Infant Dietary Pattern and its Association with Early Childhood Caries in Preschool Children: A Cross-sectional Study

DISCUSSION

Severe early childhood caries is a specific form of rampant decay of primary teeth in infants. The lesions progress quickly and occur in surfaces generally considered to be at low risk for caries.¹ The current study has identified several characteristics of feeding habits and oral hygiene practices in association with ECC.

India and a few other countries are characterized by cultural diversity and plurality at many levels. Children grow up in a network of multiple interactions with members from within and extended family influencing the daily food routine of the child. There are various parental beliefs and practices which create the backdrop for the development of the child. Although women may receive guidance from health care professionals, relatives especially grandmothers, have an important influence on breastfeeding practices. The average duration the mothers’ breastfed their infants was between 4 and 6 months with firstborn children usually being breastfed for a longer time than second-born children.⁵ In the present study, the average duration was found to be 1–1.5 years while prolonged duration beyond 2 years was observed in 27.78% of children. Mothers who are unable to timely breast-feed their children for various reasons express a feeling of inadequacy and guilt. These children are tended to be fed more and on-demand by their caregivers.⁵

Breast milk is found to contain many protective factors like immunoglobulins, lysozyme, lactoperoxidase, complement components, cells, and lipids. These host resistance factors act against different organisms and provide definite protection to infants from infection. However, concerns about human breast milk’s cariogenicity is still questionable. The role of breastfeeding in the development of ECC is complex.

In this current study, 50% of children were breastfed to sleep and 68.31% were breastfed during the night on demand. They had a higher mean deft score (4.12) than those who were not. Thus, breastfeeding during sleep time was associated with early childhood caries. This is in accordance with AAPD 1996 statement which recommends that ”ad libidum nocturnal breastfeeding should be avoided after primary tooth begins to erupt.” Similarly, caries experience was high in children who slept with the bottle in their mouth (p = 0.015). This can be explained by the fact that the breastmilk or bottle contents are constantly in contact with the dental structures, making it the ideal place for acid production and dental caries onset.¹

Erikson and Mazhari stated that in a breastfed child who also has a sugar-rich diet, human breast milk becomes highly cariogenic. The association of breastmilk with other carbohydrates may become cariogenic and lead to SECC.¹ These findings were similar to the current study where significant results (p = 0.029) were seen in children who had sugar/sweetener added to the milk. Shrutha et al. reported 100% caries prevalence in children who had 2–3 tsp sugar added to milk.⁶ Likewise, Feldens et al. stated that the potential cariogenicity of breast milk is enhanced with the addition of outside sugars.⁷ Consistent with the literature on dietary practices was the finding of a significantly greater proportion of children with caries among those who added sugar or any sweetener to bottled milk every day. This can be attributed to the length of time the fermentable contents of the bottle remain in contact with teeth. The use of baby bottles during the night is associated with the reduction in salivary flow and in capacity of salivary neutralization, which would cause prolonged exposure to fermentable carbohydrates due to stagnation in the teeth (Ribeiro).⁸

Also, in the present study, children whose sweet intake in the diet was more than 2–3 times/day had a mean deft score of 5.85 which was significantly more than children with less sweet intake. King⁹ studied patterns of sugar consumption in the early first year of life and concluded that 77% of meals and snacks given to babies contained sugar and received sweet items on an average of 4.3 separate occasions. Sugars are not only used as a foodstuff but are also given for other reasons, such as taste, as a pacifier, and means of showing love and affection.⁹

Results revealed children with a greater mean deft score failed to clean the tooth as soon as it erupted in the oral cavity. Ganesh et al. assessed oral hygiene practices in children and found that only 17% cleaned their gum pads of which 10% used a soft cloth /cotton, 6% used fingers and 1% used soft brush and paste.¹⁰ At an early age, dietary and oral hygiene practices are mostly controlled by parents or caregivers and hence it is really important to educate the parents and caregivers about maintaining oral health as soon as the first tooth erupts in the oral cavity.

In the present study, males were affected more than females (p = 0.067). A similar trend was reported by Shrutha et al. who conducted a cross-sectional study in Kanpur District, India.⁶ This can be attributed to the gender disparity and cultural advantages to boys especially predominant in certain communities. They tend to get larger and on-demand helpings of food. However, studies conducted by O’Sullivan et al.¹¹ and Hattab et al.¹² reported no sex difference in caries prevalence. The mean deft in these studies was almost equal and statistically insignificant (p > 0.05) inferring that difference in sex is not a risk factor.

Different dietary patterns in infants up to first-year are associated with early childhood caries at 3–5 years of age. Considering the above-discussed factors, after complete evaluation of children, the parents and caregivers were educated regarding good oral hygiene practices and the consequences of deleterious feeding and dietary patterns during infancy. Subsequently, the children exhibiting these feeding habits were targeted for future preventive interventions.