Clinical Reference Systems: Pediatric Advisor 10.0
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DESCRIPTION

Breast or bottle feeding can be considered prolonged after about 18 months of age. The older toddler who only occasionally nurses or drinks from a bottle may not need to be pressured into giving up the bottle or breast. Delayed weaning should be considered a problem only if it is causing one or more of the following types of harm:

• refusal to eat any solids after the age of 6 months
• anemia confirmed by a routine screening test at the age of 1 year
• tooth decay or baby-bottle cavities
• obesity from overeating
• withdrawal from other children and lack of interest in play because the child is always carrying a bottle around
• frequent awakening at night for refills of a bottle
• inability to stay with a baby sitter because the child is exclusively breast-fed and refuses a bottle or cup.

If your baby has any of these problems, read the next section. Otherwise, continue to breast or bottle feed your baby when she wants to (but no more than three times a day) and don't worry about complete weaning.

HOW TO ELIMINATE EXCESSIVE BREAST OR BOTTLE FEEDINGS

To decrease breast or bottle feedings to a level that won't cause any of the problems described above, take the following steps:

1. Reduce the number of milk feedings your child receives to three or four a day.

   When your child comes to you for additional feedings, give him extra holding and attention instead. Get your child on a schedule of three main meals a day plus two or three nutritious snacks.

2. Introduce feeding from a cup if this was not done at 6 months of age.

   Cup feedings are needed as substitutes for breast or bottle feedings regardless of the age at which weaning occurs. The longer the infant goes without using a cup, the less willing he will be to try it. Starting daily cup feedings by 5 or 6 months of age is a natural way to keep breast or bottle feedings from becoming overly important.

3. Immediately stop letting your child carry a bottle around during the day.

   The companion bottle can interfere with normal development that requires speech or two-handed play. It can also contribute to problems with tooth decay. You can explain to your child, "It's not good for you to carry a bottle around" or "You're too old for that."

4. Immediately stop letting your child take a bottle to bed.

   In addition to causing sleep problems, taking a bottle of formula or milk to bed may cause severe tooth decay. You can offer the explanations suggested above.

Once you have made these changes, you do not need to do anything more unless you want to stop breast or bottle feedings completely. Attempt total weaning only if your family is not under stress (such as might be caused by moving or some other major change) and your child is not in crisis (such as being sick or learning to use the toilet). Weaning from the breast or bottle to the cup should always be done gradually and with love. The "cold turkey" or abrupt withdrawal approach will only make your child angry, clingy, and miserable. While there is no consensus about the best time to wean, there is agreement about the appropriate technique.

HOW TO ELIMINATE BREAST FEEDING COMPLETELY

1. Offer formula in a cup before each breast feeding.

   If your child refuses formula in a cup, offer expressed breast milk in a cup. If that fails, add some flavoring he likes to the formula. If your child is older than 12 months, you can use whole milk. Some infants won't accept a cup until after they have nursed for several minutes.

2. Gradually eliminate breast feedings.

   First, eliminate the feeding that is least important to your child (usually the midday one). Replace it with a cup feeding. About once a week drop out one more breast feeding. The bedtime nursing is usually the last to be given up. There's no reason why you can't continue bedtime nursing for months if that's what you and your child want.

   Some mothers prefer to wean by decreasing the length of feedings. Shorten all feedings by two minutes each week until they are five minutes long. Then eliminate them one at a time.

3. Relieve breast engorgement.

   Because the breast operates on the principle of supply and demand, the reduced amount of sucking time eventually reduces the amount of milk your breasts produce. In the meantime, express just enough milk to relieve breast pain resulting from engorgement. (This is better than putting your baby to the breast for a minute, because she probably won't want to stop nursing.) Remember that complete emptying of the breast increases milk production.

   An acetaminophen product also may help relieve discomfort.

4. If your child asks to nurse after you have finished weaning, respond by holding her instead.

   Explain to your child that the milk is all gone from your breasts. If your child has a strong desire to suck, a pacifier may help.

HOW TO ELIMINATE BOTTLE FEEDING COMPLETELY

1. Offer formula in a cup before each bottle feeding.

   Use whole milk if your child is 1 year of age or older.

2. Make the weaning process gradual.

   Eliminate one bottle feeding every 3 to 4 days, depending on your child's reaction. Replace each bottle feeding with a cup feeding and extra holding.

3. Eliminate bottle feedings in the following order: midday, late afternoon, morning, and finally bedtime.

   The last feeding of the day is usually the most important one to the child. When it is time to give up this feeding, gradually reduce the amount of milk in the bottle each day for a week.

4. After you have completed the weaning process, respond to requests for a bottle by holding your child.

   You can explain that bottles are for little babies. You may even want to have your child help you carry the bottles to a neighbor's house. If your child has a strong need to suck, offer a pacifier.

CALL YOUR CHILD'S PHYSICIAN DURING OFFICE HOURS IF:

• Your child is over 6 months of age and won't eat any food except milk and won't drink from a cup.
• Your child has tooth decay.
• You think your child has anemia.
• This approach to weaning has not been successful after you have tried it for 1 month.
• Your child is over 3 years old.
• You have other questions or concerns.