Bottles and pacifiers: advice from a Latinx pediatrician [PODCAST]

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“Growing up in Puerto Rico, ‘babas’ (bottles: biberón/botellas) and ‘bobos’ (pacifiers:  chupetes/chupón) were very common among the families and children of the island.  I still remember our Abuelita giving us milk in our “babas,” so my younger sister and I were sure to fall asleep better.  From the time of our births, to when my sister was three years old, the “bobo” was also consistently being used in our home.

Now, as a pediatrician, one of the conversations I have most frequently with my Latino families is regarding the proper use of both ‘babas’ and ‘bobos’ for their children.  Were you aware that children should begin using training cups (commonly referred to as ‘sippy cups’) as early as nine months of age?  It is also very important that your child gradually ween off the use of bottles between the ages of 12 to 15 months.  Continued use of bottles after one year of age has been repeatedly documented to increase the risk of tooth decay in children.”

Johanna Vidal Phelan is a pediatrician.

She shares her story and discusses her KevinMD article, “Bottles and pacifiers: advice from a Latinx pediatrician.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Johanna Vidal Phelan. She is a pediatrician, and she wrote the KevinMD article “Bottles and pacifiers: advice from a Latinx pediatrician.” Johanna, welcome to the show.

Johanna Vidal Phelan: Thank you so much for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Johanna Vidal Phelan: Absolutely, thank you for the opportunity. So I was born and raised in Puerto Rico, and one of the reasons that inspired me to write the article is that I work with many Latino families. My journey has definitely been influenced by my culture, the language, my first language, which is Spanish, and how to outreach to a community here in the United States. So I’m definitely always inspired to work with children, families, and mothers, and that has definitely been what has really pushed my career forward here in the United States.

Kevin Pho: Tell me some of the challenges that immigrant populations face when trying to receive care in the United States.

Johanna Vidal Phelan: I think it is knowledge and understanding of having access to the correct information. Also, there are cultural sensitivities and racial, ethnic sensitivities that I think we all need to be aware of and understand, especially in health care. I know there’s a lot of focus right now on social determinants of health, but definitely understanding the true impact of social determinants of health in all the patient populations that we serve is really important. When I counsel and mentor medical students, I tell them there’s no way you’re going to know everything about every single population, but to ask the right questions, to show that you care, and to meet your families and patients where they are is really something that is so important to deliver good care.

Kevin Pho: So give us some examples of some of the cultural sensitivities that you encounter in the patient population that you see.

Johanna Vidal Phelan: I think it’s understanding where the families, in my case as a pediatrician I always talk about families, but where the patients or families are coming from. Some sensitivities that you need to be aware of could be based on religion. In my case, I counsel a lot of families about the importance of good nutrition in the development of a child, so understanding some of the foods and items that are associated with family and culture is important, and understanding where to meet the family halfway to make the clinical impact that you want.

A perfect example, when I do education on management of pediatric obesity, has been that when you work with a Latino family, if you advise a family to eliminate all rice from the diet, it’s not a successful technique. The family is probably not going to be able to sustain that long term, because rice, rice and beans, is such an essential part of the foods that we eat. So where do you meet the family? Where you can take some of the foods that mean so much, that are part of our culture, meet them halfway, make them healthier, and choose alternatives, so that you can achieve your clinical goals, which may be management of type 2 diabetes, for example, or having a child have a healthy diet.

Kevin Pho: All right, so let’s transition into your KevinMD article, “Bottles and pacifiers: advice from a Latinx pediatrician.” Now, for those who haven’t read the article, can you walk my audience through it and maybe share the story of why you decided to write it?

Johanna Vidal Phelan: Thank you so much for that question. I actually wrote the article first in Spanish, because I was really aiming to deliver a message that I find I say constantly to my Latino, Hispanic families. I noticed in clinical practice that my Latino families tend to use the pacifier and the bottles a lot, and we have a lot of conversations, and I can meet them where they are in regards to the use of what they call, in our Caribbean culture, we call bottles “botellas,” or we call them “babas,” and then the pacifiers we call “bobos,” which is something that we use in the Caribbean islands to refer to them.

And there is a connotation, an association of love: To give a bottle and the binky to your child means you love them. But then we’re trying to meet the family where they are and understand that doing that causes dental cavities and dental decay. I’ve seen a lot of anemia in my Hispanic families because they drink too much milk from the bottle, or they’re drinking too much juice from a bottle, and then what happens? The child is not eating the nutritive foods that are going to help them grow.

And so it’s understanding where grandma, abuela, may be coming from, or an aunt, or titi, may be coming from, and saying, “You know, I know giving the bottle to the baby is something where you love or nurture your child, but there are other ways to do that in a way that’s healthier.” And let’s discuss the true habits. Is it the child wanting to take the bottle, or is it abuela sneaking the bottle, and where are we with that? And explain to the family in a way that is simple, so that they understand why some of this behavior has to change in order for the child to be healthy.

Kevin Pho: And when you talk about this, in general, what are some of the responses that you get from the families?

Johanna Vidal Phelan: Many times I hear, “Oh, I didn’t know that,” or, “This is the way we’ve been doing it for a long time,” or, “This is how we do it in Puerto Rico,” for example. So it really has so much validity when I, as a Latina physician, say, “Oh, I remember when I was in Puerto Rico, and I remember when my grandma sneaked a bottle when I was little. I understand that.” And so they’re like, “Oh, you understand where I come from.” Like, absolutely. “But at the same time, as a pediatrician, I want to tell you that as part of your preventive care, I want to be sure your child has healthy teeth, is not having anemia, and that your child has the amazing opportunity to eat great foods that are going to help them grow healthy.”

I do a lot of preventive care, and this is a conversation that I have with families way before the one-year mark. So when the child is turning four to six months of age, I’m already having those conversations to let them know, “Let’s introduce the sippy cup earlier. Let’s start weaning the binky. It’s OK, your child is going to be OK,” and reassure the family that though they may see this as part of the cultural tradition, we’re going to do the best we can with our child and our patient here in the United States.

Kevin Pho: After a minute, it’s been a while since I’ve studied pediatrics in medical school, so for those non-pediatricians out there, you talked about some of the downsides of using the pacifier. Can you go into a little more detail about some of the health effects? You mentioned tooth decay, you mentioned nutrition effects. What are some of the other effects of using a bottle and a pacifier?

Johanna Vidal Phelan: I think that we need to determine and discuss what is normal for using a pacifier and when it’s not normal. So it is normal to use a pacifier when you’re a baby in the first six months of life. Babies like to suck, and it’s a way that they can calm, as a reflex. So using the pacifier in your child that’s less than one year is OK. What I’m trying to avoid is having a child who is four years of age with a pacifier who now has some dental malocclusion, and maybe even has some speech delay, because when a child is developing language, if they have a binky and they’re sucking when they’re older, like that toddler age group, they’re not going to talk, and you really want to develop those language skills.

The bottle is a way that we feed our babies. If you’re not breastfeeding your child, then you supplement or use a bottle. But the bottle is to be used until really 12 months of age. After 12 months of age, your toddler is developing skills where they can drink fluids from a sippy cup, they can eat food, and they chew food. And so I always compare it to an adult. We don’t walk around with a bottle drinking milk all day long. We drink fluids with our meals, and we want to be sure that we eat our meals first and then we drink the fluid. So that’s how we do it with little kids too.

I think the bottle is a rite of passage. You obtain all your nutrition when you’re a newborn and an infant from a bottle, but as you get older, you introduce solids. Children eat food, and so that’s the main source of nutrition. After 12 months, there’s really, really no need for formula. So now you’re changing from formula or breast milk to milk, or continuation of breast milk, and breast milk will be a fluid in addition to the nutritious foods with protein and grains that you want to offer your child to continue growing.

Kevin Pho: You mentioned that there was a Hispanic influence in terms of the families who show love by using the pacifier and bottles. Is this purely restricted to the Latino population, or are there any other cultures, as far as you notice, that do the same thing?

Johanna Vidal Phelan: I’ve seen it in other cultures, but it really perseveres a lot in the Latino community, to the point where we name the bottle differently. We call it “baba,” and there’s something about “baba” and “bobo,” which is very cute in our Puerto Rican culture, that it’s just almost related to love. And so I think that it is a message that I discuss with my families all the time, and it’s almost sometimes controversial, because I may be delivering that message to mom, who is in the room with me, but then I need to talk to a grandma too, and I need to reach out to the other caregivers. So I use other ways: written materials, information, communication, asking questions, and then engagement, because this is a shared decision process too, and we want the families to have the knowledge and understanding of why this medical recommendation is being made, that it is good for their child.

Kevin Pho: We’re talking to Johanna Vidal Phelan. She is a pediatrician, and she wrote the KevinMD article “Bottles and pacifiers: advice from a Latinx pediatrician.” Do you have any advice for those clinicians who may not be Latino in terms of dealing with this issue in the exam room?

Johanna Vidal Phelan: Yes. Honestly, with everything else, I ask my mentees and students and other physicians to ask questions. I think a lot of our families, and I learned this from all cultures, are so interested to share their background, their culture, and that sensitivity, that you’re taking the time to ask that one or two extra questions, really makes a big difference for the family. So if you notice one of your families, like, the child is now two and a half years old, in your office getting their well-child visits, and they’re still walking around with a bottle, sometimes we need to ask the question. Instead of saying, “Don’t do that,” you want to say, “Why? Can you tell me why you’re still using the bottle in your three-year-old child?” And then meet the family where they are, identify those barriers, and provide knowledge so that they understand why your advice is to reduce the use of bottles and use sippy cups or other tools. And I think that’s a very good example of everything else in medicine.

Kevin Pho: Now, we’re speaking in the second week of December, and of course, I’m switching topics to coronavirus and COVID, which I’m sure you see in the clinic. Now, from the Latino population perspective, are you seeing any specific issues that may be applicable to them when it comes to COVID-19 and coronavirus?

Johanna Vidal Phelan: Absolutely. We all know that Black families and Latin American families have been heavily affected by the pandemic, by COVID-19. I think one of the issues that I noted early in the pandemic is lack of information in Spanish to reach the communities. And so I really encourage families to ask questions of their providers. If they are scared, overwhelmed, they don’t know what to do, or you have a family member or a child who is sick, call your pediatrician.

Another message that is so critical to deliver is that families are scared, but children still need their well-child visits. Children still need their immunizations on time. We don’t want to change the pandemic COVID-19 situation for a measles epidemic, or for your child to have a vaccine-preventable illness. So if your child needs well-child care and your child needs immunizations, call your doctor today. Make that appointment, because these appointments are so critical for the growth and well-being of your child.

Kevin Pho: And my final question, what is your take-home message that you want to share with the KevinMD audience?

Johanna Vidal Phelan: I think that our Latino community in the United States continues to grow. We are now 18, almost 19, of the United States population, but for physicians and our physician workforce, only 5.8 percent of physicians in the United States are Latinos, and 2 percent are Latina women. So we really need everybody to be able to have this cultural knowledge and sensitivity to deliver care to all families based on cultural, ethnic, religious background, in a way that provides empathy and diversity, while we continue to increase the number of underrepresented physicians in health care, which is going to take a couple of years, and it’s going to be an effort.

We all need to be part of the solution. And so as we care for these families, learn from them, ask questions, be empathetic, and continue to mentor other students, especially those that are underrepresented, so that we increase representation of minorities in the health care workforce.

Kevin Pho: Johanna, thank you so much for your time and insight, and thanks again for being on the show.

Johanna Vidal Phelan: Absolutely. Thank you so much, sir.

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