Bottle to Cup Group

Oral health promoters, Nurseries, Playgroups, Creches, Social Services, Community pharmacists, Sure Start projects, Health Visitors, Weaning Groups, Mother and toddler/baby groups, Health professionals using local media, Supermarkets/retailers, Children's out-patients, Children's hospitals, Dental hospitals, Soft play providers, Retailers of Baby products, Parenting co-ordinators

This briefing paper from the Community Nutrition Group of the British Dietetic Association expresses concerns about the inappropriate and extended use of feeder bottles with young children.

The Community Nutrition Group is the professional-interest group of around 400 dietitians working in the community. It is the largest sub-group of the British Dietetic Association, the professional organisation of State-Registered Dietitians.

The Department of Health and MAFF recommend that infants should be introduced to drinking from a cup from 6 months of age, and the use of a bottle should be actively discouraged after the age of 1 year (COMA Report 45, Weaning and the Weaning Diet, 1994; MAFF, Healthy diets for infants and young children, 1997).

Although the exact number of young children using a feeder bottle past the age of 1 year is not known, it Is recognised by health professionals as a serious and growing problem.

Long-term health problems that can result from inappropriate and extended use of a feeder bottle include:

• bottle caries.
• poor feeding technique.
• food refusal.
• iron deficiency anemia.
• failure to thrive.
• speech problems.
• childhood obesity.

Sugary and acidic drinks given little and often throughout the day (and especially throughout the night), in a bottle, can seriously damage teeth.

Infants can chew from about 6 months old. If not encouraged, the ability to chew may not develop readily and teaching older infants to chew can be difficult.

For this reason, infants adapt more successfully to dietary changes of weaning if solid foods are offered from a spoon or given as finger foods for the infants to hold and experiment with. Solids should NEVER be added to a bottle as the ability to chew will not be so readily developed.

As weaning progresses, fluids should NOT be allowed to displace food at meal times. Drinks should be offered after meals, not before. Health professionals see a number of feeding problems arising because an infant/child has filled up on a bottle - so they have no room in the stomach to accommodate any food, and no interest in trying the food offered.

Similarly It is a natural developmental progression for sipping and swallowing to replace sucking. Feeding from a cup/beaker should begin from around 6 months. This may seem more messy and less 'convenient' initially but it is a very important skill to develop.

If fluid is allowed to displace food in the infant/young child's diet, nutritional deficiencies may arise.

For example, there would appear to be a clear link between the extended use of feeder bottles and the incidence of iron deficiency anaemia. This has important effects, including poor weight gain, poor appetite, recurrent mild infections, behavioural problems and psychomotor delay.

Iron deficiency anaemia is particularly prevalent among same Asian communities in deprived inner-city areas. A number of studies have suggested that the principal factor may be prolonged bottle-use and the use of drinks in place of solid food.

In a study of Asian mothers in the north of England, the consumption of milk, usually sweetened and g en in a feeding bottle, was found to be central to their concept of a 'healthy diet'. This idea was reinforced by family and friends.

Mothers felt that weaning should occur after one year and even as late as five years of age.

Similarly, in the Asian community of Inner-city Derby, where the incidence of iron deficiency anaemia is almost 50%, anaemic children were found to derive a much higher percentage of their energy intake from drinks.

Health professionals also see the practice of tea being given to children In feeder bottles. Tannins In the tea limit iron absorption from the diet, further aggravating the problems of iron deficiency anaemia.

Lean red meat is a particularly good source of dietary iron which is why it is important to develop good chewing skills.

Other problems may also be linked to inappropriate drinking habits, although as yet there is little research-based evidence.

For example, many speech therapists have anecdotal evidence that prolonged use of feeding bottles may lead to speech problems, particularly delayed speech, since use of a teat affects tongue mobility and discourages vocalisation.

Childhood (and possibly even adult) obesity may also be linked. Certainly, new evidence suggests that breast feeding is associated with a reduced incidence of obesity in later years, and that infants who are breast-fed are offered more appropriate drinks when additional fluids are introduced.

This briefing paper concludes that there should be less emphasis on the bottle after the age of 6 months, with the aim of discontinuing its use entirely by the age of 1 year.

COMMUNITY NUTRITION GROUP RECOMMENDATIONS

Increase public awareness about the importance of introducing a cup/beaker from the age of 6 months and not using a feeder bottle after a child is I year old.

Increase public awareness about the importance of introducing a cup/beaker from the age of 6 months and not using a feeder bottle after a child is I year old.

Manufacturers of infant feeding products have a responsibility to their customers to provide information about the use and abuse of cups and bottles, and what fluid is put in them.

For example, some infant milk formulae state 'for bottle-fed babies'. This should be rephrased to avoid the implication that it can only be given in a bottle.

The packaging on 'follow-on' formulae should only provide guidance on feeding from a cup/beaker.

Some manufacturers add a substantial amount of sugars, sweeteners, colourings and flavourings to their infant drinks, and use subtle marketing techniques to imply that a parent who gives 'plain' milk or water is depriving their child of pleasure. This is totally unethical and should cease.

Retailers, like manufacturers, have a responsibility to promote public awareness.

WHICH CUP?

The variety of drinking vessels on the market said to be suitable for making the transition from bottle to cup is overwhelming and very confusing.

They range from ordinary beakers and cups with one or two hand's to bottles whose decoration proclaims them as being for older children rather than infants. All combinations of spouts and tops are combined with one, two or no handles. Spouts range from non- spill types with membranes, to ones with one, three or five holes. Flow rates vary from simple pouring down to liquid flowing only when the child sucks. Of special concern are those 'cup kits' which supply a basic vessel with a variety of top attachments, including a teat- which of course encourages the continued use of a teat.

Speech Therapists agree that lidless cups are best to encourage the child to move on from a sucking movement and in particular to discourage tongue-thrusting. Two handles make the child present the cup at the best angle and give more control to prevent spills.

The Doidy cup has a sloping lid- less top, enabling the child to see the contents without thrusting their head forwards and downwards. This cup is particularly good for teaching cup control because the two handles and sloped top allow even very young children to drink without accidents and thus gain confidence. At the moment this cup is only available by mail order from the manufacturers. Due to consumer demand this type of cup will soon be more widely available in major retail outlets.

If parents are unhappy with the mess that can ensue from babies drinking from lid-less cups, the best cups to choose are those where the fluid can flow without sucking and where the child can easily grasp or hold the cup (often two handles or a narrow beaker are best).

Tommee Tippee have recently reintroduced a two-handled cup which can be bought with a concave plastic top with an 8mm-diameter hole near the edge. Liquid flows freely when the child drinks and the child's nose can point into the cup as if it were lid-less, yet there Is less scope for mess when the cup is waved around after drinking. This product retails more widely and cheaply than the Doldy cup.

Membrane cups, sold as valved feeder cups, any-way-up cups or no- spill cups, are particularly to be avoided. Although there will not be the curling of the tongue which occurs with a bottle or dummy teat, they still need to be sucked hard enough for tongue thrust to continue (as with a bottle).

The views of oral health specialists are very similar, with an emphasis on using a drinking vessel which pours fluid into the mouth rather than demanding sucking movements that swirl the drink around the teeth. Spouts should be short to ensure the fluid is tipped just inside the lips. Straws are good once the child can master them.

Dietitians are also keen to promote cups where no sucking is required. This ensures that drinking only occurs in response to thirst and not for comfort. Cups which are more likely to make a mess when thirst has been quenched encourage supervised drinking and distinct eating and drinking episodes throughout the day.

Cool Kids Use Cups

Resources to encourage healthier drinking practices in young children are available from the Comic Company.