The British Society of Paediatric Dentistry (BSPD) has produced a position statement on infant feeding.1 In this Q&A, BSPD President and Consultant in Paediatric Dentistry Claire Stevens gives the background to the new guidance and sets out how dental and health professionals can help spread the word.
Q1. You have just published new guidance on Infant feeding – why now?
A. BSPD believes the publication of evidence-based information to support health practitioners working with young families is overdue. We have known for some time that bottle-feeding after the age of one is linked to Early Childhood Caries (ECC). Last year, important new research2 showed that breastfeeding on demand and especially through the night after the age of one also has a potential link to ECC. Our members and others working in the dental profession see the evidence of dental decay caused either by bottle caries or extended and on-demand nursing and they are crying out for evidence-based guidance. BSPD has had the support and input of the dental leads at Public Health England in developing our position statement.
Q2. How important is this advice to parents?
A. My view is that it's always better to know the facts. Every few months, a mother who has just been told that the decay in her child's mouth is due to on-demand bottle or breastfeeding has asked ‘Why did nobody warn me?’ Now we have evidence that there is a clear risk and parents and those who support them need to know the steps that can be taken to protect those emerging first teeth.
Q3. Shouldn't the message always be ‘breast is best’?
A. Yes – it's still the right message but of course we also need to recognise that breastfeeding isn't always possible and those parents deserve our support too. After the age of one, the baby is consuming solid foods and there is an increased exposure to sugar and thus increased risk of decay. This is especially true if babies are breastfed on demand, particularly through the night. There are mothers who want to continue to breastfeed their baby after the age of one and we should respect that. However, preventive advice needs to be available so parents can minimise their child's exposure to sugar and make an informed choice as to how they wish to feed their child. We suggest parents try and limit on-demand feeding and try and ensure that fluoride toothpaste is the last thing on their child's teeth at night. The protective effect of fluoride cannot be over-estimated. And of course we advocate that by the age of one parents take their child to the dentist – Dental Check by One! (http://bspd.co.uk/Patients/Dental-Check-by-One)
Q4. How quickly do you think parents will heed your advice?
A. Now that we have relevant research, I think that word will spread rapidly. The simple message is that the age of one is an important milestone. Parents who are bottle-feeding are strongly advised to withdraw the bottle by the age of one and mothers who are breastfeeding should ideally give consideration to reducing night-time feeds.
We have had some positive comments from members of the dental team who are all aware of the importance of weaning in a way which gets children into a healthy routine.
Mrs M – dental therapist
‘I find it so disheartening when I see children as young as three with dental decay. Their parents are in denial because of what they have read on the internet. They will not accept that breastfeeding long-term can be a risk factor. I hope this paper will dispel myths.
‘There doesn't seem to be much evidence-based research around regarding the cariogenicity of breast milk. I was really happy to see this paper and I hope that it will trigger further research into nursing caries.’
Dr S – dentist
‘I welcome that this fascinating paper demonstrates that there is no ‘one size fits all’ situation for families who may need considerable tailored and uncritical support and encouragement to do the right things to secure their children's oral and general health. Thank you BSPD for highlighting the evidence that exists and for clear recommendations that more research needs to be undertaken. I also welcome the uncritical approach taken by this paper. It's important for all of us advising families to present the facts. Formula bottle feeding is sometimes the path of travel and mothers who choose it or have no choice but to choose it need uncritical support.’
Ms G - Oral health educator
‘As an oral health educator I found the new guidelines on infant feeding very useful for my personal knowledge. When giving advice to patients and parents it is much easier if you have strong, current information to refer to and I found this document very user friendly with clear and precise advice.
‘I strongly believe that education is the key; some parents will not know the risks of ECC and will think that by giving their child a healthy diet and not consuming sweets or chocolate that they do not need to worry about the child's deciduous teeth. There will also be some parents that are not aware of the risk of early childhood caries that follow family tradition. As a clinically trained person, working in an area with one of the highest rates of childhood caries, I am totally on board with the new guidelines and I believe that by getting the message out will benefit a lot of families.
‘I also know as a parent myself it is hard to change habits. I believe that what we need are simple messages that we can pass on without appearing to preach. We must also be ready to recognise that it isn't always easy and ensure we don't make parents feel they are failing if their baby won't conform!’
Q5. How easy do you think it will be to get the advice out to parents?
A. Some aspects of the internet make life challenging. Another factor is the power of the internet. There is an American website which says (at the time of writing) that breast milk contains protective factors against dental caries. It doesn't. The information on this site is not evidence-based. Although there is a reduced experience of ECC in breastfed babies up to the age of 12 months, the picture changes after baby's first birthday.
BSPD is working with a whole host of organisations to get out the Dental Check by One message, including health visitors, school nurses, doctors, midwives and pharmacists. Collaboration is key. I wouldn't call it easy, but I would say that with the right support, we can make sure parents know what to do to act in the best interests of their child.
Q6. Why are your members so concerned about weaning – surely the Number One culprit in tooth decay is sugar?
A. You are right that the Number One reason for the majority of referrals of children into hospitals for multiple extractions under general anaesthetics is dental decay, usually caused by the over-consumption of sugar. But weaning your baby onto a healthy, low-sugar diet is a great first step in the war against tooth decay. Sugar comes in many forms. It's not just in solid foods; sugary drinks in bottles are a factor. I frequently see patients in my clinic with rampant decay caused by prolonged bottle feeding. We call it bottle caries. Baby teeth exposed to a regular onslaught of sweet foods and drinks will be at risk of decay. Breast milk is sweet and over the long term when consumed on demand can cause the equivalent of bottle caries. Just recently I saw a frazzled mother on my clinic whose three-year-old was suffering with toothache. This child was being breastfed on demand through the night while the mother was also feeding her newborn baby. When I explained that frequent exposure to breast milk could be contributing to the tooth decay the mother decided to gently wean the older child from nighttime feeds whilst moving his daytime feeds to coincide with mealtimes.
Q7. Key recommendations of the new position statement:
Stop bottle feeding by the age of one
Only milk or water is placed in a baby's bottle
Consideration should be given to reducing on-demand and through the night breast-feeding after the age one
From six months an open-topped or free-flow cup is introduced
Children should receive their first dental check by the age of one – Dental Check by One (#DCby1)
Thereafter, the child should be seen once a year or more, depending on the advice of your dentist
Habits such as dummy use and digit sucking should be withdrawn by 12 months.
Q8. Anything you would like to add?
A. I would like to take the opportunity to stress once again that the wellbeing of parents with young babies is paramount. I wouldn't like our advice to cause stress in any way. It's just out there to enable parents to make the best decisions for their baby and for themselves.