinical case scenarios, rationale for actions to maintain continuity of care, and English and Spanish versions of home care information sheets to support clinical excellence in busy pediatric practice settings. No recommendations for treatment are made or intended as each clinical encounter must evolve from a unique nursing assessment of Individual children and their families.
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Title Annotation:The 15-Minute Clinical Encounter
Author:Gaffney, Kathleen F.; Farrar-Simpson, Margie A.; Claure, Delicia; Davilla, Gloria
Publication:Pediatric Nursing
Date:May 1, 2004
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