Journal of International Society of Preventive and Community Dentistry

: 2014  |  Volume : 4  |  Issue : 5  |  Page : 93--98

Preschool children's caregivers' attitudes and behavior regarding bottle feeding in Bangpakong, Chachoengsao

Orawan Suwansingha1, Praphasri Rirattanapong2,  
1 Department of Dentistry, Bangpakong Hospital, Chachoengsao, Thailand
2 Department of Pediatric Dentistry, Mahidol University, Bangkok, Thailand

Correspondence Address:
Praphasri Rirattanapong
Department of Pediatric Dentistry, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Bangkok 10400


Objectives: To study a group of preschool children«SQ»s caregivers«SQ» attitudes and behavior regarding bottle feeding in Bangpakong, Chachoengsao. Materials and Methods: The study sample comprised 320 caregivers of preschool children aged 3-6 years, who were attending the public preschools in Bangpakong, Chachoengsao, and they completed self-administered questionnaires. The questionnaires had information about demographic data, weaning status, the feeding practices for children who were still on a bottle, and the caregivers«SQ» attitudes on bottle feeding according to weaning status. Results: Of these children, 38.4% were still on a bottle while 61.6% had been weaned. Mean age at the weaning time was 3.1 ± 0.6 years. The most common reason that led caregivers of bottle feeding group to allow continuation of the habit was the child refused to wean. Of these caregivers, 56% lacked knowledge concerning the appropriate weaning time and that the use of bottles should be actively discouraged for children after 1 year of age. Attitudes between bottle feeding and weaned groups were significantly different (P < 0.05) in the following: a child should be introduced to drink from cup after 1 year of age, nursing bottle works best to stop a child from crying, early weaning results in poor mental health, and early weaning results in malnutrition. Conclusion: Prolonged bottle feeding beyond the recommended age was found in the majority of preschool children in this study. Dental professions should provide oral health promotion education program including feeding practice information to caregivers.

How to cite this article:
Suwansingha O, Rirattanapong P. Preschool children's caregivers' attitudes and behavior regarding bottle feeding in Bangpakong, Chachoengsao.J Int Soc Prevent Communit Dent 2014;4:93-98

How to cite this URL:
Suwansingha O, Rirattanapong P. Preschool children's caregivers' attitudes and behavior regarding bottle feeding in Bangpakong, Chachoengsao. J Int Soc Prevent Communit Dent [serial online] 2014 [cited 2021 Jan 28 ];4:93-98
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Dental caries is a multi-factorial infectious disease caused by plaque bacteria. When food enters the mouth, bacteria metabolize fermentable carbohydrates, producing acids, which diffuse into hard dental tissue and demineralize tooth enamel. [1] Caries can be classified by location, etiology, rate of progression, and affected hard tissues. [2]

Early childhood caries (ECC) is a disease characterized by severe decay in the teeth of infants or young children. The frequent consumption of liquids containing fermentable carbohydrates, especially milk, increases the risk of dental caries due to prolonged contact between sugars in the liquid and cariogenic bacteria on the teeth. [3] Improper feeding practices without appropriate preventive measures can lead to a distinctive pattern of caries in susceptible infants and toddlers, commonly known as a form of ECC. [4] Frequent bottle feeding at night, and extended and repetitive use of a non-spill training cup are associated with ECC. [5] Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in primary and permanent teeth. [6]

Parents' and/or caregivers' attitudes have a significant positive influence on the children's dental caries and gingival health. [7],[8] Imparting correct knowledge and empowerment of caregivers' attitude and practice will result in more effective preventive strategies to benefit children's dental health.

Some studies in the rural areas of developing countries have examined whether preschool children's caregivers are conscious of the risks and dental problems associated with bottle feeding. Typical rural areas have a low population density and small settlements. Agricultural areas are commonly rural. Chachoengsao is a rural city in the central part of Thailand. The population density is below 130 people per square kilometer. The western part of the province is the low river plain of the Bangpakong river, which is used extensively for farming rice. It is an important venue for agricultural products in the central region. The last Thailand National Oral Health Survey conducted in 2012 revealed that 51.7% and 78.5% of 3- and 5-year-old rural children, respectively, were affected by dental caries in their primary teeth with dmft values 3.0 and 4.6, respectively. [9] Most of the dental caries in primary dentition (about 50.6%) were not treated.

The objective of this research was to study a group of preschool children's caregivers' attitudes and behavior regarding bottle feeding in Bangpakong, Chachoengsao.


Approval to conduct this study was obtained from the Human Ethics Committee of Mahidol University (MU-DT/PY-IRB 2013/011.0402). A written informed consent was obtained from the caregivers who were willing to participate in this study. This sample was selected randomly, with stratification based on the location of school. Bangpakong district is subdivided into 12 subdistricts. Two schools in each subdistrict were randomly selected to obtain the desired sample size. The sample size was calculated by taking 51.7% prevalence rate of dental caries in 3-year-old children [9] at 95% confidence interval. A total of 320 primary and secondary caregivers of preschool children aged 3-6 years completed the self-administered questionnaire. None of the caregivers dropped out of this study. All the 320 completed questionnaires were returned, thus giving a response rate of 100%.

The questionnaire contained 20 items in three sections. Section I included five items about demographic data. Section II consisted of seven items about children's bottle using status and the feeding practices for children who were still on a bottle. Section III contained eight items about the caregivers' attitudes on bottle feeding according to weaning status. The scoring for caregivers' attitudes in section III was based on the responses given as agree/disagree. The questionnaire was pilot-tested on 10% of the study subjects and was assessed for the uniformity of interpretation. No major corrections were necessary. Hence, the data gathered during the pilot survey were also included in the study.

Statistical analyses

Chi-square test was performed to assess statistically significant differences in the attitudes of preschool children's caregivers on bottle feeding according to weaning status at a level of significance of P < 0.05.


Demographic data of the preschool children's caregivers are presented in [Table 1]. The preschool children's age was 2.6-5.11 years. Majority of the respondents were mothers (86%) and the age of the caregivers was 30-39 years. About 60% of the caregivers had a high school degree or lower level degree.{Table 1}

Among the 320 children, 197 (61.6%) had been weaned. The mean age of the weaned group was 4.1 ± 1.2 years, while that of the bottle feeding group was 3.2 ± 0.9 years. Mean age at the weaning time was 3.1 ± 0.6 years [Table 2].{Table 2}

In [Table 3] is presented the feeding patterns of the bottle feeding group. The results show that the amount of milk per feeding was mostly 4 ounces and about 67.5% was plain milk. Among the 123 bottle-fed children, 56% had the frequency of bottle feeding as high as 3 times per day or more; 40.7% of children were fed at bedtime while 39.8% of them were fed on demand. Only 9 children (7%) were rinsed or brushed after bottle feeding. The most common reason that led caregivers of the bottle feeding group to allow continuation of the habit was the child refused to wean.{Table 3}

[Table 4] shows the caregivers' attitudes regarding bottle feeding according to weaning status. Of these caregivers, 88.7% realized that improper bottle feeding results in dental caries and 92.8% realized that a child should be brushed after bottle feeding. However, attitudes between bottle feeding and weaned groups were significantly different (P < 0.05) in the following factors: a child should be introduced to drink from cup after 1 year of age, nursing bottle works best to stop a child from crying, early weaning results in poor mental health, and early weaning results in malnutrition.{Table 4}


Feeding habits are said to be of prime importance in the etiology of dental caries at any age, especially in preschool age children. [10] A preschool is an educational establishment offering early childhood education to children between the ages of 3 and 5 or 7, prior to the commencement of compulsory education at primary school. The children of this study belonged to the age group of 2.6-5.11 years. Children of similar age group, i.e. 2-6 year old children, were studied by Tyagi. [11]

The World Health Organization has documented many benefits of breastfeeding, particularly exclusive breastfeeding (starting from birth to the first 6 months of life and then continuing until 2 years of age or longer with complementary foods). [12] The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months, followed by continued breastfeeding for at least 12 months, and thereafter for as long as the mother and baby desire. [13] Bottle feeding is routinely used to provide supplements to breastfed infants.

The American Academy of Pediatric Dentistry Guidelines recommend that at 6 months of age, the infant should be introduced to drink from cup, and bottle feeding should be actively discouraged after the age of 1 year. [14] In Thailand, the Thai Society of Pediatric Dentistry recommends a higher weaning age of 18 months. [15] Our study showed that prolonged use of a bottle even after the age of 3 years was common in these children. ECC has been related to prolonged bottle feeding beyond 1 year of age. [16] The study of Schroth et al. showed late weaning from the bottle associated with ECC and caries activity. [17]

Among the children studied, 56% had the frequency of bottle feeding as high as 3 times per day or more. Earlier studies showed that frequent consumption of foods, snacks, and drinks between meals increases the risk for caries. [18],[19] Hence, nutritional recommendations of limiting the snacking time among children and encouraging regular meals are essential.

The results showed that 40.7% of children were given a bottle prior to sleep at bedtime. Similar practice was being followed by 45% of the subjects in the study of Vinay et al. [20] These nocturnal feeding habits are well known to contribute to caries development in young children. [21] The reasons for this include decreased salivary flow and swallow reflex during sleep which allows liquid carbohydrate to remain in the mouth and pool around the teeth. This decreased rate at which carbohydrates are cleared from the oral cavity is a determinant in caries initiation. The anterior placement of the tongue protects the mandibular anterior teeth from the decay-causing carbohydrate solutions. [22] Information on ways to control the bedtime feeding practices of young children needs to be made available. The importance of feeding needs to be emphasized prior to establishment of such a deleterious habit. [23]

Adequate oral hygiene is one of the requisites for preventing ECC. The present study showed that 57 (46.3%) of the children drank water or rinsed water or brushed their teeth after every feed. Tooth brushing is considered to be the most reliable means of maintaining oral hygiene. [24] Basic habits like drinking plain water and rinsing the mouth with water after every feed can also be instilled in children at a young age. [25] Water neutralizes the effects of acidic substances and rinsing removes the food particles left behind on the teeth.

The study of Jin et al. indicated that children whose bottle contained sweetened solution had higher ECC prevalence. [26] Plain milk was the predominant finding found in this study and sweetened milk usage formed only 24.4%. But sucrose is not the only sugar that can maintain infection. [27] Milk contains 4-5% of the disaccharide lactose, which can be fermented by oral biofilm bacteria; however, unless the bacteria are adapted to lactose, fermentation is significantly less than with sucrose. [28] However, lactose solutions can produce a rapid drop in pH. [29]

The different attitudes in both caregiver groups showed that the bottle feeding group agreed with the following: Appropriate age to introduce drinking from a cup, nursing bottle works best to stop a child from crying, and insufficient nutrition and mental health if the children did not discard the bottles themselves. Our results indicated that the bottle feeding group had a higher value for the factor "a child should be introduced to drink from cup after 1 year of age" than the weaned group. According to the responses obtained in this study, the majority of caregivers realized that primary teeth are important, and therefore should be prevented from getting decayed, and improper bottle feeding results in dental caries. Many also gave appropriate responses to other questions intended to assess attitudes on preschool dental health. However, given that caregivers embraced the concept of the appropriate weaning time, such attitude did not necessarily translate into behavior practices that are likely to prevent dental caries. The cultural pattern in the area of this study could be one of the reasons for such prolonged bottle feeding. The use of culturally appropriate delivering and reinforcing anticipatory guidance may be a more promising vehicle to changing attitudes and behaviors about oral health prevention activities. [30]

Caregivers are primary promoters of oral hygiene and they have a major influence on the dietary habits and food choices of children. Patterns of behavior learnt in early childhood are deeply ingrained and resistant to change. Caregivers have an important role in this aspect. [31]

Our results showed that most caregivers had a good attitude, but the same did not reflect in their practice. An increase in the knowledge of caregiver will influence their self-care habits and dietary practice and improve the dietary pattern, especially bottle feeding pattern, and oral hygiene habits of preschool children to prevent dental caries. However, not only increase in knowledge, but also better understanding of the attitudes of the caregivers will help dental professionals to guide the caregivers and modify the oral health prevention activities, especially with regard to feeding practice.

Limitations of the present study

The sample taken for this study only represented the children attending the public preschools in Bangpakong, Chachoengsao. It did not include children of this age of the entire community. Respondents in this study included primary and secondary caregivers, so the outcome data might be inaccurate. We did not clinically examine the children for dental caries in the study, so we could not conclude whether prolonged bottle feeding was related to dental caries in all children.


Prolonged bottle feeding beyond the recommended age was found in the majority of preschool children in this study. Dentists should prevent the occurrence of ECC by developing a caries prevention program in the high-risk group, early screening and identification of children with ECC, appropriate topical fluoride therapy, supplying infants and toddlers with a training cup, prenatal care and counseling, and by giving oral hygiene instructions.


This project was funded by Mahidol University, Bangkok, Thailand.


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