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Toddler Tips:

Breastfeeding and Dental Caries

From: NEW BEGINNINGS, Vol. 11 No. 2, March-April 1994, pp. 56-59

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.

"Toddler Tips" is a regular feature of the magazine NEW BEGINNINGS, published bimonthly by La Leche League International. In this column, suggestions are offered by readers of NEW BEGINNINGS to help parents of toddlers. Various points of view are presented. Not all of the information may be pertinent to your family's lifestyle. This information is general in nature, and not intended to be advice, medical or otherwise.

Situation

I have two children, ages three-and-a-half and two. The older one weaned about a year ago, but he already has two cavities in his baby teeth and my dentist says this is due to night nursing. He says that I should stop nursing at night or my children's teeth will be ruined. I thought that nighttime nursing wasn't a contributing factor in dental caries, but my dentist has told me this is not the case. I'm really confused now, and afraid I will have to wean my two-year-old. What should I do?

Editor's Note: La Leche League International (LLLI) frequently receives calls from worried mothers and concerned dentists about a possible connection between extended breastfeeding, particularly nighttime nursing, and dental caries in the primary teeth. There is a wide variety of opinion, but little available research on the factors that contribute to the pattern of dental caries in young children, often referred to as "nursing caries." The health and emotional benefits of human milk over artificial infant feeding products, however, are well documented and it is LLLI's contention that a small percentage of at-risk breastfed children develop dental caries in spite of breastfeeding, not because of it. In addition, dental caries are relatively rare in young children, regardless of whether or not they nurse at night, and most breastfeeding mothers will never encounter this problem.

We received many responses in answer to this situation. These responses reflect both the controversial nature of this subject, as well as the many different ways families have dealt with the challenge of balancing the child's nighttime needs and the benefits of breastfeeding against concerns about dental health.

There is no easy answer. Our hope is that the experiences presented here will be helpful to parents who need to make well-informed decisions about what is best for their own family.

Response

We have two boys. One is four years old and the other is two. Both are nursing and both have tooth decay. We first noticed our older son's teeth "wearing away" almost as soon as they came in. He had his four top front teeth by eight months, and by ten months they had begun to look translucent near the bottom. Around thirteen months, he fell and chipped his left front tooth, which seemed to accelerate the decay. By twenty months, the two teeth on either side of his front teeth were almost decayed to the gum. At thirty-one months, he fell again and cracked his right front tooth; at this point his four front teeth were pulled. He also had a molar capped when he was three-and-a-half.

Two nephews of ours encountered similar problems. We took heart knowing that the older one, now fifteen years old, has healthy permanent teeth. A niece in the same family nursed more at night than either of her brothers and had no decay. My younger brother reminded me that his four front baby teeth had all been capped. He was probably only breastfed a short time.

It seemed to my sister-in-law and me that we might be dealing with something hereditary. When we first took our older son to our family dentist (an older man who works with adults and older children), he felt the decay was due to a weakness in the enamel. The pediatric dentist we later consulted believed that prolonged breastfeeding and especially night nursing were responsible. After later seeing our younger son with the same problem, however, he conceded that there may be a genetic predisposition. He is generally supportive of breastfeeding but recommends weaning at one year.

I have since talked to four other women whose sons have had similar problems. Another nephew, now three years old, also has tooth decay. I have read articles about "bottle mouth" syndrome, use of fluoride (which we have chosen to forego), and dental health in children. It is my feeling that even if research were to prove that breastfeeding plays a role in dental caries in susceptible children (which it hasn't), the benefits still outweigh the risks.

We have agreed to disagree with our children's dentist. He is respectful of our right to do what we feel is best for our children. More important, he is respectful of our sons and is the only pediatric dentist in our area who allows parents to be present during dental evaluations and treatment.

I am sure you know many breastfed toddlers whose teeth are healthy. As this seems to be the norm, it suggests that my children would probably have tooth decay whether or not they were breastfed. Who knows? Maybe breastfeeding has actually helped slow the rate of decay! My heart goes out to you.

Candy Paulsen
Fresno CA USA

Response

When my first son, Alex, was fourteen months old, I discovered that he had four cavities. By the time I found a dentist willing to repair them, he was eighteen months old. All four teeth had to be crowned, and two of these required root canalsall under general anesthesia. Every dentist insisted that the caries were caused by night nursing. One flatly refused to fix the caries unless I weaned Alex. I insisted that Alex was more than teeth to me and continued to nurse my high-need toddlereven in the hospital recovery room. The nurses were impressed by how calmly Alex woke up, since most children scream. I cannot attribute this to anything but nursing.

There were many factors that probably contributed to Alex's decay. The main one was an antibiotic I took while pregnant that is now known to weaken baby tooth enamel. We were also lax about cleaning his teeth. In addition, Alex had a poor latch-on which delivered the milk to the front rather than the back of his mouth. Finally, he had food allergies and hypoglycemia, both of which increase the mouth's acidity and vulnerability to tooth decay.

With our second baby, we are much more careful about cleaning his teetheven first thing in the morning. I also try to make sure he rolls over onto his side when he finishes a night nursing. The movement causes him to swallow that last bit of milk.

Realize that your dentist only sees the very few toddlers who develop problems and that dental caries usually have multiple causes. Practice good dental hygiene and enjoy your healthy children. How lucky they are to have such a responsive mother!

Bonnie Pettifor
Urbana IL USA

Response

My oldest child's dentist also told me to wean her when she developed large cavities in her three front teeth when she was between two and three years old. My heart, though, said no since the rest of her teeth were fine, though she did chip a molar when she was two-and-a-half. When she did wean at four years of age, her front teeth (which had caps on them) abscessed again, so we had them pulled.

I kept wondering why she developed these cavities. She did nurse a lot, but she rarely had sugary foods. So I started to do some research.

I discovered that the teeth that had cavities developed during the month I was traveling in Japan while pregnant. I was probably not getting a balanced diet because many of the foods did not appeal to me and I had no choice of offerings.

During my second pregnancy, I ate a healthful diet. I am happy to report that my second pregnancy resulted in two girls (they were a surprise) with healthy teeth. Both have nursed for more than four years without a cavity.

So my advice is to follow your heart. The baby teeth will fall out and the permanent teeth will probably come in strong, healthy, and straight.

Kathleen Culbert
Fairfax VA USA

Response

We faced the issue of night nursing when I was in dental school and our daughter was born. Dentists are taught little, if anything, about nursing in general. Many believe that night nursing causes dental caries (tooth decay).

Since decay is caused not by sugar directly, but by acids produced from food sugars by bacteria present in plaque (the white, sticky material that collects on teeth), the regular and thorough removal of plaque by brushing is one solution that may help susceptible children. Brushing should be done twice daily, with one session before nursing down for the night. The child may accomplish the morning brushing unaided, but the bedtime job must be done by parents. In our experience, this is easier said than done. Toddlers may resist having their teeth brushed and will probably require gentle, but firm restraint.

When we brush our toddler's teeth, the parent with the toothbrush holds the child's head in his/her lap while the other parent gently restrains the arms and legs. Whenever possible, we distract the child by talking about how beautiful the teeth are, any emerging teeth, what food items are being cleaned off, and of course, the "tooth germs." If the child is not made to feel that oral hygiene is a form of punishment, but rather an expression of loving parental concern, the nightly ritual may well be accepted in time.

Although this restraint may seem extreme, we believe it is far less traumatic than having to take the child for restorative dentistry. Dental treatment of caries is especially upsetting if pre-existing toothache is involved because much more aggressive physical restraint than explained above and/or sedation may be required. Negative feelings about early dental experiences involving pain and restraint may set the stage for long-term anxiety about dental care.

Other factors that can help prevent tooth problems are regular checkups by a supportive dentist (look hard), low dietary sugar (including candy and excessive fruit juice), and good parental modeling. Our two children, now five-and-a-half and two, with five years of night nursing between them, are both caries-free.

Steve (DDS) and Mary Weeks
Round Lake IL USA

Response

When my daughter was just two years old, I realized she had two cavities. I found a pediatric dentist and made an appointment immediately. It turned out that there were three cavities, and I was very upset. Although the dentist first suggested that Beth's nighttime nursing was the cause of the cavities, I wasn't satisfied.

I shared with the dentist the information I had from La Leche Leaguethat breast milk doesn't usually pool on teeth in the same way that liquid from a bottle does because the nipple is farther back in baby's mouth. She then admitted that nursing wasn't likely to be the primary cause of cavities. She indicated that the sugar in the cold medications Beth had been taking was a much more likely culprit. We began to give all medications BEFORE brushing Beth's teeth and she hasn't had any more problemseven with subsequent molars and continued nursing.

Incidentally, the dentist also pointed out that siblings often have differing bacteria in their mouths and this, combined with different enamel development, can give each child a very different dental picture, even when following the same hygiene/eating habits.

Leah Wilhjelm
Highland Lakes NJ USA

Response

I have two daughters. One, who nursed until she was past three, is now eighteen years old and has never had a cavity. My baby, Clelia (still nursing at three-and-a-half), was found to have two large cavities in the top "baby" molars at age twenty months. I was advised to stop nursing at night.

This put me in a state of tremendous conflict. Of course, I did not want my baby to have rotten teeth. But I had no idea how not to nurse at night, as we have a family bed.

I called three different dentists, two who specialized in pediatric dentistry and one holistic dentist who uses natural remedies as part of his practice. I learned that a susceptibility to cavities may be genetic, and that it has to do with resistance to various germs in the mouth. Traditional mouth-care activities may have little or no effect on these inherited traits. I also learned that Clelia had enamel defects that may have contributed to the decay.

I photocopied information about cavities and breastfeeding from THE WOMANLY ART OF BREASTFEEDING and other sources and gave it to Clelia's dentists. They had no knowledge about how breastfeeding works and didn't know that milk does not flow out of the breast (as it does out of a bottle) unless the baby is actively sucking and swallowing. They also were not aware that generally speaking, breastfed children as a group have far fewer cavities than do children who are artificially fed.

What was funny to me was the change of attitude in one of the dentists. When I went back with new information, he said that I was right. He accepted my decision to continue nursing once I demonstrated my willingness to take full responsibility for my daughter's care.

I continued our nighttime life unchanged, except that instead of just leaning a little more forward so Clelia could nurse on both breasts, I rolled over with her from one side to the other so that whatever was happening inside her mouth would happen on both sides of her mouth evenly. I also made dental hygiene a regular part of our nighttime activities, and I take her for checkups regularly. I have accepted the fact that she has weak teeth and keep our diet healthful. She has had one new cavity in the past two years.

The benefits of our breastfeeding relationship were too valuable for me to let go without a fight!

Nikki Lee, Elkins
Park PA USA

Response

For me, the decision of what to do about my breastfed children's dental caries was and still is not clear-cut. There seem to be no easy answers.

In our family, two out of three children have had this condition. My oldest son, now nine, had no dental caries. He was fully demand fed and nursed until he was two-and-a-half. My second son, now six, was found to have caries when he was about fourteen months old. He was not eating much food at the time. My daughter, now sixteen months, has shown early signs of caries since she was about one year old.

We have yet to begin any formal dental treatment with my daughter, but we learned a lot from my son's situation. We began his treatment when he was old enough to comfortably handle it at about three years of age. I was unprepared for the common policy of not allowing parents to be present at the time dental work is done. Even though some hospitals allow parents to be present for the administration of anesthesia and in the recovery room, many dental offices will not allow parents to be with their children. Our pediatric dentist wants to begin his patient/doctor relationship with a relatively comfortable child, but he also recommends hospitalization for children not ready to accept treatment calmly. Fortunately, my son's work was done on several occasions in the dental office with me sitting right beside him.

Our pediatric dentist also would not work on a night nurser's teeth due to his presumption that the reoccurrence of problems would negate the efforts. It so happened that my son had gracefully ended his night nursing one week earlier, and this coincided with when we could get an appointment. Later, due to illness, my son started nursing again at night, but I felt that I did not have to alert the dental office. My son weaned at about four years of age. He has had no unusual caries-related problems with his permanent teeth.

With my daughter, my hopes for healthy teeth did not come true. I did not, however, implement any changes in nursing from the newborn period on because I felt that the risk was too low to warrant any compromise in her overall health.

Yet even with all my previous experience, I feel all the worry and concern anew. It is a big responsibility to continue night nursing against dental advice, especially since I feel that my daughter's teeth are genetically weak.

I continuously question myself, and meticulously observe her teeth for any signs of caries progression, infection, or pain. I gently rub/brush her teeth at least twice daily with a rubber, bristly device that goes around my finger.

I will evaluate her need for formal treatment based on her age and necessity. Cosmetic work has a different rationale than work done on teeth that will be in her mouth for a while. There are also financial considerations.

Even with all this effort and concern, I don't foresee weaning her. I know how valuable and useful the breast milk is to her health, and how important the nursing relationship is to her emotional well-being. I know how hard weaning would be for herand for me. So, as with my son, I play a "time game." I take our nursing day by day, hoping that she will be ready to get treatment if it does become necessary. I will also watch for opportune signs of weaning.

I've gained some relief and inner peace by refusing to look at the dental situation as an all or nothing package. The ideal of perfect baby teeth is not attainable for us, but we do what we feel is right for our child. I wish that the dental community was more aware of the multitude of advantages of breastfeeding. If we were all on the same wavelength, we could make better decisions by working together.

Mary Noonan
Capistrano Beach, CA, USA

Last updated 11/12/06 by jlm.
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