Breastfeeding and The Risk of Dental Caries: A Systematic Review and Meta-Analysis

Acta Pædiatrica ISSN 0803-5253
REVIEW ARTICLE
Breastfeeding and the risk of dental caries: a systematic review and

meta-analysis
R Tham1, G Bowatte1, SC Dharmage1,2, DJ Tan1,3, MXZ Lau1, X Dai1, KJ Allen2,4, CJ Lodge (clodge@unimelb.edu.au)1,2
1.Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Vic., Australia
2.Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics, Royal Children’s Hospital, Parkville, Vic., Australia
3.NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, TAS, Australia
4.Institute of Inflammation and Repair, University of Manchester, UK
Keywords ABSTRACT
Breastfeeding, Child, Dental caries, Meta-analysis, Aim: To synthesise the current evidence for the associations between breastfeeding and
Systematic review
dental caries, with respect to specific windows of early childhood caries risk.
Correspondence
Methods: Systematic review, meta-analyses and narrative synthesis following searches of
Caroline Lodge MBBS Grad Di Epi PhD, Allergy and
Lung Health Unit (ALHU), Centre for Epidemiology PubMed, CINAHL and EMBASE databases.
and Biostatistics, School of Population & Global Results: Sixty-three papers included. Children exposed to longer versus shorter duration of
Health, Faculty of Medicine, Dentistry & Health
Sciences, The University of Melbourne, Level 3, 207
breastfeeding up to age 12 months (more versus less breastfeeding), had a reduced risk
Bouverie Street, Melbourne, Vic. 3010, Australia. of caries (OR 0.50; 95%CI 0.25, 0.99, I2 86.8%). Children breastfed >12 months had an
Tel: +61 3 83440848 | increased risk of caries when compared with children breastfed <12 months (seven
Fax: +61 3 93495815 |
Email: clodge@unimelb.edu.au
studies (OR 1.99; 1.35, 2.95, I2 69.3%). Amongst children breastfed >12 months, those
fed nocturnally or more frequently had a further increased caries risk (five studies, OR 7.14;
Received
18 May 2015; revised 10 June 2015;
3.14, 16.23, I2 77.1%). There was a lack of studies on children aged >12 months
accepted 7 July 2015. simultaneously assessing caries risk in breastfed, bottle-fed and children not bottle or
DOI:10.1111/apa.13118
breastfed, alongside specific breastfeeding practices, consuming sweet drinks and foods,
and oral hygiene practices limiting our ability to tease out the risks attributable to each.
Conclusion: Breastfeeding in infancy may protect against dental caries. Further research
needed to understand the increased risk of caries in children breastfed after 12 months.
INTRODUCTION to the carbohydrate content of breast milk or formula along

Dental caries (tooth decay) is a major public health problem with factors which determine the length of contact between
affecting 60–90% of school-aged children (1), with breast milk or formula and the erupted dentition (i.e.
increased prevalence in children from lower socio-eco- frequency of feeding, and feeding practices which result in
nomic groups (2). It is caused by multi-factorial and pooling of breast milk or formula around the teeth surfaces,
complex interactions between cariogenic bacteria in the such as feeding babies to sleep). The central determinant of
mouth with dietary carbohydrates that produce acids and caries risk, however, is the age of colonisation and levels of
demineralise the teeth (2). The pain and infection caused by cariogenic bacteria (e.g. Streptococcus mutans) (7) in an
dental caries can be extremely distressing and can impact infant’s mouth. Earlier and denser oral colonization by
on quality of life and ability to function (3), lead to lost cariogenic bacteria are related to increased caries risk (8).
productivity and involve high health care costs (4) includ- Breast milk, in contrast to formula, contains breast-specific
ing general anaesthesia for treatment of severe cases. This
accounts for one of the most common causes of child
hospitalisation in industrialised countries (5) and is among Key notes
the most common causes of avoidable child hospitalisations Children exposed to more versus less breastfeeding up
(6). Early loss of deciduous dentition can lead to ongoing to 12 months had reduced risk of dental caries.
dental problems in the permanent dentition. Increased risk of dental caries in children breastfed
The evidence concerning infant feeding as a risk factor >12 months, especially if frequent or nocturnal, may be
for dental caries is inconsistent. Dental caries risk is related due to unmeasured confounders including dietary
sugars and oral hygiene practices.
Research should simultaneously investigate breastfeed-
Abbreviations ing practices including frequency and nocturnal routi-
95%CI, 95% Confidence Intervals; NOS, Newcastle Ottawa nes, along with dietary and oral hygiene practices to
Scale; OR, Odds ratio; RCT, Randomized controlled trials; RR,
more accurately determine specific risks.
Relative risk; WHO, World Health Organization.
62 ©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 62–84
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
Tham et al. Breastfeeding and dental caries
Lactobacilli and substances, including human casein and

Table 1 Search terms used for the three
secretory IgA, which inhibit the growth and adhesion of
databases electronically searched
cariogenic bacteria, particularly oral Streptococci (9,10). [PUBMED]
The risk of dental caries is also dependent on the presence #1 “Breast Feeding”[Mesh]
of teeth and rises with increasing number of teeth. Risk also #2 “Milk, Human”[Mesh]
changes as the infant’s diet starts to include foods and #3 Breast[All Fields] AND Feed*[All Fields]
drinks other than breast milk or formula, depending on the #4 Breast-fe*[All Fields]
carbohydrate content, acidity and consumption frequency #5 Infant fe* [All Fields]
of the introduced diet. #6 Infant nutrition* [All Fields]
The important aspect of timing of tooth eruption for our #7 #1 OR #2 OR #3 OR #4 OR #5 OR 6
#8 Dental caries (MeSH)
systematic review is that the deciduous teeth most at risk of
#9 Tooth decay
early childhood caries (eight upper and lower central and
#10 “Early childhood caries”
lateral incisors) start to erupt at 6 months and are fully
#11 “Nursing bottle caries”
erupted by 12 months. The next most vulnerable deciduous #12 #8 OR #9 OR #10 OR #11
teeth (four upper and lower first molars) erupt between 13 #13 animals [mh] NOT humans [mh]
and 19 months, the remainder are erupted by 33 months #14 #7 AND #12
(11). #15 #14 NOT #13
Current WHO breastfeeding guidelines recommend [EMBASE]
exclusive feeding for the first 6 months of life and comple- #1 ‘breast feeding’/exp
mentary breastfeeding up to 2 years (12). Although the #2 ‘breast milk’/exp
UNICEF calculated global prevalence of breastfeeding at #3 Breast AND Feed*
#4 Breast-fe*
12 months from 62 countries is 74%, this figure hides the
#5 Infant fe*
underlying heterogeneity between countries (13). As
#6 Infant nutrition*
opposed to low income countries, the duration of total #7 #1 OR #2 OR #3 OR #4 OR #5 OR 6
breastfeeding in high/middle income countries is shorter #8 ‘dental caries’/exp
with only 21% of US mothers breastfeeding at 12 months #9 Tooth decay
(14) and similar rates in the UK (13), Canada (5) and #10 “Early childhood caries”
Australia (15). National guidelines in high/middle income #11 “Nursing bottle caries”
countries, where the risk of infant morbidity and mortality #12 #8 OR #9 OR #10 OR #11
from gastrointestinal disease is relatively low, recommend #13 [animals]/lim NOT [humans]/lim
breastfeeding for at least 12 months (16). Thus, investigat- #14 #7 AND #12
#15 #14 NOT #13
ing windows of exposure before and after 12 months of age
[CINAHL]
is relevant to breastfeeding guidelines and practices as well
#1 “Breast Feeding”
as timing of tooth eruption.
#2 “Milk, Human”
The relationship between breastfeeding and dental caries #3 Breast AND Feed*
has been systematically (17) and narratively reviewed (18– #4 Breast-fe*
20) with conflicting results between studies. There is #5 Infant fe*
controversy about what constitutes the best form of infant #6 Infant nutrition*
feeding to prevent dental caries and promote optimal dental #7 S1 OR S2 OR S3 OR S4 OR S5 OR S6
health (21). Consequently no definitive optimal weaning #8 dental caries
times or breastfeeding practices have been determined to #9 tooth decay
specifically address the risk of dental caries. #10 early childhood caries
#11 nursing bottle caries
#12 S8 OR S9 OR S10 OR S11
#13 S7 AND S12
AIM **For #13 limit to ‘Human’
To summarise the current evidence for the association
between breastfeeding and dental caries with specific
reference to exposure windows and breastfeeding practices.
interest was the development of dental caries in deciduous
or permanent teeth. An extensive list of search terms was
METHODS used and is reported in Table 1.
Search strategy We checked reference lists of all primary studies and
We identified human English language studies through review articles for additional references. The titles and
systematically searching electronic databases: PubMed abstracts were independently reviewed for initial inclusion
Central, CINAHL and EMBASE from inception to the by two researchers (RT and GB). Disagreement was
present. Our exposure of interest was breastfeeding as resolved by discussion and if consensus could not be
compared to formula or other feeding. Our outcome of reached, a third author (CL) made the final decision.
©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 62–84 63
Breastfeeding and dental caries Tham et al.
Eligibility criteria number of teeth, and exposure to sugar in the diet (food
We included observational and experimental studies pub- or other liquid).
lished in full text. We included children and adolescents
from both general and high-risk populations (e.g. low socio- Data extraction
economic communities). Dental caries as reported by We extracted: study design; study country; age range of
appropriately qualified practitioner/researchers, a parent children; number of children; exposure and outcome
or through health records databases were included. We definitions; how the outcome data were measured; effect
excluded participants who were born prematurely estimates; confounders included in analysis; sub-group
(<36 weeks gestation) because these infants are often fed analysis; interactions; and findings.
by other sources and can have complicated medical inter-
ventions. Assessment for meta-analysis
Exposure and outcome definitions and effect estimates
Assessment of quality and risk of bias (odds ratios (OR), relative risks, prevalence ratios) with
Two researchers (RT and GB) independently conducted a 95% Confidence Interval (95%CI) were abstracted where
quality assessment of each study using the Newcastle- available for inclusion in a meta-analysis. Given the
Ottawa Scale (NOS) (22). Study quality was graded on a biological plausibility of the potential associations, we
scoring system (see Tables 2–5 for key criteria). Differences aimed to assess exposure to breastfeeding in two specific
in assessment and grading were resolved by discussion with time windows: (i) Up to 12 months of age (upper and lower
a third researcher (CL). incisors present) and (ii) Beyond 12 months of age (other
The assessment of risk of bias was guided by the GRADE teeth erupting up to 33 months- increased risk of caries). As
system for rating the quality of the evidence of observational there were very few mothers who exclusively breastfed
studies (23). infants until 12 months or beyond, within these time
Literature review identified key confounders that should windows we categorized studies into: (i) Never breastfed
be controlled for in breastfeeding and dental caries studies: compared to any breastfeeding and (ii) More versus less
socio-economic status, age, mother’s educational level, breastfeeding. This category was created to include all
Table 2 Newcastle-Ottawa Quality Assessment score for Cohort studies nested in Randomized Controlled Trials
Selection of Outcome of Adequate
non- exposed Ascertainment interest not Assessment Adequate follow up
RCT Representativeness cohort of exposure present at start Comparability of outcome follow up time of cohorts Score/10
Feldens et al. (30) * * * * ** * * 8

Feldens et al. (27) * * * * ** * * 8
Table 3 Newcastle-Ottawa Scale Quality Assessment score for Cohort Studies

Selection of Outcome of Adequate
non-exposed Ascertainment interest not Assessment follow Adequate follow
Cohort studies Representativeness cohort of exposure present at start Comparability of outcome up time up of cohorts Score/10
Feldens et al. (25) * * * * ** ** * * 10

Chaffee et al. (26) * * * * * * * * 8
Hong et al. (31) * * * ** ** * 8
Kramer et al. (29) * * * * ** * * 8
Kramer et al. (28) * * * * ** * * 8
Ollila (38) * * * ** * * 7
Silver (32) * * * * * 5
Tada et al. (33) * * * * 5
Tanaka et al. (34) * * * ** ** * 8
Thitasomakul et al. (35) * * * * ** * 7
van Palenstein * * ** * * 6
Helderman et al. (36)
Yonezu et al. (37) * ** * * 5
Table 4 Newcastle-Ottawa Scale Quality Assessment score for Case-Control Studies

Adequate Representativeness Selection of Definition of Ascertainment Method of Nonresponse
Case control case definition of cases controls controls Comparability of exposure ascertainment rate Score/10
Bahuguna et al. (39) * * * * * 5

Matee et al. (40) * * * * 4
Roberts et al. (41) * * ** * 5
studies, which compared groups with relatively more assessed by dental professionals through oral examination.
(longer duration of breastfeeding) and relatively less breast Key characteristics are summarised in the Appendix.
milk exposure (shorter duration). To choose between
multiple reported ORs for a single study we preferentially Quality assessment
selected: estimates for exclusive breastfeeding or, if not Tables 2 3, 4, and 5 detail the NOS score assigned to
available, any breastfeeding; then the longest duration each included study. The cohort and cross-sectional
compared with the shortest. If there were multiple ages of studies that were embedded in RCTs of a range of
outcome within the particular group then we chose the breastfeeding promotion interventions (25–30) scored
oldest age reported. highly as the study designs overcame many sources of
We performed meta-analysis if there were three or more bias and reporting limitations that were apparent in the
studies in each time window and category of breastfeeding. other cohort, case–control and cross-sectional studies.
Random effects meta-analyses were performed if the Other cohort studies were weakened by the method used
heterogeneity (I2) was >25%. Heterogeneity was considered to ascertain infant feeding practices (self-report) which
to be high, and results unreliable if I2 values were >75%. We subjected them to recall bias, recruitment of children
were unable to quantitatively assess for publication bias as through oral health services (selection bias), lack of
no group contained more than 10 studies. Studies not reporting of the absence of caries at the commencement
meeting these criteria were qualitatively assessed. of the study (ascertainment bias), loss to follow –up and
Statistical analysis was performed using Stata IC 13 accounting for these participants (attrition bias), and lack
(StataCorp., LP Texas, USA). of controlling for confounders. Case–control study designs
were inherently subject to recall bias when ascertaining
infant feeding practices. Furthermore, cases and controls
RESULTS were not representative of the broader population as they
Search results were recruited in settings where children were likely to
Electronic literature search (2 October 2014) and manual have caries. Selection bias was also a problem as the
search found 480 peer-reviewed scientific articles after selection of controls was not clearly described. Cross-
duplicate papers were removed. Of these, 366 were sectional studies were the weakest but most common
excluded after abstract review for failing to meet the study design. The studies which scored <4 were classified
eligibility criteria. A large number of these papers were as unsatisfactory due to major limitations in study design
not related to breastfeeding or dental caries, were not in and reporting. Studies that scored 4 were classified as
English or were not original research. Of the remaining 114 satisfactory, however, all of these studies lacked consid-
full text articles, 51 were excluded as: (i) they did not assess eration of key confounders. In the higher quality studies
the relevant exposure (breastfeeding) and outcome (dental (≥5) there were limitations in how exposure was ascer-
caries) or (ii) all feeding types were analysed together or (iii) tained as many studies used self-report questionnaires
data were duplicated in more than one paper or (iv) no (recall bias).
analysis was reported or studies lacked control or com-
parator groups [Fig. 1 (24)]. In total 63 papers were Meta-analysis
included. We meta-analysed the small number of studies which
included statistical effect measures.
Characteristics of included studies
Although the 63 papers did not include randomised Breastfeeding up to 12 months of age
controlled trials (RCT) of breastfeeding, six cohort studies One prospective cohort (34) and four cross-sectional
(25–30) were nested within RCTs of breastfeeding promo- studies (48,52,59,70) reported odds ratios for the associa-
tion interventions. There were eight additional cohort tion between children who were exposed to more versus
studies (31–38) and three case–control studies (39–41). less breastfeeding up to 12 months (OR 0.50; 0.25–0.99, I2
The remaining 46 studies were cross-sectional in design 86.8%) (Fig. 2). There were not enough studies to perform
(42–86). The studies were predominantly conducted in high metaregression for formal investigation of this heterogene-
and middle income countries with only eight studies from ity. There appeared to be differences, however, based on the
low income countries (87). All caries outcomes were comparison groups of the included studies. The two studies
Table 5 Newcastle-Ottawa Scale Quality Assessment score for Cross-sectional Studies

Selection of non- Ascertainment Assessment
Cross-sectional Representativeness exposed cohort of exposure Comparability of outcome Score/7
Alaluusua et al. (42) * * * 3

al-Dashti et al. (43) * * ** 4
Azevedo et al. (44) * * * ** 5
Campus et al. (45) * * ** * 5
~o et al. (46)
Carin * ** 3
Dini (47) * * * * 4
Du et al. (48) * ** * 4
Dye et al. (49) * * ** ** 6
Folayan et al.(50) * * * 3
Folayan et al. (87) * * * 3
Forsman et al. (51) * * * 3
Hallett et al. (52) * * ** ** 6
Hallonsten et al. (53) * * * 3
Haq et al. (54) * * 2
Hardy (55) * 1
Harrison et al. (56) * * ** 4
Holt et al. (57) * * * 3
Hong et al. (58) * * ** * 5
Iida et al. (59) * * * * * 5
Johansson et al. (60) * * * 3
Livny et al. (61) * * * 3
Majorana et al. (62) * * ** 4
Masumo et al. (63) * * * ** 5
Mattos-Graner et al. (64) * * ** 4
Nobile et al. (65) * * * 3
Nunes et al. (66) * ** ** 5
Perera et al. (67) * * * 3
Prakash et al. (68) * * * * 4
Prakasha Shrutha et al. (69) * * 2
Qadri et al. (70) * * * * 4
Retnakumari (71) * * * 3
Rosenblatt (72) * * * 3
Sankeshwari et al. (73) * * * 3
Santos (74) * * 2
Sayegh et al. (75) * * ** 4
Sayegh et al. (76) * * * ** 5
Serwint et al. (77) * * * 3
Slabsinskiene et al. (78) * * * 3
Songo et al. (79) * * 2
Tanaka, (80) * * ** * 5
Tiano et al. (81) * * * 3
Tyagi, (82) * 1
Vachirarojpisan et al. (83) * * * * * 5
Vazquez-Nava et al. (84) * * ** * 5
Wendt (85) * * * * 4
Yonezu et al. (86) * 1
which compared ever breastfeeding in the first 12 months Breastfeeding after 12 months of age
with never breastfeeding (48,70), both showed a marked Two cohort studies (33,34), one case control study (40) and
protective effect of breastfeeding on dental caries compared four cross-sectional studies (52,65,75,78) reported odds
with other feeding. Whereas the three studies which ratios for the association between more or less breastfeed-
compared a longer duration of breastfeeding in the first ing after the age of 12 months and dental caries. The
12 months to a comparison group which included children comparison groups for these studies included both those
who had had some exposure to breastfeeding did not who had never been breastfed and those who had been
(34,52,59). A meta-analysis on this three study subgroup breastfed for shorter durations. The pooled estimate was
found an OR of 0.92; 0.69–1.23, I2 0% (Fig. 3). OR 1.99; 1.35–2.95, I2 69.3% (Fig. 4).
Records identified through database Additional records identified
Identification
searching PubMed, Embase, CINAHL, through other sources and hand
Medline = 817 searching = 10
Records after duplicates removed (n=347) = 480
Screening
Title and abstract review – exclude n= 366
Not breastfeeding = 170
Not dental caries = 54
Not English = 30
Not research = 75
Pre-term babies = 3
Records screened = 480
Review papers = 32
Study protocols = 2
Eligibility
Full text articles assessed for Full paper reviews – exclude

eligibility = 114 BF not exposure or DC not outcome = 7
Breast & bottle feeding grouped together = 3
Data duplicated in other paper = 1
No analysis of BF and DC = 29
No control/comparator group = 12
Articles included in synthesis = 63

Included
Articles assessed for meta-analyses =

Breastfeeding at 12 months: n=5
Breastfeeding beyond 12 months: n=6
Breastfeeding on demand or nocturnally: n=6
Figure 1 PRISMA Flow diagram of review.
Only two studies (26,80) reported prevalence ratios so (25,27,30) the intervention group demonstrated a lower
these could not be meta-analysed. incidence of caries at 12 months (OR = 0.52, 0.27–0.97,
p = 0.03) and 4 years (RR = 0.78, 0.65–0.93, p = 0.004).
Nocturnal breastfeeding in those breastfed longer than Investigating breastfeeding frequency at 12 months, the
12 months study also found a doubled risk of caries when feeding
One cohort (36), one case–control (40) and three cross- frequency was 3–6 times/day (RR = 2.04, 1.22–3.39,
sectional studies (67,84,86) reported odds ratios for the p = 0.000) and ≥7 times/day (RR = 1.97, 95%CI 1.45–
association between more versus less nocturnal breastfeed- 2.68, p = 0.000) compared to 0–2 times/day. Analyses were
ing and the risk of dental caries amongst the subgroup of adjusted for maternal schooling level, daily meals, bottle use
children breastfed longer than 12 months. The pooled for fruit juice/soft drinks, consumption of high density sugar
estimate was OR 7.14; 3.14–16.23, I2 77.1% (Fig. 5). and number of teeth. Another birth cohort study nested in
an intervention conducted through maternal health centres
Narrative synthesis in Brazil (26) found that, in adjusted regression models, as
The majority of studies (n = 46) were not included in the breastfeeding continued beyond 6 months the prevalence
meta-analyses due to methodological differences in the ratio of caries in breastfed children increased (compared to
measures of exposure and outcomes, or reporting of breastfeeding <6 months) but was only significant when still
correlational analyses only. breastfeeding at ≥24 months: 6–11 months (PR = 1.45, 95%
CI 0.83–2.53); 12–23 months (PR = 1.39, 95%CI 0.73–
Studies embedded in randomised controlled trials (RCTs) 2.64); ≥24 months (PR = 1.85, 95%CI 1.11–3.08). A birth
It is not ethical to conduct randomized trials assigning cohort study nested in a breastfeeding promotion interven-
participants to breastfeeding and non-breastfeeding groups tion in Belarus found no significant difference in caries
in order to more definitively assess the association between incidence or prevalence in the intervention group when
breastfeeding and dental caries. However, a number of children were aged 6.5 years (28,29).
RCTs have been conducted that investigated the impact of
breastfeeding promotion programmes (25–30). In a RCT of Breastfed versus formula fed
an intervention that provided monthly advice on healthy Studies that examined ever versus never breastfed children
feeding practices over 12 months via home visits in Brazil reported a range of findings. Six cross-sectional studies
More vs Less Breastfeeding up to 12 months and risk of caries

Odds
Study
ID Ratio (95% CI)
Cohort study
Tanaka (2013) 0.67 (0.27, 1.65)
Cross-sectional study
Du (2000) 0.19 (0.08, 0.46)
Hallett (2003) 1.00 (0.71, 1.41)
Iida (2007) 0.80 (0.42, 1.53)
Qadri (2012) 0.27 (0.18, 0.41)
Overall (I-squared = 86.8%, p = 0.000) 0.50 (0.25, 0.99)
NOTE: Weights are from random effects analysis
.1 .5 1 5
Odds Ratio
Figure 2 More versus Less breastfeeding (including never breastfed) up to 12 months of age and the risk of dental caries
More vs Less Breastfeeding up to 12 months and the risk of caries

Study Odds %
ID Ratio (95% CI) Weight
Cohort study
Tanaka 0.67 (0.27, 1.64) 10.47
Hallett 1.00 (0.71, 1.41) 69.99
Iida 0.80 (0.42, 1.54) 19.53
Overall (I-squared = 0.0%, p = 0.645) 0.92 (0.69, 1.23) 100.00
.05 .25 .5 1 1.5 2

Odds Ratio
Figure 3 More versus Less Breastfeeding (excluding never breastfed) up to 12 months of age and the risk of dental caries.
reported no significant difference in the prevalence of caries one cross-sectional study reported an increased risk of
between the two groups (49,61,72–74,83); one cohort and dental caries in ever breastfed children of borderline
one cross-sectional study reported significantly lower caries significance (p = 0.08) (77); and one cross-sectional study
in breastfed children (32,57); one cross-sectional study found a lower adjusted caries risk in breastfed versus bottle-
found a lower adjusted caries risk in breastfed versus bottle- fed children.
fed children (OR = 0.61, 95%CI 0.39–0.97, p = 0.038) (70);
one cohort study reported higher caries increment in Breastfeeding duration
breastfed children between 12 to 18 months but the Three of four cohort studies found that breastfeeding beyond
association disappeared in the multivariate analysis (35); 12 months was correlated or associated with increased caries
Breastfeeding beyond 12 months and risk of caries

Study
ID Odds Ratio (95% CI)
Cohort study
Tanaka (2013) [=18 mth] 2.47 (0.94, 6.51)
Tada (1999) [=18 mth] 6.65 (2.90, 15.25)
Case-Control
Matee (1994) [1yr vs 3yr] 2.40 (0.67, 8.65)
Hallett (2003) [>13mth] 1.50 (0.94, 2.40)
Nobile (2014) [= 20mth] 1.26 (1.01, 1.57)
Sayegh (2002) [>18mth] 1.50 (1.09, 2.07)
Slabsinskiene (2010) [>13mth] 10.00 (1.28, 78.12)
.5 1 5 10 15
Odds Ratio
Figure 4 Breastfeeding beyond 12 months and the risk of dental caries.
Nocturnal breastfeeding beyond 12 months and risk of dental caries

Study
ID Odds Ratio (95% CI)
Cohort study
van Palenstein (2006) 35.00 (6.29, 194.87)
Case-Control
Matee (1994) 17.80 (6.30, 50.30)
Perera (2014) 2.54 (1.29, 5.01)
Vazquez-Nava (2008) 3.60 (2.51, 5.16)
Yonezu (2007) 10.66 (2.23, 50.96)
.5 1 5 10 15 20
Odds Ratio
Figure 5 More versus Less nocturnal breastfeeding and the risk of dental caries in those breastfed longer than 12 months.
prevalence compared with shorter durations of breastfeeding. rose in children breastfed beyond 12 months. Ollila et al.’s
Chaffee et al. (26) found that the adjusted prevalence ratio (38) survival analysis found no difference between children
of caries in children breastfed ≥24 months was 2.1 (95%CI breastfed >12 months and those not. Cross-sectional studies
1.5–3.25) compared to children breastfed <6 months. reported variable findings: increased caries prevalence in
Yonezu et al. (37) found significantly more caries in children breastfed longer than those breastfed for shorter
children breastfed >18 months than those weaned times (44,45,53,54,63,65,71,75,78,81,85); and no difference
<18 months. Feldens et al. (25) found the risk of caries in caries prevalence between duration groups (66,82).
The few studies that controlled for confounding factors results we found before and after 12 months of age. The
found decreased caries risk with shorter breastfeeding cariogenicity of human breast milk has not been extensively
duration (6–12 months) compared to longer duration examined under in vivo conditions, however animal studies
(>13 months) (26,34,45,76,80) and increased risk of caries suggest that at high frequency exposures, human breast milk
if breastfed <6 months (31,48). has greater cariogenicity compared to bovine milk but less
than infant formula (90,91). Relative cariogenicity of breast
Breastfeeding on demand and nocturnally milk will also depend on the comparison group. Below
In addition to the meta-analysed studies, a number of cross- 12 months it is usual to feed infants either breast milk or
sectional studies reported significant correlations between formula which have around the same carbohydrate content.
infants/children breastfed during the night (44,67), on After 12 months, however, children in high income coun-
demand (68) or sleeping with a nipple in the mouth tries are often weaned onto cow’s milk which has half the
(60,71,76) and increased prevalence of dental caries. One carbohydrate content of human milk. However, each
cohort study found an increased adjusted risk of dental element is subject to modification by risk factors such as
caries with increased daily breastfeeding frequency includ- socio-economic status, maternal educational level, maternal
ing nocturnal feeding (25). oral health, maternal smoking status, position in birth
order, sugars in diet, oral hygiene and exposure to fluoride
(2).
DISCUSSION Breastfeeding duration, frequency of breastfeeding and
Qualitative assessment of studies investigating breastfeed- nocturnal breastfeeding during sleep are most often
ing up to 12 months of age suggested that children who analysed as separate breastfeeding behaviours, however
were exposed to more breastfeeding (longer duration) they are inter-related. Nocturnal breastfeeding is often
compared to less or no breastfeeding were protected from used to comfort an infant or child who may then fall
dental caries. Meta-analysis of five studies also found asleep with the nipple in their mouth. In this position, the
reduced risk of dental caries in children breastfed more tongue fills the mouth and holds the breast milk against
versus less up to 12 months, however, the heterogeneity the surfaces of the teeth, thereby prolonging the exposure
between studies was too high to make the estimate reliable. of the substrate to the cariogenic bacteria that are
In contrast, children who were breastfed beyond 12 months attached to the teeth surfaces and hence increasing the
had an increased prevalence of dental caries. Amongst risk of dental caries. It is possible that children breastfed
those who continued to be breastfed after 12 months, there beyond 12 months are also engaging in nocturnal breast-
was a further increased risk of caries in children who were feeding but the modification of dental caries risk by infant
breastfed nocturnally. feeding practices has not been examined in depth in any
Three elements are essential for dental caries to occur: a of the studies included in this review. In addition, children
tooth, cariogenic bacteria (e.g. Streptococcus mutans) and >12 months are no longer being exclusively breast or
substrate for the bacteria (sugar) (2). The risk of developing bottle fed and the diet is expanding to include other fluids
dental caries changes as factors associated with each and solids. It has been reported that children who are
element change. The first tooth usually erupts in an infant’s breastfed for longer durations also have more frequent
mouth between 6 and 12 months of age. As each tooth cariogenic food intakes (25,53,58). Oral hygiene practices
erupts the risk of developing dental caries increases, hence to remove bacterial plaque are important as more teeth
age and number of teeth increases risk. Cariogenic bacteria erupt to reduce the risk of dental caries. Only a few
are transmitted to the child via close contact with the studies included in this review controlled for key con-
mother’s saliva (88) but their levels and cariogenicity vary founding factors and this may have resulted in an over-
between individuals (2) depending on maternal bacterial estimation of the role of prolonged, frequent and noctur-
levels, maternal caries prevalence, oral hygiene practices nal breastfeeding in the development of dental caries.
and exposure to dietary sugars (21). Breast milk is known to Until the dietary and oral hygiene details of these children
contain immunomodulatory factors along with a rich are controlled for we cannot be certain whether pro-
microbiome which is responsible for establishing normal longed, frequent or nocturnal breastfeeding can be prin-
intestinal flora (89). Initial protection from dental caries cipally associated with early childhood caries.
may be mediated through establishment of a healthy oral This is the first systematic review of breastfeeding and
microbiome in infants through exposure to breastfeeding dental caries that includes critical exposure windows,
and contact with skin and breast milk microbiomes. limited meta-analyses and a range of study types. We
Additionally, the child’s oral microbiome changes over provide quantitative evidence that is suggestive of the
time with the emergence of new teeth. The essential potentially protective effects of breastfeeding from dental
substrates for cariogenic bacteria are simple carbohydrates caries up to 12 months, but higher risk of dental caries in
(sugars) which can be in a range of forms (e.g. lactose, children breastfed beyond 12 months, frequently, and/or
sucrose, glucose). The longer these sugars are in contact nocturnally. However, there is high heterogeneity between
with teeth, the higher the risk of dental caries. The amount the studies included in the meta-analyses (possibly due to
of carbohydrate (cariogenicity) contained in the different differing comparison groups) and lack of controlling for key
milks and formulas may also help to explain the different confounders (e.g. other foods/drinks in the diet, oral
hygiene, maternal oral health status) which limits the breast-fed from formula-fed infants. J Pediatr Gastroenterol
reliability of the results. Nutr 2013; 56: 127–36.
11. The American Dental Association. Tooth eruption: the primary
teeth. J Am Dent Assoc 2005; 136: 1619.
12. World Health Organization. Infant and young child feeding.
CONCLUSION Fact Sheet No 342. Available at: http://
Breastfeeding up to 12 months of age is not associated with www.who.int/mediacentre/factsheets/fs342/en/February
an increased risk of dental caries and in fact may offer some 2004. (accessed on 10th April 2015).
protection compared with formula. However, children 13. unicef GLOBAL DATABASES. Infant and young child
breastfed beyond 12 months, a time during which all feeding. In: data.unicef.org, editor. Available at:
http://data.unicef.org/nutrition/iycf. (accessed on April 30,
deciduous teeth erupt, had an increased risk of dental
2015) October 2014.
caries. This may be due to other factors which are linked 14. Li R, Fein SB, Chen J, Grummer-Strawn LM. Why mothers
with prolonged breastfeeding including nocturnal feeding stop breastfeeding: mothers’ self-reported reasons for stopping
during sleep, cariogenic foods/drinks in the diet, or inad- during the first year. Pediatrics 2008; 122: (Suppl 2): S69–76.
equate oral hygiene practices. Further research with careful 15. Australian Institute of Health and Welfare. 2010 Australian
control of pertinent confounding factors is needed to national infant feeding survey: indicator results. Canberra,
elucidate this issue and better inform infant feeding guide- Australia: AIHW, 2011.
16. Department of Health. Breastfeeding. Available at: http://
lines. As per recommendations from previous reviews
www.health.gov.au/breastfeeding: Australian Government
(17,19), the introduction of food sources to infants should Department of Health. (accessed on 11th April 2015).
be low in simple carbohydrates (sugars) and oral hygiene 17. Valaitis R, Hesch R, Passarelli C, Sheehan D, Sinton J. A
practices should start with the eruption of the first tooth so systematic review of the relationship between breastfeeding and
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oral and general health benefits. J Am Dent Assoc 2013; 144:
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19. White V. Breastfeeding and the risk of early childhood caries.
CONFLICT OF INTEREST STATEMENT Evid Based Dent 2008; 9: 86–8.
Preparation of the manuscript was assisted by funding from 20. Ribeiro NM, Ribeiro MA. Breastfeeding and early childhood
the WHO, which had no part in determining the outcomes caries: a critical review. J Pediatr 2004; 80: S199–210.
or presentation of findings. None of the authors has any 21. Leong PM, Gussy MG, Barrow SY, de Silva-Sanigorski A,
conflicts of interest to declare. Waters E. A systematic review of risk factors during first year of
life for early childhood caries. Int J Paediatr Dent 2013; 23:
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APPENDIX Study characteristics and summary of NOS QA
Other variables
included in the
References [NOS QA Type of study/brief Sample size (gender Outcome definition and models as
score] description Study population/Country % given if reported) Exposure definition age Exposure estimate (95% CI) confounders Interactions
Randomised controlled trial (RCT)

Feldens et al. (30) RCT of an intervention that Mothers who gave birth in N = 500 Intervention group Age 12 months Intervention group risk of caries: Number of teeth
[8* Good] provided monthly advice public health system; Sao Intervention n = 200 received advice at home Early Childhood Caries (ECC) OR = 0.52 (0.27–0.97) p = 0.03
on healthy feeding Leopoldi, Brazil; October Control n = 300 –decayed surfaces ≥1 in any cf control group
Breastfeeding and dental caries
practices (exclusive 2001 – June 2002 primary tooth (decay)

breastfeeding up to
6 months. >6 months
encouraged to continue
breastfeeding and
introduce foods) up to
12 months via home
visits
Feldens et al. (27) As for Feldens et al. Mothers who gave birth in N = 340 Intervention group Age 4 years Ref group = control with RR = 1.0 None reported
[8* Good] (2007) public health system; Sao Boys = 195 (57.4%) received advice at home 1. ECC –dmfs ≥1 in any ECC: Interv RR = 0.78 (0.65–0.93)
Leopoldi, Brazil; October Intervention n = 141 primary tooth (decay) p = 0.004
2001 – June 2002 Control n = 199 2. Severe-ECC (S-ECC) – dmfs NNT = 7 (4–20)
≥5 or one or more cavitated, S-ECC: Interv RR = 0.68 (0.5–
missing, filled smooth surface 0.92) p = 0.01
of anterior teeth. NNT = 8 (5–30)
3. Affected teeth (decayed or Affected teeth: Mean
cavitated) – dmft Interv = 3.25 (4.25) cf
Control = 4.15 (4.57) p = 0.023
Cohort
Chaffee et al. (26) Birth cohort study nested Birth to 38 months years; Porto 715 pregnant women Breastfeeding duration: Dental status evaluated at Fully adjusted regression models Maternal age; Education; High frequency day
[8* Good] in a cluster RCT of an Alegre, Brazil; Low income <6 months 38 months Breastfeeding at stages and S-ECC: Parity; Pre-pregnancy time breastfeeding
intervention in maternal families 6–11 months Severe-ECC – 1 or more Prevalence ratio BMI; Smoking status; Long duration, high
health centres, 2008– 12–23 months affected maxillary teeth or 4 or <6 = 1 Social class; Child age; frequency
2011 24 months+ more decayed, missing due to 6–11 = 1.45 (0.83–2.53) gender; Time varying
caries or filled tooth surfaces 12–23 = 1.39 (0.73–2.64) bottle use; Feeding
(dmfs ≥4) ≥24 = 1.85 (1.11–3.08) habits; Length-for-age z
scores
Feldens et al., (25) Birth cohort study (nested Cohort of children aged 340 children Breastfeeding: Age 4 years Adjusted model: Maternal schooling; Daily
[10* Very good] in an RCT of an 4 years; Sao Leopoldo, Brazil (baseline = 500); Frequency Severe ECC RR of S-ECC associated with daily meals and snacks; Bottle
intervention in a birth Boys = 195 (57.4%) ≥1 cavitated, missing or filled breastfeeding frequency at use for fruit juice/soft
cohort) smooth surfaces in primary 12 months: drinks at 12 months;
maxillary anterior teeth, or 0–2 RR = 1.0 High density sugar at
dmfs values ≥5 3–6 RR = 2.04 (1.22–3.39) 12 months; Teeth at
≥7 RR = 1.97 (1.45–2.68) 12 months
p = 0.000
Hong et al. (31) Longitudinal birth cohort Iowa, USA N = 509 Breastfeeding duration Age 5 years and 9 years Tooth level: Caries in (e) at 5 years Gender, hypoplasia,
[8* Good] study Questionnaires: 3– <6 months Dental caries in: Mean dfs parental education level,
6 months from birth ≥6 months (a) All primary teeth BF <6 months = 0.55 family income level,
Dental exams: 5 years (b) 2nd deciduous molars (e) BF ≥6 months = 0.33 gestational weeks, birth
and 9 years p = 0.02 weight, age at time of
Person level: caries in (e) at 5 years dental exam, average
Breastfeeding <6 months daily fluoride intake
OR = 15.58 [no 95% CI reported] (mg), home tap water
(p = 0.005) fluoride level(ppm),
average daily soda pop
intake, daily tooth-
brushing frequency
Tham et al.
©2015 The Authors. Acta Pædiatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 2015 104, pp. 62–84
Tham et al.
Appendix (Continued)
Type of study/brief Sample size (gender % given Other variables included in
References [NOS QA score] description Study population/Country if reported) Exposure definition Outcome definition and age Exposure estimate (95% CI) the models as confounders Interactions
Kramer et al. (29) Prospective cohort study Children aged 6.5 years Total n = 13,883 Experimental vs control Age 6.5 years The experimental intervention had None reported
[8* Good] nested in RCT of BF Belarus Experimental n = 7108 groups Dental caries no significant effect on the DMFT/
promotion intervention Control n = 6781 DMFT/dmft dmft numbers or proportions (both
(PROBIT) all teeth and incisors only)
Kramer et al. (28) Prospective cohort study Children aged 6.5 years Exclusive BF at 3 months: Children aged 6.5 years No significant difference in dmft in None reported
[8* Good] nested in RCT of BF Belarus EBF3 n = 2862 Dental caries EBF3 and EBF6 groups
promotion intervention Exclusive BF at 6 months dmft
(PROBIT) EBF6 n = 621
Ollila and Larmas (38) Cohort study 11 day care centres N = 183 (baseline) Breastfeeding Baseline 2.5 years Prolonged breastfeeding (≥ None reported
[7* Good] Time points: Oulu, Finland N = 175 (follow up) <12 months Follow up 9.6 years 12 months) had no effect on caries
Baseline = mean age ≥ 12 months Restoration due to caries in a onset in terms of survival estimates
2.5 years (0.7– primary 2nd molar and first in either the deciduous molars or
4.3 years) permanent molar on upper permanent molars.
Follow up 7 years right and lower left (teeth id
later = mean age numbers: 55 and 75; 16 and
9.6 years (3.1- 36)
12.7 years)
Survival analysis
Silver, (32) Longitudinal cohort study Town north of London 3 years olds n = 161 Questionnaire at age 3: 3 years & 8–10 years Babies that were breast fed only had None reported
[5* Satisf] Baseline 3 years (1973) Boys = 84 (52%) Breast fed Dental caries significantly lower dmft cf children
Follow up 8–10 years 8–10 years olds Bottle fed dmft bottle fed, especially those with
(1979) Kendall’s Tau n = 161 (unsweetened/ sweetened bottle content.
instead of X2 Boys = 85 (53%) sweetened) p < 0.01
Tada et al. (33) Cohort Infants N = 392 Breast feeding (yes/no) 18 months & 3 years Breast feeding at 18 months of age None reported
[5* Satisf] Examination at Chiba city, Japan Boys = 215 (54.8%) Dental caries significantly associated with caries
18 months and 3 years dmft increment increase in caries in
of age – increment All upper anterior teeth OR = 6.65
change was analysed. Upper anterior (2.89–15.2, p = <0.05)
Molar
Tanaka et al. (34) Prospective cohort study Pregnant women and their N = 315 Breast feeding duration: Aged 41–50 months Adjusted OR Adjusted for: Maternal age
[8* Good] 5 surveys at baseline, 2– infants <6 months; 6– Dental caries dft (missing Risk of breastfeeding duration and at baseline; Maternal
9 months, 16– Neyagawa City, Japan 11 months; 12– teeth excluded) ECC: smoking during
24 months, 29– 17 months; Moderate ECC = 1–4 teeth <6 months OR = 1 pregnancy; Family
39 months, 41– ≥18 months with caries not involving 6–11 months OR = 0.67 (0.27– income; Parental
49 months. maxillary anterior teeth 1.62) education level; Child’s
Dental exam at 41– Severe ECC = ≥1 caries in 12–17 months OR = 1.09 (0.45– gender; Birth weight; Age
50 months maxillary anterior teeth or ≥5 2.71) at first tooth eruption;
caries in all teeth ≥18 months OR = 2.47 (0.95– Tooth brushing
6.59) frequency at 4th and 5th
Quadratic trend p < 0.05 surveys; Use of fluoride;
Statistical significance was lost Regular dental check-
when comparing risk for M-ECC ups; Household smoking
with caries free and S-ECC and at 5th survey; Age at oral
caries free – but the trend was examination
towards positive associations with
increased BF duration
75
76
Thitasomakul et al. (35) Longitudinal observational All women in district who gave N = 495 Type of milk feeding: Age 9–12 months & 12– Bivariate analysis: crude caries None reported
[7* Good] community based study birth November 2000 to Boys = 254 (51.3%) Breast feeding 18 months increment between 9–12 months
– birth cohort. October 2001 Bottle feeding Dental caries and 12–18 months was
Followed up at 9, 12 and Thepa district Thailand Mixed breast- and bottle Crude caries significantly higher among children
18 months feeding increment = from 9– who were breast fed cf bottle fed or
12 months and 12– mixed feeding.
18 months Negative binomial analysis – no

Incidence density = tooth association between increased
surface developing caries; incident density and breastfeeding
Incidence density ratio = ratio reported.
of incidence density of those
exposed to those not exposed
to the particular independent
variable concerned.
van Palenstein Helderman Retrospective cohort Children aged 25–30 months – N = 163 breastfed Breastfeeding: Children aged 25–30 months Significant associations: None reported
et al. (36) recruited through children (children Total number Dental caries >2 nocturnal breast feedings and
[6* Satisf] immunization records at excluded who Of feeds (low/high) ECC – presence of caries in ≥1 ECC OR = 35 (p < 0.0001)
health centres consumed ‘jaggery; and Total exposure time to tooth >15 min feeding per night
Daik-U, Burma those who were bottle breastfeeding (low/high) OR = 100 (p < 0.0002)
fed and breastfed from Median value sets low/
5 months) high
Prolonged breastfeeding
beyond 12 months age
Yonezu et al. (37) Prospective cohort Infants attending preventive N = 922 at 18 months Prolonged breastfeeding Aged 18 months, 24 months Mean dft of children being breastfed None reported
[5* Satisf] Control sample = 205 dental care programs at public N = 742 at 24 months or bottle feeding at and 36 months at 18 months (0.36) was
children weaned off health centres N = 910 at 36 months 18 months Dental caries dft significantly higher than the control
breast or bottle feeding Japan N = 592 followed group (0.06) p < 0.05
<18 months longitudinally Mean dft of children being
breastfed at 24 months (0.51) was
significantly higher than the control
group (0.11) p < 0.05
Case control
Bahuguna et al. (39) Case control Outpatient department of Case n = 400 Breast feeding duration Children aged 1–18 years Significantly higher proportion of None reported
[5* Satisf] Cases had caries paedodontics and preventive Control n = 400 ≤6 months Dental caries case subjects were breastfed for
Control were caries free dental clinic > 6 months DMFT/deft longer than 6 months compared to
Lucknow, India Bottle feeding (no detail control (p < 0.001)
reported) Significantly higher proportion of
cases had been bottle fed
(p = 0.017)
Matee et al. (40) Case control Children aged 1–4 years Case n = 116 Breastfeeding duration Case mean age = 1.6 years Duration of breastfeeding (1 year vs None reported
[4* Unsatisf] Cases = rampant caries attending maternal and child Control n = 243 Night feeding (duration Control mean 3 years) OR = 2.4 (0.7–9.1)
Controls = no caries health centres in 9 out of 25 of nipple in the mouth: age = 2.1 years p = 0.18
regions in Tanzania 0 h, ½ h, 1 h, >1 h) Dental caries Night breast feeding habits
Bottle feeding and Rampant caries (≥2 caries OR = 17.8 (6.3–50.3) p < 0.0001
content in bottle lesions in maxillary incisors) Linear hypoplasia OR = 15.6 (8.0–
30.5) p = <0.0001
Roberts et al., (41) Case control 1–4 year old children Case n = 109 Breast feeding frequency Aged 1–4 years Dental caries No significant association between None reported
[5* Satisf] Cases = caries South Africa Control n = 109 Breast feeding duration dmft frequency and duration of breast
Controls = caries free Bottle feeding dmfs feeding and dental caries
prevalence
Tham et al.
Tham et al.
Cross-sectional
Alaluusua et al. (42) Cross-sectional Children aged 5 who N = 144 Duration of exclusive Aged 5 years Distribution of dmfs among children None reported
[3* Unsatisf] participated in a longitudinal Boys = 59 (41%) breastfeeding: Dental caries with longer or shorter duration of
nutrition and health study that <2 months dmfs breastfeeding was equal
promoted breast feeding up <2–6 months
to 12 months; Finland >6–9 months
>9–12 months
>12 months
al-Dashti et al., (43) Cross-sectional Children aged 18–48 months N = 227 Infant feeding practices Aged 18–48 months Children breast fed at birth None reported
[4* Satisf] born and continuously Boys = 101 (44.5%) Breast fed Dental caries – no detail significantly more likely to be caries-
resident in Kuwait. Bottle fed provided re how this is free than those breast and bottle
Recruited through hospital Breast and bottle fed assessed fed or bottle fed only
and health centre
Azevedo et al. (44) Cross-sectional Preschool children; age 36– N = 369 Infant feeding practices Age 36–71 months Breastfeeding during night None included as None
[5* Good] 71 months; Brazil public Boys = 188 (51%) including patterns and S-ECC – ≥1 dmfs in primary time = 265 (72%) – statistically confounders
health centres duration of bottle maxillary anterior teeth associated with SECC (p = 0.02);
feeding and Breastfeeding after 12 months of
breastfeeding age = 70% of SECC children and
50% of non-SECC children –
significant association b/w
breastfeeding children >12 months
and presence of SECC (p = 0.004)
Campus et al. (45) National cross-sectional 4 years old children, Italy N = 5538 (aged 47.2 monthsDuration of breastfeeding Age 4 years Children BF for >13 months had Gender; Parent nationality;
[5* Good] survey; March 2004– +/ 3.5 months) (≤13 months or Dental caries dmfs significantly higher dmfs than those Parent education; Pre-
April 2005 Boys = 2518 (45.5%) >13 months) BF ≤13 months (p < 0.05) term births; Age of tooth
Association between prolonged BF eruption; Toothbrushing
and dental caries only seen in habits; Disease or
bivariate analysis and no conclusion medication during
about harmful consequences can pregnancy
be drawn from multivariate
modelling
Carin
~o et al. (46) Cross sectional survey; Children aged 2–6 years; n = 452 Feeding Aged 2–6 years Bivariate analysis Child’s primary caregiver;
[3* Unsatisf] October – November Northern Philipines – 3 areas Aged 3–6 years Breastfed only Dental caries No significant difference in Feeding practices;
1999 in 2 regions Stratified 3–4 and 5– Mixed breastfed and ECC associations between Toothbrushing; Snacking
6 years bottle fed dmft breastfeeding, bottle feeding and frequency; Type of
Bottle fed only weaning age and ECC snacks eaten; Last dental
No answer visit; Reason for last visit
Weaning age
≤2 years old
>2 years
Still breast or bottle
feeding
No answer
Dini et al. (47) Cross-sectional survey; Children enrolled in municipal N = 245 Breast feeding and/or Aged 3–4 years Statistically significant: None reported
[4* Satisf] 1998 nurseries; 3–4 years; Boys = 137 (56%) bottle feeding Dental caries dmfs or dmft Caries in molars and incisors and
Araraquara, Sao Paolo, Brazil Duration of children who were never breast fed
breastfeeding: or those who were breast fed
Never beyond 24 months age OR = 3.1
≤24 months (1.1–8.4) p = 0.03
>24 months
77
78
Du et al. (48) Cross sectional survey Children in kindergartens; N = 426 Infant feeding – breast Aged 24–47 months; Mean Bottle fed only children had Stepwise logistic
[4* Satisf] urban Hanchuan, China Boys = 250 (59%) and /or bottle age = 40 months statistically significant higher regression: Gender
Duration of breast Dental caries (dmfs or dmft) prevalence of incisor caries (male/female); Age
feeding Rampant caries = 2 or more (p < 0.05) and rampant caries (24–35 months /36–
teeth with caries affecting (p < 0.01) cf with partially or fully 47 months); Education
palatal and /or labial surfaces breast fed children. (low/high); Income
of primary incisors Children who had been wholly (low/high); Feeding
bottle fed had higher risk of caries (bottle/breast)

cf children partially or wholly
breastfed:
rampant caries OR = 5.27 (2.16–
12.89) p = 0.003
incisor caries OR = 2.38 (1.03–
4.76) p = 0.042
Dye et al. (49) Cross sectional National Children aged 2–5 years; N = 4236 History of breast feeding – Aged 2–5 years In models adjusted for poverty, Poverty Poverty and
[6* Very good] Health and Nutrition USA Boys = 2081 (49.1%) yes or no Dental caries – decayed or education and race/ethnicity the Education of parent educational
Examination Survey III – filled primary dental surfaces findings indicate that there is no Race/ethnicity attainment
1988–1994 (dfs) relationship between caries and a
history of ever breastfeeding
Folayan et al. (50) Cross-sectional Children aged 6–71 months; N = 396 -Exclusive breastfeeding Aged 6–71 months Significant predictors of dmft: None reported
[3* Unsatisf] 3 randomly selected LGAs in Boys = 217 (54.8%) Almost exclusive: breast dmft Duration of breastfeeding
Lagos State, Nigeria milk with water Rampant caries = caries (p = 0.002) & form of
supplement affecting 1 or more maxillary breastfeeding [exclusive
Partial/mixed incisors with or without breastfeeding] (p = 0.03)
breastfeeding involvement of primary molars No significant association b/w form
Caries = caries affecting of breast feeding and rampant
tooth/teeth exclusive of caries or caries.
maxillary anterior tooth/teeth No sig association b/w duration of
No caries breastfeeding and caries or no
caries – however significant
association between duration of
breastfeeding and rampant caries
(p = 0.02)
Folayan et al. (87) Cross-sectional Children attending the Child N = 205 Duration of breastfeeding Aged 1–16 years No association found between None reported
[3* Unsatisf] Dental Health Clinic of 2 Boys = 108 (52.7%) Breastfeeding on Rampant caries rampant caries, duration of breast
hospitals in Nigeria 1–5 years n = 91 demand or leaving the feeding (p = 0.13), form of
6–10 years n = 88 nipple in mouth breastfeeding (p = 0.84) or
11–16 years n = 26 overnight during night duration of bottle feeding
feeding. (p = 0.07) in children aged 1–
Duration of bottle 5 years
feeding
Forsman et al. (51) Cross-sectional study; 2 (1) Vaxjo, Sweden; Vaxjo -Exclusive breastfeeding Aged 4 years Results reported in frequencies and None reported
[3* Unsatisf] sites Children born 1962 and n = 726 for first 5 months (B) Dental caries t-tests
1963; Gothenburg n = 115 -Exclusive water diluted defs and deft No significant differences in caries
Data on infant feeding infant dry milk formula between the B and F groups in both
extracted from records in for first 5 months of life sites.
Children’s Welfare Centre, (F)
Vaxjo
(2) Gothenburg, Sweden
Children born in 1964
Questionnaire
Tham et al.
Tham et al.
Hallett et al. (52) Cross-sectional; Preschools; N = 2515 Duration of breastfeeding: Aged 4–5 years Multivariate analysis Sleep with bottle (y/n);
[6* Very good] Self administered North Brisbane, Australia Boys = 1307 (52%) None; <3 months; 3– ECC- dmfs and dmft ≥ 1 Ref = no breastfeeding Sip from bottle (y/n);
questionnaire 6 months; 7– <3 months OR = 1.0 (0.7–1.3) Ethnicity; Family income
12 months; (p = 0.9)
>13 months 3–6 months OR = 0.7 (0.5–1.0)
(p = 0.05)
7–12 months OR = 1.0 (0.7–1.4)
(p = 0.9)
>13 months OR = 1.5 (0.9–2.3)
(p = 0.09)
Hallonsten et al. (53) Cross-sectional survey; Child welfare centres (n = 48 N = 200 Breastfeeding Aged 18 months No significant difference in defs of None reported
[3* Unsatisf] 1981–1982 centres); 3 counties in Duration of Dental caries children with caries being breastfed
Comparative study of 4 Sweden breastfeeding defs and children with caries not being
groups (breastfeeding breastfed
and dental caries) No analysis of association between
defs and breastfeeding duration
Haq et al. (54) Cross-sectional Recruited from hospitals, N = 530 Feeding: Aged 5 months – 6 years No significant difference in caries Sweet drink intake
[2* Unsatisf] private dental clinics and Breast fed Dental caries between those breast fed, bottle analysed with each
public dental clinic, Dhaka, Bottle fed dmft fed or mixed fed. exposure
Bangladesh Mixed fed Longer duration of feeding (either
Breastfeeding duration: breast, bottle or mixed fed)
6 months – 1 year significantly associated with
1–2 years prevalence of caries.
2–3 years
Hardy (55) Cross-sectional Village communities in Greece N = 225 Breast fed Aged 2–6 years No significant difference in caries None reported
[1* Unsatisf] Wholly breast fed = 159 Bottle fed Dental caries dmft between the two groups.
Wholly bottle fed = 66
Harrison et al. (56) Cross-sectional Vietnamese migrants; N = 60 Breastfed Mean age Correlational statistics. None reported
[4* Satisf] Vancouver, Canada Boys = 31 (52%) Breastfeeding duration 32.4 months 21.3 No association between dental
Dental caries – defs caries and nursing caries and
Nursing caries (≥2 maxillary breastfeeding.
teeth have decay)
Holt et al. (57) Cross-sectional Maternal and child welfare N = 555 Breast feeding Aged 12 – 60 months A significantly higher proportion of None reported
[3* Unsatisf] centres in Camden and Boys = 275 (49.5%) No breastfeeding for Caries – visible cavity involving children wholly breastfed (95%)
Islington Health Authority, >2 weeks = Wholly dentine were caries free compared with the
London, UK bottle fed Rampant caries – labial or proportion of children wholly bottle
palatal carious lesions fed (82%) (p < 0.01)
involving ≥2 maxillary incisor
teeth
Hong et al. (58) Cross-sectional Singapore 190 children Breast feeding Mean Presence of dental decay: Child racial group,
[5* Good] Boys = 98 (51.6%) till 10 months; age = 36.3 months 6.9 Adjusted frequency of sweets,
Chinese = 60% > 10 months Dental caries Breastfeed <10 months (ref) importance of baby
Malay = 32% dmfs/dmft breastfeed >10 months: RR = not teeth, plaque on teeth
Other = 7% significant [Results not shown]
Risk for decayed and filled teeth
(dt)
Adjusted
Breastfeed <10 months (ref)
breastfeed > 10 months: mean
ratio = 1.85 (1.12–3.05)
p = 0.016
Risk for decayed and filled surfaces
79
80
(ds)
Adjusted
Breastfeed <10 months (ref)
breastfeed > 10 months: mean
ratio = 2.32 (1.44–3.70)
p = 0.001
Iida et al. (59) Cross-sectional Children aged 2–5 years N = 1576 History of BF = ever BF; Aged 2–5 years ECC – Adjusted Birth weight; Age; Gender; Race/ethnicity
[5* Good] National Health and USA Boys = 793 (50.3%) Overall BF Dental caries Hx of BF: aOR = 0.97 (0.63–1.49) Race/ethnicity; Poverty Poverty status
Nutrition Examination duration = age when ECC = presence of any dfs on p = 0.89 status; Maternal age at
Survey child completely stopped any primary tooth S-ECC – Adjusted child’s birth; Maternal
BF or being fed breast S-ECC = presence of any dfs Hx of BF: aOR = 0.83 (0.49–1.40) history of smoking during
milk; Exclusive BF on any maxillary incisor p = 0.47 pregnancy; History of
duration = Age when No statistically significant hospital admission; Time
child was first fed associations between of exclusive since last dental visit
something other than breastfeeding duration or full
breast milk or water; Full breastfeeding duration
BF duration = Age when
child was first fed
formula, milk or solid
foods on a daily basis
Johansson et al. (60) Cross-sectional Preschool children presenting N = 1206 Breastfeeding continues Aged 6 months – 5 years Children breast fed when sleeping None reported
[3* Unsatisf] for well children visits at Boys = 622 (51.6%) after falling asleep Dental caries had significantly higher deft (1.48)
paediatric clinic in Boston deft cf children who were not (0.61)
Medical Centre, USA p = 0.0003
Those bottle fed in bed or at nap
time did not have a significantly
higher deft (0.53) those who did
not (0.64) p = 0.233
Livny et al. (61) Cross-sectional Children in Jahalin Bedouin N = 102 Breastfeeding only Aged 12–36 months No significant associations between None reported
[3* Unsatisf] community, Jerusalem Boys = 56 (54.9%) Breastfeeding and bottle Dental caries dmft feeding practices and caries/no
feeding caries
Majorana et al. (62) Cross-sectional Children aged 24—30 months N = 2450 Exclusive breastfeeding Aged 24—30 months Moderate and high caries was not None reported
[4* Satisf] Questionnaire Brescia, Italy Males = 1181 (49.3%) Moderate-high mixed Caries – dmfs observed in subjects exclusively
feeding (58–99% breast ICDAS score for severity breast fed, whereas high caries
milk) severity level was predominant in
Low mixed feeding (1– children fed with formula
57% breast milk) OR = 6.75 (6.00–7.58) p < 0.01
Masumo et al. (63) Cross-sectional Manyara (high fluoride rural Child-caretaker pairs Current breastfeeding Aged 6–36 months Breast feeding status was not Age; Plaque score;
[5* Good] area) and Kampala (low Manyara n = 1221 (yes/no) Dental caries significantly associated with ECC in Enamel hypoplasia;
fluoride urban area), Uganda Boys = 616 (50.5%) Breastfeeding duration ECC = dmft multiple variable models Teeth present; Sugar
Kampala n = 816 Decayed (dt) – cavitated Manyara: consumption; Number
Boys = 414 (50.7%) dt = absent or present Currently breastfeeding aOR = 0.8 of teeth present
(0.30–2.17) p = NS
Kampala
Currently breastfeeding aOR = 1.4
(0.70–2.79) p = NS
Significantly higher prevalence of
caries in children breast fed 25–
36 months compared to those
breastfed 6–12 or 13–24 months
Tham et al.
Tham et al.
Mattos-Graner et al. (64) Cross sectional Children attending 9 public N = 142 Duration of breastfeeding Aged 1–2.5 years Children never breastfed or breastfed None reported
[4* Satisf] school nurseries, (0–3 months; 3– Dental caries to 3 months exhibited higher caries
Sao Paolo, Brazil 31 months); ds (no missing or filled teeth prevalence than children breastfed
Frequency of breast were found) for longer period (X2 = 4.11,
feeding p < 0.05)
Nobile et al. (65) Cross-sectional Children in kindergartens in N = 515 Occurrence and duration Aged 36–71 months Prevalence of ECC significantly Potential confounders
[3* Unsatisf] Southern Italy Boys = 262 (51%) of breast feeding: History Dental caries increased with duration of breast included in the models
(yes/no); duration (≤4; ECC: ≥1 decayed, missing of feeding OR = 1.26 (1.01–1.57) but these are not
5–10; 11–19; filled teeth (dmft) p = 0.039 specified.
≥20 months) S-ECC: In children Prevalence of S-ECC significantly Possibly: Dental visit in
Bottle feeding – sleep <3 years = any sign of increased with breastfeeding previous year; Age;
with sweetened bottle or smooth surface caries; in OR = 2.06 (1.13–3.76) p = 0.019 Mother’s education level;
pacifier children aged aged 3– Start using cup; Sleep
5 years = 1 or more with bottle or pacifier;
cavitated, missing or filled Start toothbrushing;
smooth surfaces in primary Maternal age at delivery;
maxillary anterior teeth; or Mother’s age
dmft ≥4 at age 3; dmft ≥5 at
age 4; dmft ≥6 at age 5
Nunes et al. (66) Cross-sectional Preschool children; Low income N = 241 Non-exposed = those Aged 18 – 42 months Prolonged breastfeeding not Child age; Nocturnal bottle
[5* Good] families; Non exposed n = 192 breast fed for Mean age = 34.5 months associated with ECC in this model. feeding with infant
Sao Luis, Brazil Exposed n = 49 <12 months Dental caries [Data not shown] formula; Daily sucrose
Exposed = those still ECC, dmft consumption between
breastfeeding at time of main meals
examination
Perera et al. (67) Cross-sectional Children aged <60 months in a N = 285 Exclusive breastfeeding - Aged <60 months No significant difference in the deft None reported
[3* Unsatisf] pediatric ward of a teaching Boys = 138 (48.4%) breast milk up to Dental caries of children exclusively breast fed
Hospital; Sri Lanka 6 months deft and those not exclusively breastfed
Overnight feeding (bottle p = 0.28
or breast) Children fed overnight with breast
milk had caries prevalence of
51.4% cf children not fed overnight
(29%) OR = 2.54 (1.29–5.01)
along with higher mean deft
p = 0.001
Prakash et al. (68) Cross-sectional Playschools and private N = 1500 On-demand breastfeeding Age 8–48 months On demand breastfeeding and None reported
[4* Satisf] hospitals (not defined) Dental caries presence of caries X2 = 17.71
Children aged 8–48 months p = 0.001
Urban Bangalore, India
Prakasha Shrutha et al. (69) Cross-sectional Children aged 3–5 years - Play N = 2000 Breastfeeding frequency Age 3–5 years Prevalence of dental caries showed None reported
[2* Unsatisf] homes/preschools in Kanpur Boys = 974 (48.7%) 5 times Dental caries inverse relationship with frequency
District, India 5–10 times dmft of breastfeeding but not significant
>10 times Caries prevalence increased with
Duration of duration of breastfeeding and
breastfeeding p < 0.05
<6 months Caries prevalence higher in children
6 months–1 year who were introduced to the bottle
1–1.5 years around 2 years of age p < 0.001
1.5–2 years
Age bottle feeding
introduced
<6 months
6 months–1 year
1–2 years
81
Not introduced
82
Qadri et al. (70) Cross-sectional survey Children aged 3–5 years N = 400 Feeding practices during Aged 3–5 years Logistic regression: Models are adjusted but
[4* Satisf] 20 kindergartens in Syria Boys = 191 (47.8%) infancy: predominately Dental caries Fully adjusted dietary practices confounders included
breastfed vs bottle fed. dmft (bottle vs breastfeeding) and (1) are not reported
ECC dmft OR = 0.61 (0.39–0.97) (possibly age, gender
p = 0.038 (2) ECC OR = 0.27 and dietary practices are
(0.18–0.41) p < 0.001 the covariates).
Age was only significant factor
associated with dmft and ECC

Retnakumari et al. (71) Cross-sectional Children attending N = 350 Duration of breastfeeding: Aged 12–36 months Significant association between None reported
[3* Unsatisf] immunisation clinic, day care Male = 171 (48.9%) Night feeding only Dental caries caries severity and duration of
centres – aged 12– Present now defs breastfeeding (analysis not shown)
36 months ≤1 year Severity of decay higher in children
Kerala, India 1–2 years who fell asleep with nipple in the
>2 years mouth (OR 2.92, p < 0.05) [95%
Falling asleep with nipple CI not reported]
in the mouth
Rosenblatt et al. (72) Cross-sectional Pediatric clinic –two public N = 468 Feeding practices: Aged 12–36 months No significant association between None reported
[3* Unsatisf] maternity hospitals Boys = 222 (47.4%) Breast feeding Dental caries type of feeding and presence of
Recife, Brazil Breast feeding + baby deft caries
bottle sugared milk
Baby bottle sugared milk
Cup+ sugared milk
Sankeshwari, (73) Cross-sectional Children aged 3–5 years; 20 N = 1250 Breastfeeding: history, Aged 3–5 years Significant [unadjusted] associations None reported
[3* Unsatisf] preschools in Belgaum, India Boys = 663 (59.4%) duration, timing, Dental caries – dmft (ECC) (X2) between lower prevalence of
frequency ECC and history of breastfeeding
Bottle feeding: (yes/no: p = 0.02), duration of
history, duration, timing, breastfeeding (6–24 months/
frequency, contents <6 months or >24 months:
p = 0.001).
Santos, (74) Cross-sectional Outpatients of the Pediatric N = 80 Breastfeeding Aged up to 36 months No significant associations were None reported
[2* Unsatisf] University Hospital, Brazil Boys = 45 (56.3%) Dental caries found between the prevalence of
caries and nocturnal bottle- and
breast-feeding.
Sayegh et al. (75) Cross-sectional Kindergartens in Amman, N = 1140 Infant feeding practice: Aged 4–5 years Breast feeding duration >18 months Characteristics included in
[4* Satisf] Jordan Boys = 582 (51.1%) Breastfeeding Dental caries or never (grouped together) – OR stepwise regression:
Bottle feeding Dmft caries in any teeth = 1.5 (95% CI Age; Social class; Sleep
Both Incisors; 1.1–2.1) p < 0.05 with mother; Bottle
Duration incisors and canines; Breast feeding on demand cf not feeding time; Use of
Frequency (on demand) molars; breast feeding on demand OR comforter; Confectionery
incisors, canines and molars caries in any teeth = 1.8 (95% CI at bed or night time
1.3–2.5) p < 0.05
Sayegh et al. (76) Cross-sectional Kindergartens in Amman, N = 1075 Breastfeeding/ Bottle Aged 4–5 years Caries: Breastfeeding 18 months vs Characteristics included in
[5* Good] Jordan Boys = 553 (51.4%) feeding duration: Dental caries never – not significant [data not the stepwise multiple
<6–18 months dmft shown] logistic regression
>18 months Caries = dmft ≥1 Severe caries: Breast feeding > model: Dental plaque;
Breastfeeding/ Bottle Severe caries = dmft >4 18 months vs never breastfeeding Sleeping beside mother;
feeding frequency: OR = 2.3 (95% CI 1.1–4.8) Use of comforters;
Never; Not on demand; Confectionery;
On demand Marmalade/jam/honey/
halawi at breakfast or
dinner
Tham et al.
Tham et al.
Serwint et al. (77) Cross-sectional Hospital based pediatric clinic, N = 110 Ever breast fed Aged 18–36 months Ever breast fed and caries OR = 2.9 Controlled for familial
[3* Unsatisf] California, USA Boys = 55 (50%) Bottle feeding was Dental caries: (95% CI 0.9–9.9) p = 0.08 – characteristics: Maternal
primary interest Caries borderline significance. cavities; Mother aims to
Non-caries keep teeth by age 65;
Child drank fluoride
water; fluoride
supplements; Brush
child’s teeth
Slabsinskiene et al. (78) Cross-sectional Kindergartens in 10 counties in n = 80 Duration of breast Aged 2.5–3.5 years In children who breastfed beyond None reported
[3* Unsatisf] Subset questionnaire Lithuania feeding: Dental caries 13 months the risk of developing
Children with no caries ≤12 months dmft/dmfs S-ECC was high OR = 10.0 (95%
n = 40 Children with S- >13 months No caries CI 1.28–78.12)
ECC n = 40 S-ECC
Songo et al. (79) Cross-sectional Dental units of five hospitals or N = 158 Breast feeding: Aged 4–6 years Children being exclusively breast fed None reported
[2* Unsatisf] private clinics in Kinshasa, Boys = 79 (50%) Exclusive Dental caries - dmft or have both bottle and breast
Democratic Republic of Mixed with bottle presented with lower caries levels
Congo Bottle feeding only OR = 0.16 (95% CI 0.04–0.66)
Tanaka et al. (80) Cross-sectional Public health centre N = 2056 Breastfeeding duration Aged 3 years Adjusted Prevalence Ratios (95% CI) Adjusted for: gender;
[5* Good] Fukuoka City, Japan Boys = 1087 (52.9%) regardless of exclusivity: Dental caries Breastfeeding duration (months) Toothbrushing
<6 months dmft >1 <6 PR = 1 frequency; Use of
6–11 months 6–11 PR = 0.79 (0.6–1.05) Fluoride; Regular dental
12–17 months 12–17 PR 0.86 (0.66–1.13) check-ups; Between
≥18 months ≥18 PR 1.66 (1.33–2.06) meal snack frequency;
Breastfeeding for 18 months or Maternal smoking during
longer significantly associated with pregnancy; Exposure to
higher prevalence of dental caries environmental tobacco
smoke at home; Parental
education levels
Tiano et al. (81) Cross-sectional Public day care centres in 2 N = 68 Breast feeding duration Aged 18–36 months CCL prevalence is significantly Not reported
[3* Unsatisf] municipalities in Brazil ≤12 months Dental caries associated with duration of
13 months + CCL = cavitated carious breastfeeding (p = 0.02)
lesions ECC prevalence is not associated
ECC = any stage of carious with duration of breastfeeding
lesion
Tyagi (82) Cross-sectional Kindergartens in Davangere, N = 813 Duration of breast Aged 2–6 years Mean dfs increases with duration of Not reported
[1* Unsatisf] Karnataka, India Boys = 395 (48.6%) feeding: Dental caries breast feeding, but not statistically
3–9 months dfs significant
10–12 months
13–24 months
25–42 months
Vachirarojpisan et al. (83) Cross-sectional Health centres, U-Thon District N = 520 Method of feeding: Aged 6–19 months Bivariate analysis of 15–19 month Multivariate models
[5* Good] in Suphan Buri Province, Boys = 272 (52.3%) Breast feeding Dental caries group: controlled for: Age;
Thailand Bottle feeding or mixed dmfs; dmft Significant association between Number of teeth present
feeding Intensity of ECC (I-ECC) = breastfeeding and I-ECC
ratio of affected teeth (non (p = 0.018). Significant association
cavitated + cavitated): erupted lost in multivariate models that
teeth include all age groups.
Vazquez-Nava et al. (84) Cross-sectional study Children aged 4–5 years who N = 1160 Breast feeding Aged 4–5 years Significant association between Not reported
[5* Good] within prospective cohort had been longitudinally Boys = 585 (50.2%) Breast feeding Dental caries (assessed from breastfeeding beyond 12 months
study studied since 4 months of >12 months & at night 2 years of age) & at night and dental caries
2005 age. Bottle feeding deft and defs OR = 3.6 (2.51–5.16) p < 0.001
Not reported
83
84
Wendt & Birkhed (85) Cross-sectional study Preschool children in Baseline n = 671 Breast feeding: Examined at 1 year, 2 years Significantly more children with
[4* Satisf] within prospective Jonkoping, Sweden - 1 year n = 632 ≤2 months and 3 years of age caries than without caries at the age
longitudinal study comparison of Swedish 1 year caries free Still breast fed Dental caries of 3 had either been breast fed for
3 time points: 1 year, children and immigrant n = 629 dmfs ≤2 months or >12 months
2 years, 3 years children 2 years n = 298
2 years caries free
n = 276
3 years n = 270
3 years caries free
n = 210
Yonezu et al. (86) Cross-sectional Infants attending preventive N = 105 Bed time breast feeding Aged 18 months Odds of caries at 24 months was None reported
[1* Unsatisf] dental care programs at public Dental caries significantly higher OR = 10.66
health centres. Children have dft (2.23–50.96) for bedtime breast
been or are being breastfed fed children than children not
breast fed at bed time (p < 0.05)
ECC = Early childhood caries; S-ECC = Severe early childhood caries; dmfs/t = decayed, missing, filled and extracted deciduous surfaces/teeth; defs/t = decayed, extracted due to caries, filled deciduous surfaces/
teeth; DMFT = Decayed, Missing, Filled and Extracted permanent surfaces/teeth; ICDAS = International Caries Detection and Assessment System (Reference: ICDAS Foundation. What is ICDAS?. https://
www.icdas.org/what-is-icdas, 9 March 2015).
Tham et al.

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Acta Pædiatrica ISSN 0803-5253

Breastfeeding and the risk of dental caries: a systematic review and

INTRODUCTION to the carbohydrate content of breast milk or formula along

Lactobacilli and substances, including human casein and

Feldens et al. (30) * * * * ** * * 8

Table 3 Newcastle-Ottawa Scale Quality Assessment score for Cohort Studies

Feldens et al. (25) * * * * ** ** * * 10

Table 4 Newcastle-Ottawa Scale Quality Assessment score for Case-Control Studies

Bahuguna et al. (39) * * * * * 5

Table 5 Newcastle-Ottawa Scale Quality Assessment score for Cross-sectional Studies

Alaluusua et al. (42) * * * 3

Records identified through database Additional records identified

Records after duplicates removed (n=347) = 480

Full text articles assessed for Full paper reviews – exclude

Articles included in synthesis = 63

Articles assessed for meta-analyses =

Figure 1 PRISMA Flow diagram of review.

More vs Less Breastfeeding up to 12 months and risk of caries

Tanaka (2013) 0.67 (0.27, 1.65)

Du (2000) 0.19 (0.08, 0.46)

Hallett (2003) 1.00 (0.71, 1.41)

Iida (2007) 0.80 (0.42, 1.53)

Qadri (2012) 0.27 (0.18, 0.41)

Overall (I-squared = 86.8%, p = 0.000) 0.50 (0.25, 0.99)

NOTE: Weights are from random effects analysis

More vs Less Breastfeeding up to 12 months and the risk of caries

ID Ratio (95% CI) Weight

Tanaka 0.67 (0.27, 1.64) 10.47

Hallett 1.00 (0.71, 1.41) 69.99

Iida 0.80 (0.42, 1.54) 19.53

Overall (I-squared = 0.0%, p = 0.645) 0.92 (0.69, 1.23) 100.00

NOTE: Weights are from random effects analysis

.05 .25 .5 1 1.5 2

Breastfeeding beyond 12 months and risk of caries

ID Odds Ratio (95% CI)

Tanaka (2013) [=18 mth] 2.47 (0.94, 6.51)

Tada (1999) [=18 mth] 6.65 (2.90, 15.25)

Matee (1994) [1yr vs 3yr] 2.40 (0.67, 8.65)

Hallett (2003) [>13mth] 1.50 (0.94, 2.40)

Nobile (2014) [= 20mth] 1.26 (1.01, 1.57)

Sayegh (2002) [>18mth] 1.50 (1.09, 2.07)

Slabsinskiene (2010) [>13mth] 10.00 (1.28, 78.12)

Overall (I-squared = 69.3%, p = 0.003) 1.99 (1.35, 2.95)

NOTE: Weights are from random effects analysis

Figure 4 Breastfeeding beyond 12 months and the risk of dental caries.

Nocturnal breastfeeding beyond 12 months and risk of dental caries

ID Odds Ratio (95% CI)

van Palenstein (2006) 35.00 (6.29, 194.87)

Matee (1994) 17.80 (6.30, 50.30)

Perera (2014) 2.54 (1.29, 5.01)

Vazquez-Nava (2008) 3.60 (2.51, 5.16)

Yonezu (2007) 10.66 (2.23, 50.96)

Overall (I-squared = 77.1%, p = 0.002) 7.14 (3.14, 16.23)

NOTE: Weights are from random effects analysis

Randomised controlled trial (RCT)

practices (exclusive 2001 – June 2002 primary tooth (decay)

18 months Negative binomial analysis – no

bottle fed had higher risk of caries (bottle/breast)

associated with dmft and ECC

Feldens et al. (25) * * * * * * 10