Janna L. Cataldo, MD
July 15, 1998
Exclusive breastfeeding is the preferred method of infant feeding in the first
six months of life, and continued breastfeeding throughout the first year and
into the second year carries with it a multitude of advantages for both the
mother and the infant.1,10,27,28 Both the American
Academy of Pediatrics and the American Academy of Pediatric Dentistry have as
primary goals the promotion of optimal health for children. The issue of dental
caries in infants and young children is one that both pediatricians and pediatric
dentists are intimately concerned with. 18 When
discussing dental caries in young children, a clear association between inappropriate
bottle feeding (prolonged use of the bottle, carrying it in the mouth all day,
and being put to bed with it at night) 8,11 and
an increased incidence of caries involving the upper incisors starting on the
smooth surfaces, exists. This has been variously termed nursing caries, baby
bottle tooth decay and early childhood caries. 19
However, when discussing breastfeeding, the association is not as clear. A debate
has emerged over the last twenty years over whether breastfeeding ad lib through
the night , or prolonged breastfeeding beyond 12 months of age, are causes of
"nursing caries" in a similar fashion as "baby-bottle tooth decay".3,4,5,8,9,10,14,17,20
A review of the current literature gives us a better understanding of this issue.
Nursing caries is caused by the fermentation of sugars present in liquids fed
to the infant by bacteria present in the mouth. 7,22,25
It has been shown that streptococcus mutans is present at much higher concentrations
in the mouths of infants and young children with caries than in those without.11,19,22
The streptococcus mutans bacteria is most commonly transferred to the infant
from his/her mother. 7,25,27 The mothers with
the highest levels of streptococcus mutans and usually an associated history
of dental caries are the most likely to do this. 11,13,31
In addition, there are other genetic factors which may predispose an infant
to dental caries. 5,11,21 Research on dental
caries in adults has shown that factors present in the saliva may be protective.
21 These include factors which cause decreased
bacterial aggregation and adherence to tooth surfaces and plaque pH regulation
to inhibit breakdown of tooth enamel. The absence of these substances is associated
with increased rates of dental caries. 21 The
occurrence of early childhood caries also appears to vary significantly with
race, culture and socioeconomic status. 11,13,34,36
In studies comparing bottle-fed to breast-fed babies, bottle-fed babies have
been found to have a higher incidence of dental caries overall.4,9,10,18,26,30,32
This has been attributed to bottle-propping and giving the baby a bottle of
formula, milk or juice to sleep with at night.11,14,24
However, nursing caries has been identified in babies that have been exclusively
breastfed without receiving any bottles.14,19,23,28
How can this occur?
Infants who sleep with their mothers and nurse all night long have been reported
to have an increased risk of nursing caries.8,23,36
The breastfed baby while actively suckling has the nipple at the junction of
the hard and soft palates, with the tongue filling the oral cavity, and very
little if any remaining milk present after swallowing.2,5,12
It is important to remember that isolated feedings from the breast at night
in addition to daytime feedings are essential in the first few months of life
to initiate a good milk supply and to ensure adequate growth for the infant.1,29
When the baby falls asleep at the breast, the nipple retracts.2
If the mother is also asleep and the baby does not completely remove the breast
from his mouth, milk can pool in the babies mouth, coming into contact with
the lingual surface of the upper incisors.29
In addition, during sleep there is a decrease in the amount of saliva produced,
which decreases the clearance of the milk.11,15
In a baby with a family history of caries and a high streptococcus mutans count,
this can lead to rampant nursing caries.
Other contributing factors, not explored in most articles reporting nursing
caries in the breastfed babies are: what constitutes the rest of the baby’s
diet, since most babies presenting with caries are older than 12 months;12,35
is fluoride supplementation being given;10 and,
what is the hygiene practice in this baby's family?2,4,5,10,35
There are no good studies comparing breast-fed babies that are matched for appropriate
solid food diet and excellent hygiene practices, and matched for streptococcus
mutans colonization and family history of caries.24
Before we say that night-time breastfeedings are a problem, we need to look
at all of the factors present in each case, and maintain the breastfeeding relationship
as much as possible. 31,33
In summary, it is true that some breastfed babies have been reported to have
nursing caries.15,16 However, breastfeeding itself
does not need to be stopped in order to prevent further caries.16,33
Further research is needed before we should ever say to a parent that they need
to stop breastfeeding because of caries in the infant, as we know from case
reports that further caries can be prevented while breastfeeding is maintained.15,16
The following steps are recommended:10,14,15,16,19,27,29,36
- breastfeeding as the preferred method of infant feeding
- exclusive breastfeeding for the first six months of life, and continued
breastfeeding with appropriate introduction of solids for the rest of the
first year and into the second year
- proper attention to dental hygiene at the first tooth eruption
- early dental evaluation of infants with a family history of dental
caries (6 to 12 months of age) with regular follow-up
- never allow a baby to be propped with a bottle
- never allow a baby to go to bed with a bottle containing anything
other than water
- dental evaluations for infants without a family history of caries
should begin at 12 months
- breastfeedings at night should not be continuous, and the baby should
be removed from the breast when the feeding is complete
- fluoride recommendations from the AAP and ADA should be followed
If all of these steps are followed, a much healthier population of infants
From San Diego County Breastfeeding Coalition
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- Degano MP and Degano RA (1993) Breastfeeding and oral health. NYSDJ
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- Roberts GJ, Cleaton-Jones PE, Fatti LP, Richardson BD, Sinwel RE, Hargreaves
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