Saturday, March 29, 2014

Bottles for toddlers, nursing for toddlers

Well, it's been a while since I blogged: choosing nursery school programs (my baby is now three! How did that even happen?) while working full time and studying tends to do that to a girl. In fact, for a while I kind of lost my obsession with infant feeding politics, and even found myself contemplating the idea of starting a blog about education instead. Still, now that the school thing is settled and things are starting to quieten down, I'm looking forward to posting a bit more frequently than I have done these past few months.

So: bottles for toddlers vs. nursing for toddlers. Many parents can't help noticing that there seems to be a bit of a double standard in the world of toddler-feeding advice: nursing beyond the age of 12 months is officially condoned and even encouraged by the Powers That Be (the World Health Organisation (WHO), American Association of Pediatrics (AAP) and the National Health Service in the UK), while bottle-feeding parents are advised in no uncertain terms to stop the bottle at 12 months, if not before. This chafes at some bottle feeders; the attachment that babies form to their bottles not only makes bottle weaning quite tricky, but also makes many parents reluctant to take away something that seems to give their child so much comfort. Is this double standard justified or not?

Bottle problems
Pediatricians and health visitors tend to be down on bottles because they come across so many examples where prolonged, frequent use of bottles causes lots of problems; this is why in child welfare departments, there is a lot of talk about "delayed bottle weaning" as a social problem, and many public health authorities actually carry out "bottle-to-cup" campaigns in an attempt to get babies off the bottle. The "prolonged bottle use" thing and the problems that it is associated with tend to be seen most often in young, poor parents with low levels of education and a lack of family support; they are also commoner in certain ethnic groups. You see a lot of kids dragging bottles and dummies around in the South Yorkshire city I where grew up (which has quite a lot of poverty and social problems).

Feeding toddlers meals is a PITA; you have wrestle your screaming gremlin into a chair, nag/beg/persuade the food into them, and then clear up all the mess. By contrast, toddlers love their bottles, and all you have to do is fill it up and hand it to them. It keeps them quiet in the house, in the stroller, in the car seat. It can be awfully tempting to just keep handing out the bottles rather than make serious efforts to get the kid eating proper meals at proper times. But this results in a child having a constant drip-feed of calories into their mouth, greatly increasing the risk of serious dental decay. Before long, parents often start putting regular fridge milk in the bottle rather than formula, with the result that the toddler fills up on way too much cow's milk, causing serious nutritional imbalances. Worse still, sweet drinks and juice sometimes get put in. Toddlers drop bottles constantly, pick them up covered in grot, and then put them straight into their mouths again. Having a bottle teat (or pacifier) in the mouth too much may also increase the risk of dental malocclusion such as an overbite. The worst problems are seen in toddlers who are "put down to sleep with a bottle"; this can lead to rampant tooth decay, sometimes requiring the removal of multiple teeth. (Oh, if you do a search for "baby bottle mouth" or "bottle rot," by the way, for God's sake make sure "image search" is switched off first; there are some truly disturbing pictures of rotten teeth out there on the Web).

Does doing-bottles-past-12-months have to look like the above scenario? By no means. My own nieces, for example, continued to have a single bottle of formula with their bedtime story (before tooth brushing) for many years, and suffered from none of the above problems; they ate meals and drank properly from a cup during the daytime. A bottle of formula around bedtime was just a comforting bedtime ritual for them, not to mention being a much-appreciated nutritional backup for times when picky eating was playing havoc with their diets. Clearly, then, the whole bottles-for-toddlers thing is very much a question of degree. I think a distinction needs to be drawn between parents letting their toddlers wander around with bottles (or lie down with them at night) versus those who allow bottles for toddlers but only in a careful and restricted way.

What about breastfeeding?
Honestly, I think breastfeeding a toddler is a little different to bottles for a couple of reasons.

The expression on this mummy sheep's face somehow
 makes me feel that nursing has been "extended"
a bit longer than she's comfortable with...
For one thing, bottles can potentially be filled up with all sorts of stuff like sugary drinks, whereas nothing comes out of a breast except breastmilk. Breasts, unlike bottles, can't be dropped on the ground and put back in the mouth covered in germs. It's not quite clear whether daytime breastfeeding is connected with tooth decay; if it is, the relationship seems to be a lot less strong than with extensive bottle-feeding. And breastfeeding for longer does not seem to be linked with dental malocclusion, unlike prolonged and extensive use of pacifiers and bottle teats. This is probably because although sucking milk out of a breast may look superficially similar to sucking out of a bottle, what's actually going on inside is surprisingly different. For a start, when a breast goes into a child's mouth, the action of the palate s-t-r-e-t-c-h-e-s the nipple it to make it conform to the inside of the mouth, whereas a bottle teat undergoes little stretching while the child's mouth adjusts to conform to the shape of the teat. (This interesting article gives a rather graphic blow-by-blow account of the different oral dynamics of bottle- vs breastfeeding; I particularly enjoyed the description of the baby removing milk from the bottle with a "piston-like stripping action"--where do these health professionals get their metaphors from?)

But I think the big difference between breastfeeding and bottle usage during the toddler years is that breastfeeding is by its nature self-limiting. Nursing means mum has to sit/lie down while kiddo has to interrupt whatever play or activity they are engaged in--which of course toddlers resent doing. So the vast majority of toddler/mother pairs quickly cut down on nursing as the child becomes more mobile. Bottles, on the other hand, are not attached to a person, so if you are stressed, overstretched, uneducated or just a bit lazy, it can be tempting to let the kid wander around with one or have in their mouth constantly in the stroller or car seat. I remember thinking about this suddenly last summer when I was at South Yorkshire Wildlife Park for the day; you saw a lot of toddlers and preschoolers walking around with a bottle or dummy on and off throughout the day, but you couldn't possibly do extended nursing like that. Like, what would you do--get one tit out and shuffle along backwards on your knees for hours on end? All in all, I can see why public health authorities generally don't bother much about extended nursing as a possible health concern in the way they worry about prolonged use of bottles; most of the issues which are associated with excessive use of bottles don't really apply to breastfeeding.

I do think, however, that a partial exception should be made for nighttime nursing; if mothers bedshare, night-nursing is the one type of nursing which really can potentially go on for hour after hour, and there does appear to be the potential for breastmilk to "pool" in the mouth. The jury seems to be out on whether night nursing causes tooth decay; personally, however, I feel that if there is any question that it could…. really, why on earth would one choose to take the risk, given that early childhood caries is irreversible, painful, traumatic and often very expensive to deal with? Toddlers don't need to eat all night long.

Conclusion
I talked about this a bit in a previous post, but something we have to bear in mind that public health advice tends to be written with the lowest common denominator in mind. I am guessing that The Powers That Be feel more comfortable imposing a crude blanket rule of No Bottles After After Twelve Months, because the parents who are most likely to make genuinely dodgy parenting decisions are the least likely to able to understand and apply advice that is complicated or nuanced in any way. And imagine being the doctor who's had the horrible experience of dealing with a child who has to have a mouth full of rotten teeth yanked due to never-ending sip-feeding out of a bottle. I can understand why health care workers who have to deal with the results of genuinely dodgy bottle use would start to have an almost viscerally negative attitude towards the sight of a toddler drinking from a bottle.

So… I do understand that well-educated formula feeding mothers (who wouldn't dream of letting their toddler wander around with a grubby bottle for hours on end) may find such blanket rules a bit frustrating, but I think the key thing here is to understand that these rules are written primarily with the intention of protecting the children of the less-well-informed from iron deficiency anemia and "bottle rot," not to further alienate and condemn formula feeding mothers, and do not really apply to sensible and restricted bottle usage.


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