Abstract
Background
Early childhood caries constitute one of the most prevalent chronic diseases among children which have been found to be related to infant feeding practices.
Objective
to determine the association of early childhood caries with breastfeeding and bottle-feeding practices among children of preschool age.
Patients & Methods:
Information about oral health, infant feeding and other child and family characteristics were obtained through structured interviewer administered questionnaire from mothers of preschool children. Intra-oral examination of the children was done and dental caries status was recorded according to the World Health Organization (WHO) criteria. The data were analysed using Statistical Package for Social Sciences (SPSS) version 20.0. Statistical analyses of association of early childhood caries with various categorical variables were performed using chi-square. A logistic regression analysis was also performed with factors that were significant. P-value ≤ 0.05 was considered statistically significant.
Results
Of the 302 children in this study, 44% were solely breastfed, 2% were solely bottle-fed while 54% were both breastfed and bottle-fed. Statistical analysis showed that ECC significantly increased with night time bottle feeding (OR=4.5, p=0.001, CI=1.8-11.1), whereas it was significantly lower in children who were breastfed for 3 to 6 months (OR= 0.1, p<0.001, CI=0.03-0.18) as compared to those who were breastfed greater than 12 months duration.
Conclusion
. This study has shown that breastfeeding for the first 3 – 6 months of life is associated with low incidence of dental caries while babies solely bottle-fed and night time bottle feeding are associated with high incidence of childhood dental caries
Keywords: Early Childhood, Dental caries, Breastfeeding, Bottle-feeding, Southwest Nigeria
Introduction
Early Childhood Caries (ECC) was formerly known as baby bottle tooth decay, nursing caries, nursing bottle syndrome, bottle mouth caries and milk bottle syndrome1-3. ECC is defined as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled primary tooth surface in any primary tooth in a child ≤ 71 months of age. Severe early childhood caries (S-ECC) is the presence of any sign of smooth surface caries in children < 3 years of age; ≥1 cavitated, missing (due to caries), or filled smooth surface in maxillary anterior teeth from ages 3 through 5 years; or the presence of ≥1 decayed, missing (due to caries), or filled primary tooth surfaces of ≥4 at age 3 years, ≥5 at 4 years, or ≥6 at age 5 years4. Dental caries comprise the single most chronic disease affecting children globally with the largest unmet health needs, if left untreated can lead to significant acute and chronic conditions. These include, bacteraemia, early loss of tooth, malocclusion in the permanent dentition, high cost of treatment, low self esteem and failure to thrive1,5,6. Infant feeding habits such as at-will breastfeeding, prolonged and nocturnal breastfeeding, prolonged day time and nocturnal use of baby bottle that contain fermentable liquids, continued use of sweetened pacifiers and diet are some of the common risk factors for ECC7. The American Academy of Pediatrics identifies human milk as the ideal nutrient for infants on the basis of the extensive scientific evidence demonstrating that breastfeeding and the use of human milk provide multiple health-related advantages to infants, mothers and society8. Breastfeeding is recommended by paediatricians and other healthcare professionals to be continued for at least the first year of life and beyond, as long as mutually desired by mother and child9. Prolonged, unrestricted and night time breastfeeding, however have been reported to be potential risk factors for the development of ECC3,10-12.The purpose of this study was to determine the association of early childhood caries (ECC) with breastfeeding and bottle-feeding practices among children of preschool age attending immunisation and Well baby clinics at the Lagos University Teaching Hospital (LUTH).
Patients and Methods
Approval for research was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital (LUTH) and informed consent was obtained from mothers before each child was enrolled. A table of random numbers was used to select children attending immunization and Well baby clinics at LUTH into the study. A confidence interval of 95% was used for the sample size calculation, with an absolute precision of 0.05 and an estimated prevalence (p=50%). After calculating the finite population correction factor for sample size, a minimum sample size of 302 was required.
A pre-tested structured questionnaire was used to collect information about infant feeding practices from the mothers of the children during an in-person interview. The questionnaire consisted of demographic information of the child, feeding practices, which included the type of infant feeding method (breastfeeding, bottle feeding or mixed), frequency of breastfeeding and nocturnal breastfeeding; nocturnal bottle-feeding; and duration of breast and bottle feeding. For the purpose of this study the socioeconomic status was based on a composite of two indices: mother’s education and father’s occupation12. This allocated each child to a social class I to V, social class V being at the bottom of the table. Two trained examiners were calibrated to carry out the clinical examination of the children according to the WHO oral health survey methods. Kappa scores higher than 0.9 were attained for both inter and intra-examiner calibration exercises for identifying cavitated and non-cavitated carious lesions indicating high reliability between investigators. The children were examined by using disposable explorer, dental mouth mirrors and flashlights. Gauze pads were used to clean and dry teeth surfaces before examination. Children having one or more decayed (non-cavitated or cavitated), missing (due to caries), or filled tooth surfaces (dmfs) in any primary tooth up to 71 months of age or younger were considered to have ECC. Children from ages 3 through 5, with one or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth or decayed, missing, or filled score of ≥ 4 (age3), or ≥ 5 (age 4), or ≥ 6 (age 5) surfaces were considered to have S-ECC. Children with untreated caries were referred to the Department of Child Dental Health, of Lagos University Teaching Hospital, Lagos.
The data was analysed using Statistical Package for Social Sciences (SPSS) version 20.0. Statistical analyses of association of early childhood caries with various categorical variables were performed using Chi-square and Fisher’s exact test. A logistic regression analysis was performed with (caries yes/no) as the dependent variable and other selected parameters as independent variables. P-value ≤ 0.05 was considered statistically significant.
Results
Table 1 shows the socio-demographic data of the children. A total of 302 children were examined in the study. Their age ranged from 6 to 70 months with a mean age of 36.9 months (+/- 19.7 months). There were 158 (52.3%) girls and 144 (47.7%) boys with a ratio of 1.1:1. The highest distribution of children was in the age group 36 to 41 months. Most of the respondents were Yoruba 151 (50%), followed by Igbo 102 (33.8%). Majority of the children 118 (39.1%) were from the high socio-economic Class I.
Table 1 . Distribution of children according to gender, ethnic group and socio-economic status.
Characteristics | Frequency | Percent |
Gender | ||
Male | 144 | 47.7 |
Female | 158 | 52.3 |
Total | 302 | 100.0 |
Ethnic group | ||
Yoruba | 151 | 50.0 |
Igbo | 102 | 33.8 |
Hausa | 18 | 6.0 |
Efik and Urhobo | 31 | 10.3 |
Total | 302 | 100.0 |
Socio-economic status (SES) | ||
I | 118 | 39.1 |
II | 56 | 18.5 |
III | 80 | 26.5 |
IV | 32 | 10.6 |
V | 16 | 5.3 |
Total | 302 | 100.0 |
Table 2 shows the association infant between feeding methods and early childhood caries (ECC). The total number of children with ECC was 64(21.2%). One hundred and thirty four (44.4%) children were solely breastfed, 6(1.99%) were solely bottle-fed and the rest 162 (53.6%) were both breastfed and bottle-fed. Children who were solely bottle-fed had a caries prevalence of 33% followed by those who were both breastfed and bottle-fed (25.3%) and those who were solely breastfed had the least caries prevalence least (15.7%). There was no statistically significant difference in the three methods of infant feeding with regards to the prevalence of dental caries among the children, (P=0.099).
Table 2 . Association between infant feeding methods and ECC.
Method of Feeding | Caries free | Caries Affected | Total | P value | |||
Freq | % | Freq | % | Freq | % | ||
Breast | 113 | 84.3 | 21 | 15.7 | 134 | 44.37 | 0.099 |
Bottle | 4 | 66.7 | 2 | 33.3 | 6 | 1.99 | |
Both | 121 | 74.7 | 41 | 25.3 | 162 | 53.64 | |
Total | 238 | 78.8 | 64 | 21.2 | 302 | 100.0 |
The association between breastfeeding duration and ECC is seen in Table 3. The children, whose duration of breastfeeding was greater than twelve months had the highest prevalence of caries (57%), followed by those whose duration of breastfeeding was less than three months (25%). Children who were breastfed for duration of three to six months had the least prevalence of caries. There was a statistically significant association between the duration of breastfeeding and the prevalence of dental caries (P< 0.001).
Table 3 . Association between breastfeeding duration and ECC.
BRF Duration | Caries free | Caries Affected | Total | P value | |||
Freq | (%) | Freq | (%) | Freq | (%) | ||
< 3 months | 9 | 75.0 | 3 | 25.0 | 12 | 4.1 | <0.001* |
3-6 months | 102 | 93.0 | 8 | 7.0 | 110 | 37.2 | |
7-12 months | 92 | 90.0 | 10 | 10.0 | 102 | 34.5 | |
>12 months | 31 | 43.0 | 41 | 57.0 | 72 | 24.3 | |
Total | 234 | 79.0 | 62 | 21.0 | 296 | 100.0 |
Table 4 shows the association of the frequency of breastfeeding, nocturnal breastfeeding and early childhood caries (ECC). A total of 257(86.8%) children were breastfed greater than seven times during the day time while 39 (13.2%) were not breastfed greater than seven times during the day time. The prevalence of ECC was marginally higher in those who were breastfed greater than seven times during the day time 54(21%) than those who were not 8(20.5%) This relationship was not statistically significant (P= 0.943). The prevalence of caries was higher (21.2%) in those children who were breastfed at night than those who were not (12.5%) but there was no statistically significant difference in the two groups (P=0.474).
Table 4 . Association of frequency of breastfeeding, nocturnal breastfeeding and ECC.
Breast Feeding | Caries free | Caries Affected | Total | P value | |||
Freq | (%) | Freq | (%) | Freq | (%) | ||
Freq of breastfeeding >7 | |||||||
Yes | 203 | 79.0 | 54 | 21.0 | 257 | 86.8 | 0.943 |
No | 31 | 79.5 | 8 | 20.5 | 39 | 13.2 | |
Total | 234 | 79.1 | 62 | 20.9 | 296 | 100.0 | |
At night | |||||||
Yes | 227 | 78.8 | 61 | 21.2 | 288 | 97.3 | 0.474 |
No | 7 | 87.5 | 1 | 12.5 | 8 | 2.7 | |
Total | 234 | 79.1 | 62 | 20.9 | 296 | 100.0 |
The association of bottle-feeding duration, nocturnal bottle-feeding and ECC is shown in Table 5. A total of one hundred and sixty-eight children were bottle-fed, more than half 100(59.5%) of the children were bottle-fed for less than 12 months while 2(1.2%) were bottle-fed for more 24 months duration . There was no statistically significant association between the duration of bottle-feeding and the development of ECC (P= 0.668). Out of the 55 children who were bottle-fed at night, a significantly higher percentage (51%) had ECC compared to those who were not bottle-fed at night (13%). There was a statistically significant association between children who were bottle-fed at night and those who were not and the occurrence of ECC (P<0.001).
Table 5 . Association between duration of bottle-feeding, nocturnal bottle-feeding and ECC.
Caries free | Caries Affected | Total | P value | |||||
Freq | (%) | Freq | (%) | Freq | (%) | |||
Duration | ||||||||
<12 | 72 | 72.0 | 28 | 28.0 | 100 | 59.5 | 0.668 | |
13 – 18 | 45 | 78.9 | 12 | 21.1 | 57 | 33.9 | ||
19-24 | 7 | 77.8 | 2 | 22.2 | 9 | 5.4 | ||
>24 | 1 | 50.0 | 1 | 50.0 | 2 | 1.2 | ||
Total | 125 | 74.4 | 43 | 25.6 | 168 | 100.0 | ||
Night time bottle feeding | ||||||||
Yes | 27 | 49.0 | 28 | 51.0 | 55 | 32.7 | 25.573 | <0.001** |
No | 98 | 87.0 | 15 | 13.0 | 113 | 67.3 | ||
Total | 125 | 74.0 | 43 | 26.0 | 168 | 100.0 |
The factors that were significantly associated with ECC were put into a model in Table 6. After adjusting for confounding variables, children who were breastfed <3 months (OR=0.15, p= 0.012), 3 to 6 months (OR=0.07, p<0.001) and 7 to 12 months (OR=0.12, p<0.001) were less likely to have ECC than those who were breastfed greater than 12 months. Also children who slept with their feeding bottle were 4.5 times more likely to have ECC than those who did not.
Table 6 . Logistic regression model for ECC.
Variables | B | P-value | OR | 95% CI | |
Lower | Upper | ||||
Duration of breastfeeding | |||||
< 3months | -1.912 | 0.012 | 0.148 | 0.033 | 0.656 |
3-6 months | -2.626 | 0.000 | 0.072 | 0.030 | 0.175 |
7-12 months | -2.137 | 0.000 | 0.118 | 0.051 | 0.272 |
>12 months | 1 | ||||
Sleep with bottle | |||||
Yes | 1.503 | 0.001 | 4.496 | 1.819 | 11.113 |
No | 1 |
Discussion
The idea that breastfeeding- especially on demand at night can lead to an increased risk for ECC has concerned the dental community since it was first raised in the literature13. Kotlow presented case reports of clinical observations suggesting that breastfeeding on demand may be associated with ECC13.
The present study has identified several characteristics of breastfeeding and bottle-feeding practices and early childhood caries (ECC). Night breastfeeding and the frequency of breastfeeding were not associated with ECC but children who were breastfed > 12 months duration were more likely to have ECC than those who were breastfed less than 12 months duration. This finding is similar to that by Azevedo et al and Shantinath et al3,14. Similar observations were also made in Nigeria15, New Guinea16 and China17. Shantinath et al showed that the average age of weaning was six months earlier for caries-free group than for caries group14. In Azevedo’s study, breastfeeding in children older than 12 months was strongly associated with S-ECC3. Yonezu et al in their study reported that breastfeeding at 18months was significantly associated with the higher prevalence of caries and higher number of decayed, missing and filled teeth18. Other studies have reported that there is no association between breastfeeding and ECC19-21. A study by Hong et al showed that shorter duration of breastfeeding may be associated with increased risk for ECC22. Different definition of prolonged duration of breastfeeding have been used, some studies have cut points exceeding 18 months to define the uppermost duration category 23-25while others used earlier cut points such as (≥ 13 months) to define long duration of breastfeeding19,26,27. A systematic review suggested that breastfeeding for duration of more than one year, as well as night time breastfeeding after the eruption of teeth is associated with some form of ECC, but the lack of consistent methodology used in previous studies makes it difficult to draw conclusions28. In the present study although the prevalence of ECC was lowest in those who were solely breastfed and highest among those who were solely bottle-fed, the differences in caries levels in relation to type of feeding was not statistically significant which is similar to other reports15, 29,30. In a study carried out among Turkish rural children to determine the association of ECC with microbiological and dietary variables, the authors showed that the method of infant feeding was significantly associated with caries, with higher prevalence occurring in children who were bottle-fed only31. Some authors have reported that children who were never breastfed or those that were solely bottle-fed have a higher risk for ECC when compared to breastfed babies10,32,33. In a Brazilian study to determine the early feeding practices and severe ECC among preschool children, breastfeeding ≥ 7 times daily was a risk factor for severe ECC34. Breastfeeding provides the ideal nutrition for infants, and there are a number of health benefits to the breastfed child, including reduced risk for gastrointestinal and respiratory infections. However, frequent and prolonged contact of enamel with human milk has been shown to result in acidogenic conditions and softening of enamel35. The American Dental Association’s (ADA) statement on ECC states that ‘unrestricted, at-will nocturnal breastfeeding after the eruption of the child’s first tooth can lead to an increased risk of caries’36. The American Academy of Pediatric Dentistry (AAPD) Policy on early Childhood Caries recommends that ‘Ad libitum breast-feeding should be avoided after the primary tooth begins to erupt and other dietary carbohydrates are introduced’37. In the present study, bottle feeding at night was a clear determinant for ECC, there was a significantly higher prevalence of ECC in children who were bottle-fed at night than those who were not . This report agrees with other studies that examined bottle-feeding in detail that duration of bottle feeding particularly at night is the most important determinant for ECC development rather than bottle-feeding itself21,38. In a Canadian study carried out among Northern Manitoba children, 87.9% the mothers stated that they bottle-fed their child at some point and stopped at 30 months39. This is more than twice the AAPD-recommended bottle weaning age of 12–18 months37. Also, 86% of mothers admitted that they put their child to bed with the bottle, which is contrary to expert advice37. Feeding during the night can lead to prolonged exposure to fermentable carbohydrates and also salivary flow and function is reduced during sleep creating dentally harmful environment21. The question now is why is breastfeeding which is otherwise a health promoting behaviour associated with deleterious dental outcome such as early childhood caries? Chaffee et al gave a possible reason for this in their study that repeated, prolonged exposure to human milk could enhance the progression of caries in the presence of highly refined sugar which is present in most modern diets40.
The result from this study does not intend to discourage mothers from breastfeeding their children but we are in agreement with the AAPD guideline for infant oral care which states that Ad libitum breastfeeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates should be introduced. Also infants should not be put to sleep with bottle filled with milk or liquids containing sugars37. Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle between 12 to 18 months of age.
Limitations of this study include being a cross sectional study, the ability of the mothers to recall details of infant feeding practices as this may cause overestimation or underestimation of information.
There is need for a longitudinal study to determine the role of oral hygiene and other dietary fassctors in the aetiology of ECC among Nigerian children where prolonged breastfeeding is practiced and promoted.
Conclusion
This study has shown that breast feeding for the first 3 – 6 months of life is associated with low incidence of dental caries while babies solely bottle-fed and night time bottle feeding are associated with high incidence of childhood dental caries.
Acknowledgment
We acknowledge all the mothers and children who participated in the study.
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
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