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JDC PUBLIC HEALTH

Caries Prior to Age 3 and Breastfeeding:A Survey of La Leche League Members

Karin Weber-Gasparoni DDS, MS, PhD Michael J. Kanellis DDS, MS Steven M. Levy, DDS, MPH Julie Stock, MA

r. Kanell s s ass stant dean for Pat ent Serv ces, College ofent stry, and professor, and Dr. Weber-Gasparon s ass stant

professor, both in the Department of Pediatric Dentistry,and Dr. Levy s professor and Graduate Program D rector,

epartment of Prevent ve and Commun ty Dent stry, all atThe University of Iowa, IA City, Iowa; Ms. Stock is Director ofAcadem c Adv s ng and Assessment, Roosevelt Un vers ty,Ch cago IL and s a former med cal nformat on l a son La

A1994 Centers for Disease Control and PreventionCDC con erence in At anta, Ga., recommen ehe term early childhood caries (ECC) to de-scri e a istinct enta isease t at a ects t e primarydentition at a very young age.1 According to this deni-tion, ECC is an infectious disease initially affecting theprimary incisors of infants and young children and isassociated with inappropriate feeding practices.1 Histori-ca y, ot er names or t is con ition ave inc u e a ybottle tooth decay (BBTD), nursing caries, nursing bottle

syndrome, and rampant caries.2-10 ECC is currently deas t e presence o 1 or more ecaye noncavitate ortated lesions), missing (due to caries), or lled tooth suin any primary toot 11 in c i ren rom irt t roug months of age. In children younger than 3 years old,sign of smooth-surface caries is indicative of severe EC

soter et al14 proposed and validated a caries pattern of Efor dental caries in any maxillary incisor surface for chyounger t an 59 mont s o .

The etiology of ECC is multifactorial. Early Strecoccus mutans co onization, ename ypop asia, poohygiene, and high frequency of sugar consumptionamong the many ECC risk factors cited in the scienliterature. ,15-25 Nocturnal feeding is also described inliterature as playing a major role in caries developm

ue in part to a re uction o sa ivary ow uring s eehours and especially when practiced for prolonged peof time.23,2 -31

ABSTRACT Purpose: The purpose of this study was to conduct a secondary data analysis of results froma 1985 survey of La Leche League International (LLLI) members to further investigate therelationship between breast-feeding and caries prior to age 3 (CPA3).Methods: Subjects were 576 LLLI mothers who responded to a 23-item questionnaireconcerning the following factors for their oldest child: (1) breast-feeding habits; (2) uoridestatus; (3) use of antibiotics; (4) carbohydrate ingestion; (5) history of caries; and (6) oralhygiene practices.Results: CPA3 was reported in 10% of all children breast-fed for more than 3 years.Later weaning was found to be signicantly associated with CPA3 (odds ratio [OR]=2.03;P =.0001). Late initiation of oral hygiene was marginally associated with CPA3 (OR=0.77;P =.08). Among children who developed CPA3, bivariate analyses found a greater frequencyof breast-feeding (P =.012) and presence of night-time breast-feeding (P =.049) to be associ-ated with caries detected at an earlier age. Children with caries on their maxillary incisors were more likely to have been breast-fed at night (P =.027) and more frequently duringthe night (P =.032).Conclusion: This retrospective study, based on a report of La Leche League Internationalmembers, found later weaning to be signicantly associated with an increased likelihoodof developing CPA3. (J Dent Child 2007;74:52-62

K EYWORDS : DENTAL CARIES , BREAST -FEEDING , L A L ECHE L EAGUE I NTERNATIONAL

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While there is widespread agreement that sugared beveragescontribute to caries development,8,39 the relative cariogenic-ity of bovine and human milk is less well understood. Theliterature suggesting an association between breast-feedingand caries is not conclusive and is based largely on case re-ports.40-42 A stu y con ucte y A a uusua et a 3 conc u ethat breast-feeding alone does not cause the development ofcaries or affect levels of Streptococcus mutans in children. Astudy by Weerheijm et al44 found that prolonged breast-feed-ing did not lead to higher caries prevalence. Within-groupcomparisons, owever, suggest t at requent reast- ee ingand low exposure to uoride can be considered factors incaries eve opment.44 In a stu y o 3 - to 71-mont -o owsocioeconomic status (SES) Brazilian children, night-timebreast-feeding and breast-feeding past 12 months of agewere associated with severe ECC.45 n a systematic review ofthe literature, Valaitis et al was unable to draw conclusionsregar ing t e re ations ip etween ECC an reast- ee ingpartly because of inconsistencies in the methodology and

i erences in e nitions o ECC an reast- ee ing amongreviewed studies.2,4,8,23,25,28,47-68

During the 1980s, the predominant feeling among dentalprofessionals was that prolonged, on-demand breast-feedingcould lead to dental caries. Women who chose to breast-feedt eir c i ren on- eman were o ten counse e y entiststo wean their children by 1 year of age.9 La Leche LeagueInternational (LLLI), a Schaumburg, IL-based internationalorganization that promotes the benets of breast-feeding,however, did not believe at the time that dental caries couldbe caused by on-demand breast-feeding. Because of thenature of this controversy, in 1985 a medical informationiaison wit LLLI eci e to survey a samp e o LLLI mot -ers to obtain some indication about whether or not thesebeliefs were based in fact. This liaison devised a dental surveythat was approved by 2 dentists, which was subsequentlymailed to LLLI members throughout Illinois.9 The infor-mation o taine t roug t is survey, w i e 2 eca es o ,has not been reported in the dental literature. A report of thesurvey n ings at t is time presents a unique opportunityto revisit the relationship between prolonged on-demandbreast-feeding, as reported by members of LLLI.

The purpose of this study was, as reported by La Leche

League International-member mothers, to explore the as-sociations etween enta caries, reast- ee ing, iet, orahygiene, antibiotics, and uoride.

METHODS

The relationship between prolonged breast-feeding and thedevelopment of caries prior to age 3 (CPA3) was explored byconducting secondary data analysis on results from a 1985survey o LLLI mem ers. T e origina survey was esigne y

a medical information liaison at LLLI whose primary interestwas to evaluate the relationship between dental caries andprolonged on-demand breast-feeding9 The survey was

which was sent to all accredited volunteer LLLI counin Illinois. They were encouraged to share the surveyother LLLI members. In addition, while not speciinstructed to do so, some LLLI administrators forwathe survey to LLLI members throughout the western o t e Unite States. For t is reason, t e tota num esurveys distributed is unknown.

The survey instrument consisted of 23 questions cerning breast-feeding practices as well as other arelated to oral health, including:

1. uori e status;2. use of antibiotics;3. car o y rate ingestion;4. presence of caries and caries pattern (involving m

lary incisors or not); and5. oral hygiene practices.

Duration of breast-feeding was assessed by asking ong mot ers reast- e t eir c i ren. Respon ents cchoose between: (1) under 1 year; (2) 1 to 2 years; (3) 2years; or 4 over 3 years. Regar ing reast- ee ing prathe questionnaire included questions about: (1) frequof breast-feeding; (2) age at weaning; and (3) noctubreast-feeding habits. Only mothers who reported that tchildren had caries were asked to respond to questions arequency o reast- ee ing an nocturna reast- ee

practices. Mothers responded to the survey questions rately for each of their children. For these analyses, onresponses for the rst-born child were included.

The primary dependent variable was whether orthe child developed cavities prior to age 3, as reportthe LLLI mother. The actual wording of the questiot e survey was: At w at age were cavities rst ete

Available responses included: under 1 year; 1 to 2 yeato 3 years; and over 3 years.

dentifying the exact age of children when carierst detected is not possible, since interpretation ofavai a e age ranges cou ave varie among responFor example, 2 to 3 years could be interpreted as 23 mont s y some an 24 to 47 mont s y ot ers. the purposes of these analyses, the corresponding agegories in months (rather than in years) were dened to 11 months; 12 to 23 months; 24 to 35 months; and

months and older. Wit t is interpretation, c i ren in t e rst 3 age gro

were classied as under 3 years of age. Because moststudy sample (66%) was weaned from breast-feedingto age 3, the authors were interested in exploring repocaries experience among children under 3 years of ag

urvey responses were entered into a data program (Statistical Package, version 11.5, SPSS Inc, Chicagoor statistica management. C i ren w o were not r

fed were excluded from the analyses. Bivariate an with the remaining sample were conducted to explor

relationships between the dependent variable, presencaries prior to age 3 (CPA3), and each independent va e A secon ivariate ana ysis was one wit t e s

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association between breast-feeding variables believed to beassociated with CPA3 and expressions of caries severity.

The dependent variables for this secondary analysiswere measures of caries severity: presence of more than3 cavities; and a caries pattern involving the incisors.14In epen ent varia es inc u e : 1 requency o reast-feeding; (2) occurrence of night-time breast-feeding; and(3) later weaning. Chi-square statistics were used to assesssignicant bivariate relationships (P

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to eve opment o CPA3. O c i ren wit CPA3, 7started solids later (after 6 months) compared to 55%those who did not develop CPA3.

Results from forward stepwise logistic regression an(level of signicance=0.10) also found later weaningsigni cant y associate wit t e pro a i ity o eve oCPA3 (OR=2.03; P =.0001). Children breast-fed for a ger period of time were at higher risk of developing Ccompared to those breast-fed for a shorter period of tEarlier initiation of daily oral hygiene was signicantlyciated with lower likelihood of developing CPA3 (OR=P .08). No other main effects were statistically signian t e interaction etween age o weaning an initiaof oral hygiene was not signicant (Table 4).

Among the 58 children reported to have CPA3:1. 31 (55%) reported exposure to uoridated water

ing the rst 3 years of life;2. 48 83% reporte regu ar use o uori ate toot pa3. 27 (47%) indicated the ingestion of antibiotics be

t e age o 1 year; an4. 35 (60%) were reported to be exposed to sweets m

than twice a day.No association was found in either bivariate or multi

ate analyses between these 4 variables and presence of CForty-two 72% o t e CPA3 group c i ren

portedly had more than 3 cavities. In separate bivaana yses among t ese 58 c i ren, caries experience o than 3 cavities was not signicantly associated witof the independent variables (later weaning, frequenbreast-feeding, night-time breast-feeding, and night ning pattern), (Table 5). Also, among these 58, earlier a

w ic caries was rst etecte was not signi cant y aated with night-time nursing pattern or later weaning,

was signicantly associated with the presence of nightbreast-feeding (P =.049) and a greater frequency of brfeeding (P =.012), (Table 5). Approximately 41% (N=of breast-fed children who reportedly developed C

were being breast-fed 6 or more times per day when c was rst etecte . Twenty- our percent N=8 a cdetected between ages 2 and 3 compared to 64% (N=that had caries detected before age 2.

This study found that 92% (N=23) of children w

CPA3 who reportedly had caries detected before aa so presente wit a a it o nig t-time reast- eecompared to 71% (N=22) for those with caries detea ter age 2 P =.049 . Overa , resu ts s owe t at mosthe children (80%) with CPA3 were breast-fed duringnight when caries was rst detected.

Caries pattern (dened as either incisor pattern wchildren were reported to have either several cavities inteet or cavities in ot ront an ac teet or no incpattern for those reported to have either 1 or 2 randcavities or several cavities in molars) was not signi

associated with later weaning or frequency of breast-febut was signicantly associated with night-time breast-ing (P 027) and night nursing pattern (P= 032; Table

Table 2. Summary of Responses to Selected SurveyQuest ons of Mothers Whose Ch ldren ReportedlyDeveloped CPA3 N=58

Valid %

>3 cavities?

Yes 72

No

At what age were cavities rst detected (ys)?

3 CAVITIES

TOTAL HI -SQUAREP VALUE

A GE ( YS)CARIES WAS FIRST DETECTED

TOTAL CHI -SQUAREP VALUE

ARIES PATTERN OTAL

Yes % No. % No. % 0-2 % 2-3 % o. % Incisor % Noincisor patter

% o %

Later weaning (age of weaning; ys)

3 27 64 10 63 37 4 16 64 21 64 37 64 22 69 13 56 3 4

Total 42 100 16 100 58 100 25 100 33 100 8 00 32 100 23 100 55 100

Frequency of breast-feeding

ot nurs ng 8 19 3 19 11 19 2 8 9 27 1 19 4 13 7 30 11 20

1-2x/day 2 5 1 6 3 5 Chi-square=5.82

0 3 9 3 Chi-square=11.02

1 3 2 9 3 5

3-5x/day 11 26 9 56 20 3 =.121 28 13 0 0 3 =.012 10 31 8 35 18 33

x/day 21 50 3 19 24 41 16 4 8 24 4 41 17 53 6 26 23 42

Total 42 100 16 100 8 100 2 100 33 100 8 00 32 100 23 100 100

Night-time breast-feeding

es 33 80 12 80 45 0 Chi-square=0.02

23 92 22 1 5 80 Chi-square=3.87

28 90 15 65 43 0

o 8 20 3 20 11 20 =.619 2 8 9 29 1 20 =.049 3 10 8 35 11 20

Total 41 100 1 100 41 100 2 100 31 100 6 00 31 100 23 100 54 100

Night nursing pattern

1-2x/night 12 35 46 18 38 26 12 50 8 38 8 27 9 56 17 38

3-4x/night18 53 46 24 1

Chi-square=0.52

13 57 11 6 4 1Chi-

square=3.94

19 6 4 25 23 1

Child on breastt roug outnight

12 1 8 11 P =.771 4 17 1 5 11 P =.139 2 7 3 19 11

Total 34 100 13 100 47 100 23 100 24 100 7 00 29 100 16 100 45 100

* Bivariate analyses among the 58 children who reportedly developed CPA 3 Signicance=P

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day frequency of breast-feeding and low uoride exposure,however, were important factors in the development ofcaries. Duration of breast-feeding also had no associationwith dental caries in a study conducted by Matee et al.3A strong association was found, however, between caries

eve opment an t e a it o a owing c i ren to s eepwith the breast nipple in their mouths.

The association between later initiation of solids and thedevelopment of CPA3 in this study approached signicancein the bivariate analysis, suggesting that early introductiono so i s cou e protective o enta caries. T is trenis not supported by the literature. It is suggested that theear ier a c i starts eating so i s, t e ear ier e s e coube exposed to inappropriate feeding practices, which couldincrease caries prevalence.47 Al-Dashti et al47 showed thatbreast-feeding practices were associated with a delay inintroducing sugar to the diet, which offered a further indi-rect a vantage. Ear ier weaning rom t e reast cou a soincrease the likelihood of bottle feeding, which, in turn, isassociate wit caries preva ence in presc oo c i ren.77 Inthis study, later weaning was not controlled for in the analy-sis and logistic regression analysis also showed no signicantassociation between CPA3 and initiation of solids.

Some studies have shown a signicant relationship be-tween ora ygiene status an t e inci ence o enta car-ies10,78,79 while others have not.55,80,81 Professional consensussuggests that oral hygiene should begin with the eruptionof the rst tooth, since formation of dental plaque on thedental surfaces is considered a risk factor for dental decay.2Alaluusua and Malmivirta 19 reported visible plaque to bethe best predictor of future caries risk in 92 19-month-oldc i ren w o were o owe or 1 years. Fraiz an Wa ter2investigated the factors associated with the development ofdental caries in preschool children receiving routine dentalcare and found the presence of visible plaque on the maxil-lary incisors to be strongly associated with the developmento enta caries. In t e stu y, mu tivaria e ana ysis ounlater initiation of daily oral hygiene to be marginally asso-ciate wit t e eve opment o CPA3 P =.08; OR=0.7 .

ate initiation of daily oral hygiene (after age 3) was seen inonly 10% of the breast-fed children who developed CPA3.The survey instrument, however, did not assess how effec-

tive the oral hygiene was, the periods during the day whenit was accomp is e , or w et er or not toot - rus ing wasaccomplished by the parents or by the children.

Results from the bivariate analyses conducted in thesecondary analyses for children who developed CPA3 sug-gest that the presence of night-time breast-feeding habitand both greater night and day nursing frequency could beimportant factors associated with CPA3. Caution is neces-sary in interpretation, owever, since no urt er mu tivari-able analyses were conducted due to the small number ofsubjects (N=58).

The literature on night-time breast-feeding is not asextensive as for bottle-feeding. Nocturnal feeding, however,

as een extensive y imp icate in t e iterature as a pre

reported their concern for allowing children to be ebottle- or breast-fed on-demand during the night.23,28-One reason for their concern is that saliva ow decrmarkedly during the sleeping hours, which is thougaffect mechanical self-cleansing and buffering cao owing ermentation o cariogenic su strate.10,29-31 T

frequency of breast-feeding during night sleeping houbeen reported in the literature to be more harmful to a chdental health than the frequency of breast-feeding duthe day. Derkson and Ponti7 found frequency of noctu

reast- ee ing to e a actor re ate to caries eve opmOn the other hand, frequency of breast-feeding during

ay as een reporte to ave no association wit caries.3 It is possible that the night-time breast-feepractices as well as high frequency of breast-feedchildren in the current study with CPA3 placed themhigher risk for dental caries. It would be inappropr

owever, to consi er t e reast- ee ing practices o children as the only causative factors in the developmt is enta isease ase so e y on t e in ormation coin this LLLI survey.

Although human milk has been reported to be mcariogenic than bovine milk, no study has shown humilk alone to be a sufcient predisposing factor in c

eve opment. Eric son et a ,84 a ter a series o stu iehuman breast milk, concluded that human breast milk ain an n v tro model is not cariogenic. However, if anocarbohydrate source is available for bacterial fermenand the child is exposed to unlimited breast-feeding, humilk can be highly cariogenic.84

n the current study, when mothers of children wCPA3 were as e a out t e met o s t ey use to mathe carious process in their child, 98% of them reportechanges in their nursing practices. This was not surprisince LLLI mothers are known to be devoted to their beabout the benets of breast-feeding. In a 1996 statemregar ing reast- ee ing an enta caries,70 LLLI o cistated that all the benets from breast-feeding should been into consi eration against any se - imiting ris o caries in the primary teeth in early childhood. A mrecent LLLI publication has cited that weaning irequired to prevent and treat early childhood caries.85 T

present studys design did not assess whether the chi w o eve ope caries were sti nursing at t e time caridetected. It is possible that breast-feeding could have alceased when caries was detected, so no changes in nupractices could actually have been made by the mo

This research study was subject to the limitations oretrospective studies based on maternal recall, survey iment, study sample, and that caries data were self-repo

T e survey instrument use y LLLI a severa e cies, partially related to wording of the questions and fato gather information on all items from all the respon

mothers. Although no actual skip pattern was built intosurvey, 12 of the 23 questions were written in such at at on y mot ers w ose c i ren a caries were supp

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and loss of important information about those children whowere breast-fed and did not develop dental caries.

t is also important to acknowledge that very little isknown about the respondents, since it was not possible todetermine the number of questionnaires sent or the responserate or t e survey. Important con oun ing varia es, sucas SES and educational levels of the responding mothers,were not controlled for in this study. Some of these mothersresponses could have been subject to bias due to their beliefsabout the benets of breast-feeding, especially in thosequestions assessing requency o reast- ee ing, presence onight-time breast-feeding, and night-time nursing patternat t e time o caries eve opment or etection.

Although this survey was conducted approximately 21years ago, the feeding practices among LLLI mothers today,as well as the LLLI position regarding breast-feeding anddental caries, remain the same.83 La Leche League continuesto encourage mot ers to respon to t eir a ies esire tonurse on demand and throughout the night. Concernsa out an prevention o enta caries are a resse in ar-ticles published by the organization and at local and nationalconferences. LLLI encourages parents to foster good dentalhealth during the time breast-feeding continues.5-87

ealth professionals should recognize the benets ofreast- ee ing an e ucate mot ers w o c oose to reast-

feed their child on-demand about the remaining uncer-tainties concerning prolonged unrestricted breast-feeding,and the importance of implementing benecial dental habitsto assure a child will reach a healthy dental balance.

pecic recommendations should include:1. a consistent daily oral hygiene regimen as early as pos-

si e, con ucte y an a u t;2. a healthy diet, low in carbohydrates;3. exposure to optimal uoride levels and daily use of

uoridated toothpaste; and4. routine early professional dental care.

CONCLUSIONS

Based on a maternal report of La Leche League International-member mothers, this study found that of the breast-fedchildren in this study, 10% reportedly developed caries priorto age 3. Later weaning was t e on y varia e signi cant yassociated with an increased likelihood of reportedlydeveloping caries prior to age 3.

ACKNOWLEDGEMENTS

The authors would like to greatly thank Dr. Jimmy R.Pinkham, Professor Emeritus, Dr. David Johnsen, Dean, andMs. Jane R. Jakobsen, Adjunct Assistant Professor, Collegeo Dentistry, T e University o Iowa, Iowa City, IA, or

their valuable contributions to this manuscript, as well as Dr.Donald Duperon, Professor Emeritus, School of Dentistry,University of California at Los Angeles for making the data

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