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Prolonged Bottle-feeding and Iron Deficiency Anemia

Am Fam Physician. 2006 Aug 15;74(4):661-662.

Iron deficiency anemia in young children can cause delayed mental and psychomotor development and behavioral disturbances. These problems may persist into adolescence and can result in impaired learning, decreased school achievement, and lower mental and motor development test scores. Iron deficiency without anemia is more common than iron deficiency with anemia. In the general population, the prevalence of iron deficiency is 9 percent among children 12 to 30 months of age. The prevalence increases substantially in urban areas and is highest among children in lower socioeconomic groups.

One simple technique to reduce the risk of iron deficiency anemia is to limit the amount of cow’s milk children ingest. In a previous study, 8 percent of children between two and five years of age were still being bottle-fed. The current recommendation for bottle-feeding is to introduce a cup at six months of age and wean off the bottle by 15 months of age. Only one study examined the relationship between prolonged bottle-feeding and iron deficiency. Brotanek and associates studied the impact of prolonged bottle-feeding on the prevalence of iron deficiency anemia in children.

The participants in the study were from the National Health and Nutrition Examination Survey III. This was a national survey of noninstitutionalized children, two months and older and living in households. The participants completed an extensive interview and were examined at a mobile health center. Data evaluated from this survey included the feeding practices of children one to three years of age. In addition, laboratory data on measures of stored iron were incorporated. Independent variables included age, sex, economic status based on federal poverty level, caretaker education, weight-for-height status, birth weight, and blood lead levels. The authors also considered the child’s race and ethnicity, including black, white, and Mexican American. However, other minority and ethnic groups were excluded from the analysis because their sample sizes were too small.

There were 2,121 children who met the inclusion criteria and were enrolled in the study. The prevalence of iron deficiency was 5.7 percent among whites, 8 percent among blacks, and 16.9 percent among Mexican Americans. There was a significant correlation between iron deficiency and prolonged bottle-feeding in the participants, with 12.4 percent of children with iron deficiency still being bottle-fed at 24 to 48 months of age. In the study, 36.8 percent of Mexican American children, 16.9 percent of white children, and 13.8 percent of black children were still being bottle-fed at 24 to 48 months of age. The odds ratio for developing iron deficiency anemia was 2.8 (95% confidence interval [CI], 1.3 to 6.0) for children still being bottle-fed at this age and 2.9 (95% CI, 1.5 to 5.6) for Mexican American children.

The authors conclude that prolonged bottle-feeding increases the risk of iron deficiency anemia in children. In addition, Mexican American ethnicity is a significant risk factor. The authors add that screening practices and nutritional counseling should be directed at these two high-risk groups, and they encourage physicians and other health care providers to educate parents about the importance of being weaned from the bottle by 15 months of age.

Brotanek JM, et al. Iron deficiency, prolonged bottle-feeding, and racial/ethnic disparities in young children. Arch Pediatr Adolesc Med. November 2005;159:1038–42.


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