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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2020  |  Volume : 38  |  Issue : 2  |  Page : 98-103

Association between early childhood caries and feeding practices among 3–5-year-old children of Indore, India

1 Department of Pedodontics and Preventive Dentistry, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
2 Department of Preventive Dental Sciences, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia
3 Departments of Public Health Dentistry, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India

Date of Submission05-Feb-2020
Date of Acceptance07-Jun-2020
Date of Web Publication28-Jun-2020

Correspondence Address:
Dr. Ullal Anand Nayak
Department of Preventive Dental Sciences, Ibn Sina National College for Medical Studies, Mahajer Street, Jeddah, Mecca
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_60_20

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Background: The impact of early childhood caries (ECC) seen in infants and young children to the society is enormous. Most studies on ECC have been focused on specific ethnic and lower socioeconomic communities, however fewer studies are conducted in India as compared to other developed countries. Aims: The study investigates the association between selected feeding practices and the presence of early ECC among 3–5 year-old children of Indore city. Methodology: A cross-sectional sample consisted of 640 preschool children of different socioeconomic status (SES). A self-administered questionnaire was used to obtain information about demographic backgrounds and feeding history of the child. The caries experience of children was recorded. Statistical Analysis: The data were evaluated using Chi-square and multivariate logistic regression. Results: The prevalence of ECC was found to be 64%. ECC was found to be significantly associated with age, SES, breastfeeding for more than 1 year, bottle feeding, bottle content used other than water, feeding at night, and cup drinking after 1 year. Conclusion: The present study indicates that ECC and feeding habits have a significant relationship. The content of the bottle feed and feeding practices at night are the strongest factors among all feeding habits associated with ECC

Keywords: Bottle feeding, breastfeeding, early childhood caries

How to cite this article:
Barjatya K, Nayak UA, Vatsal A. Association between early childhood caries and feeding practices among 3–5-year-old children of Indore, India. J Indian Soc Pedod Prev Dent 2020;38:98-103

How to cite this URL:
Barjatya K, Nayak UA, Vatsal A. Association between early childhood caries and feeding practices among 3–5-year-old children of Indore, India. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2022 Dec 3];38:98-103. Available from: http://www.jisppd.com/text.asp?2020/38/2/98/288230

   Introduction Top

The impact of early childhood caries (ECC) seen in infants and young children to the society is enormous. They have obvious pain and infection, along with eating and speech problems, low self-esteem, and are being distracted from playing and learning activities. ECC has a complex multifactorial etiology with factors such as infant feeding practices, health beliefs, dental knowledge, diet, socioeconomic status (SES), health care system, and ethnicity playing important roles.[1]

There are few studies regarding childhood caries in India as compared to other developed countries. The policy of “Global goals for oral health by the year 2000” adopted by the World Health Organization and the International Dental Federation in 1982 expected that 50% of 6-year olds would be caries free.[2]

However, most studies on ECC have been conducted among specific ethnic, lower socioeconomic communities, and extrapolation of current risk assessment models to the general population may not be possible/feasible. The purpose of this study therefore was to investigate the association between selected feeding variables with the presence of ECC in 3–5-year-old children of Indore city.

   Methodology Top

School-going children of age 3–5 years attending government, private, and public schools in Indore were classified as per school pattern to determine the SES. A list of preschools of Indore district was obtained from the District Education Officer, Indore. Indore district is divided into six geographic zones based on the information available from the map issued by Indore Municipal Corporation. Two preschools from each zone were selected through a two-stage cluster sampling procedure. Data were collected during a period of 4 working days at each preschool. The sample size was calculated before the beginning of the study. Assuming that ECC prevalence was about 40% in accordance with the literature, a margin of error of 5%, and a 95% confidence level, a sample size of 640 children was estimated. Inclusion criteria included children going to preschool between 3 and 5 years of age, whose all primary teeth have erupted. Children not within the age group and incompletely filled questionnaire were excluded from the study.

Prior permission for the study was obtained from the concerned head of the preschools. A self-administered questionnaire was prepared according to Hallett and O'Rourke, 2003.[3] The questionnaire covered demographic backgrounds and feeding and dietary variables. A letter of consent for participation was obtained from the parents after which they were asked to fill the questionnaire. Fully filled questionnaires were analyzed to attain a predetermined sample size. The examination was carried out for children using the Type-3 examination criteria of the American Dental Association.[4] All primary teeth were examined and caries experience was recorded using the decayed missing filled teeth (deft) and decayed missing filled surfaces (defs) index as introduced by Gruebbel in 1944[5] where d indicated for decayed tooth/surface, e-tooth indicated for extraction, and f indicated for filled tooth/surface. Modified Kuppuswamy's scale[6] was used to determine the SES of the parents. The data obtained were analyzed using SPSS version 12 (SPSS South Asia, Bengaluru, Karnataka, India). Data were summarized using proportions for categorical variables. Median and interquartile range was used to summarize the scores of deft and defs. Chi-square test was used to test the association between various factors and ECC. Odds ratio was used to assess the risk. Multivariate logistic regression was used to assess the adjusted odds ratio.

   Results Top

A total of 640 children participated in the study. The average prevalence of ECC was 64.1%. The highest prevalence of ECC was seen in 5-year-old children (78.28%). The deft/defs scores in 5-year-old children were highest (deft = 5/defs = 6) (P = 0.001). However, no statistically significant gender difference was observed. The prevalence of ECC and deft/defs scores was highest in lower SES group children (79.8%) (P < 0.001) [Table 1].{Table 1}

The children who were breast-fed for more than 1 year had the highest prevalence of ECC (70.9%), whereas children breast-fed till 6 months of age (36.5%) had the lowest prevalence (P < 0.001). The children who were not bottle-fed at all had a statistically lowest prevalence of ECC (P < 0.001) when compared to other groups. The children who were bottle-fed for 2 years had the highest prevalence of ECC (78%). The deft/defs scores for groups having different durations of breastfeeding and bottle feeding were found to be nonsignificant [Table 2].{Table 2}

The statistically highest prevalence of ECC was found among children who were fed with juice (94.7%), followed by cows or buffalos milk (76.8%) followed by children who preferred cold drink (70%) followed by children fed with infant formulae (61.1%). The children who were fed with water had no ECC. Furthermore, the deft/defs scores in children with different bottle contents were found to be significant.

The significantly higher ECC prevalence was associated with the habit of feeding at night (76.3%) compared to those who were not (58%) (P < 0.001). Similarly, the prevalence of ECC in children who used to sip continuously during the day (74.3%) was significantly higher as compared to those who did not (57.4%) (P < 0.001).

Earlier commencement of cup drinking showed a statistically low prevalence of ECC (58.8%) and lower deft/defs scores (deft = 3/defs = 4) when compared to children who started cup drinking after 1 year (67.3%) (deft = 5/defs = 6).

No statistical correlation was found between the time of starting solids, frequency of snacking, regularity of meals, and ECC.

However, univariate and adjusted odds ratio for age and SES were found to be significant [Table 3].{Table 3}

Children who were breast-fed till 3 months and 6 months had significantly lesser chances of ECC when compared to children who were breast-fed for more than 1 year. The children who were bottle-fed for all the different durations had significantly higher chances of ECC when compared to those who were not bottle-fed at all. With odds ratio, the risk of ECC was more in children who were fed at night as compared to those who were not, but the comparison was statistically nonsignificant, whereas who were allowed to sip continuously during the day had statistically significant more likelihood of ECC as compared to those who did not [Table 4].{Table 4}

   Discussion Top

The prevalence of ECC observed in our study was 64.1%. The prevalence of ECC reported in literature ranges from 36% to 85%[7],[8],[9] while in India a prevalence of 44% has been reported for caries in 8–48-month olds.[10] The higher prevalence of caries in developing countries may be attributed to improper coverage of oral health services.[11]

The prevalence of ECC was significantly higher in the 5-year-old group compared with the younger age group, which concurs with previous studies.[12],[13],[14] The highest prevalence and severity of ECC in the present study were seen in lower SES group children. This could be explained as the individuals belonging to lower SES groups experience financial, social, and material pitfalls that compromise their ability to care for themselves, obtain professional health-care services, and live in a healthy environment.[14]

Since breastfeeding has positive effects on the health of the infant, the WHO recommends breastfeeding till 24 months of age.[15] Infants who are breast-fed are found to have lower levels of dental caries as compared to nonbreastfed infants.[16] However, certain reports suggest increased risk for ECC with prolonged exposure of teeth to daytime or nighttime breastfeeding.[16],[17] In the present study, it was observed that the lowest prevalence of ECC was seen in children breast-fed till 6 months of age, and the children who were breast-fed for more than 1 year had the highest prevalence of ECC.

The study finding reported that breastfeeding up to 1 year of age is associated with significantly lower ECC experience compared to not breastfed at all or breastfeeding extended beyond 12 months. The human breast milk contains caries protective elements such as maternal immunoglobulins, enzymes, leukocytes, and specific antibacterial agents.[17] Beyond 12 months, the caries protection from breastfeeding diminishes progressively with depletion of protective elements.[18]

The present study reveals that the bottle feeding irrespective of its duration and whether it is given in the day or night has a higher risk of having ECC. Feeding during the night may lead to prolonged exposure to fermentable carbohydrates and create a dentally harmful environment in the oral cavity.[19],[20] The night time milk-bottle feeding showed the most prominent impact on the presence of ECC.[21]

Milk-based formulas for infant feeding, even those without sucrose in their formulation, proved cariogenic in some studies.[22],[23] Nevertheless, cow's milk contains calcium, phosphorus, and casein, all of which are thought to inhibit caries.[24] Furthermore, Rugg-Gunn et al.[25] found an inverse relationship between consumption of milk and caries increment in a study of adolescents in England which coincided with present findings that cow's milk and juice when used as bottle content had the highest risk of having ECC.

The American Academy of Pediatrics Policy statement relating to oral health explains that for children 0–3 years of age and with erupted teeth, juice should not exceed 1 cup (8 oz) per day and served only at mealtime.[26] This was confirmed with the present study that juice had a higher prevalence and severity of ECC. Daily frequency of snacks was reported to be an important risk factor for ECC.[9] Consumption of snacks is one of the strongest factors in the occurrence of ECC in the developing world, and its important role in the etiology of dental caries was confirmed in the multivariate analysis in various studies,[27] but in the present study, the frequency of snacking did not affect the prevalence of ECC; however, the ECC severity varied with the frequency of snacking.

Dietary changes are more difficult once habits are established, suggesting the importance of encouraging caregivers to adhere better to established feeding guidelines early.[28] Dietary factors practiced prior to 1 year of age have a significant association with severe ECC during preschool age, necessitating that timely intervention is important.[29] Breastfeeding performed until 24 months of age does not increase the risk of ECC. However, it is necessary to increase the intake of fluoridated water and also to educate the caretakers with prevention strategies.

   Conclusion Top

This study has contributed to knowledge about the dental caries experience and feeding habits of 3–5-year-old children schooling in socioeconomically different areas of Indore (India). The findings indicate that ECC and feeding habits are significantly associated. Children from deprived families seemed to be most vulnerable with respect to ECC. The content of the bottle feed and feeding practice at night are the strongest factors among all feeding habits associated with ECC.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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