June 2008

Objectives: To evaluate the effectiveness of intensive counselling on bottle weaning. Methods: A randomised prospective controlled study was conducted. Parents of 4-month-old babies who attended an inner-city clinic affiliated with the Department of Paediatrics, University of Louisville, Louisville, Kentucky with predominately African-American, indigent population were invited to participate. The parent/infant pairs were randomized to either intervention or control groups. Demographic information was recorded and both groups were surveyed on the parent’s beliefs and knowledge of weaning from the bottle. The intervention group parents received scripted counselling, including use of feeding cups, and were shown pictures of severe early childhood caries and a dental model of early childhood caries at four, six, nine, and 12 month visits. Two paediatricians who are on the clinic staff used the same script when talking to parents while showing the same photos and dental model to assure symmetry. The control group parents received brief counselling on the use of a feeding cup at 6 month and bottle weaning at nine and 12 months with no photographs or dental models shown. Two dentists, blinded to the group assignment, examined all of the children between the ages of 12 months and 24 months. Results: One hundred eighty-five parent/infant pairs were enrolled and 132 pairs (65 control and 67 intervention) remained at the end of the study. Demographic variables, socioeconomic status and race were similar for both groups. When surveyed, more of the control mothers believed that children should be weaned by 12 months (p=0.049). Yet, only 17% of their infants were weaned by 12 months, compared to 27% of the intervention infants (p=0.168). Conclusion: This small study demonstrated no change in parental behaviour after intense counselling. Key words: baby bottle, dental caries, weaning Introduction For many years the recommendation has been to wean the baby from the baby bottle by 12 months of age. There are several problems related to long term baby bottle exposure. Inappropriate feeding practices with the baby bottle are associated with dental caries in young children. Known for many years as baby bottle tooth decay, early childhood caries (ECC) is a distinctive pattern of rampant decay that classically presents in a child aged six or younger (Paediatric Dentistry Reference Manual, 2004). Children from low-income families are also at higher risk for experiencing dental caries and among minority populations in the United States, ECC is in epidemic proportions (Pinkham et al., 1998; Johnsen, 1982). It has been recognized as a significant public health problem (Proceedings, 1998; Oral Health in America: A Report of the Surgeon General, 2000). The U.S. Surgeon General in the report, “Oral Health in America”, stated that dental caries is the single most common chronic childhood disease – five times more common than asthma and seven times more common than hayfever (Oral Health in America: A Report of the Surgeon General, 2000). To educate parents and to identify disease early, the American Academy of Paediatrics (AAP) recommends that every child should begin to receive oral health risk assessment by six months of age from a paediatrician or a qualified paediatric health professional (American Academy of Paediatrics, 2003). The AAP Guidelines for Health Supervision II recommends the introduction of the cup at eight months of age and complete weaning by 15 to 18 months of age (Korsch et al., 1988). The recommendations of the American Academy of Paediatric Dentistry (AAPD) are: 1) No bottle in bed or ad libitum nocturnal breastfeeding, 2) Wean from the bottle by 12 to 14 months, 3) Juice should be from a cup, not a bottle, 4) Oral hygiene should begin with the eruption of the first tooth, 5) The first professional visit should occur within six months of the eruption of the first tooth, no later than 12 months, 6) Measures should be taken to lower the mutans streptococci levels of the mother/primary caregiver to decrease the risk of developing ECC. (AAPD, 2004) The literature contains contradictory information on when to wean despite strong recommendations from the AAP (Frazier et al., 1998). Specified ages to achieve weaning varied from 12 to 18 months. Koranyi et al., (1991) reported that 94% of paediatricians provide information to parents about weaning and that 80% recommend specific ages to begin and accomplish bottle weaning, 12 and 16 months respectively. Frazier et al., (1998) observed that vague and inconsistent recommendations from experts hamper the counselling and education efforts among physicians. Furthermore, there is evidence that some types of parental education may not work well in high-risk populations (Benitez et al., 1994; O’Sullivan and Tinanoff, 1993). Children with ECC are more likely to have parents who do not know that it is wrong to put a child to bed with a bottle (O’Sullivan and Tinanoff, 1993; Febres et al., 1997). Some authors feel that par- Correspondence to: Professor Sofia Franco, M.D. Department of Paediatrics/C&Y, University of Louisville SOM, Louisville, KY 40292, USA. E-mail: smfran01@ louisville.edu