Pattern of oral health among breastfed infants (6- 24 months)

Pattern of oral health among breastfed infants (6- 24 months)
Mahjabeen Khan1, Nadia Sultan Ali2, Nasreen Qamar3, Amyna Sajwani4, Mashal Butt5, Samrin Riaz6

How to CITE:

KhanM,AliNS, SajwaniA,ButtM, Riaz S,QamarN. Pattern of oral health among breastfed infants (6-24months). J PakDent Assoc. 2012; 21( 03) : 161 – 166


The objective of this study was to determine the oral health status of breastfed infants (6 to 24) months and the associated risk factors for poor oral health of lowsocial groups inKarachi Pakistan.


This is an observational study and involves the recruitment of 910 infants. The infants were from disadvantaged communities from rural area of Gadap Town in Karachi, Pakistan. Data on feeding practices and infant’s oral health was collected. The data was analyzed on Statistical package for social sciences windows version 15


The oral examination of infants had resulted in 59.2 %good oral health. Breastfeeding practices were observed as exclusive 400 (44%) and predominant 360 (39.6%). The study found a significant association between oral health and exclusive and predominant breastfeeding practices with p-value less than or equal to ≤ 0.05. The risk factors associated with poor oral health were infant`s age, male gender, maternal body mass index, exclusive or predominant breastfeeding.


The good oral healthwas found in two third of breastfed infants between six to 24 months of age and the associated risk factors for poor oral health in lowsocial class include lowmaternal bodymass index, infants` age,male infants and pretermbabies.


Oral health,Breastfed infants,Exclusive breastfeeding, Predominant breastfeeding


lobally there has been conflicting information about breastfeeding and pattern of oral health. Currently early weaning is recommended to promote oral health but this is in conflict with breastfeeding policy and practices before six months of exclusive breastfeeding time. Globally every baby requires breastfeeding and human milk. Breast milk is recognized as the most complete, cheap and powerful forms of nutrition for infants in low social groups in developing countries like Pakistan. The benefits of breastfeeding in terms of immunologic status, nutrition, and oral health have been explored widely in developed countries. However, According to the American Academy of Pediatrics (AAP) there are some exceptions which include Fetal galactosemia, mothers infectedwith HIV or taking antiretroviral medications, maternal untreated active tuberculosis, drugs dependent ,on cancer chemotherapy drugs and mothers infected with human Tcell lymphotropic virus type I or II. Breastfeeding is associated with reduced risk of acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, obesity, type 1 and 2 diabetes mellitus, childhood leukemia, sudden infant death syndrome, and necrotizing enterocolitis in infants. Breastfeeding is a norm in Pakistan but optimum breastfeeding practices rate are very low. Breastfeeding practices have been a norm in the society in Asia and particularly in Pakistan. The geographical, social and religious aspects of breastfeeding practices have been very strong in Pakistan. However, in Pakistan there is a need for general and some specific issues in relation to oral health to be addressed by the Paediatricians and dental researchers. Exclusive breastfeeding practice is recommended upto six months and top feeding with introduction of solid food and bottle feeding is the major source of infection resulting in bad oral hygiene of infants during 6-24 months of age. The oral mucosal infection is the seed for the infant to have early dental carries in their lives and bad overall health in childhood and adolescent. There is paucity in the data for oral health status in relation to breatfeeding practices infants in Pakistan. The objective of this study was to determine the oral health status of breastfeeding infants between 6-24 months and the associated risk factors for bad oral hygiene in Karachi, Pakistan. This study was developed to determine the breastfeeding practices and infant’s oral health status.


This is an observational study and involves the recruitment of 910 infants aged between 6-24months.The infants were from disadvantaged communities from rural area of Gadap Town, Karachi, Pakistan. Mothers were invited to join the study at the time of the first home visit by Community HealthWorkers in Gadap Town, Karachi. Data on breast feeding practices and infant’s oral health was collected. Information collected were time of nitiation and duration of breastfeeding, introduction of solid food and infant’s oral hygiene status at the time of interview of mothers. Mother’s interviews were conducted at the postnatal checkups, infants’ vaccination and follow up of the growth in awell-baby clinical examination between 6-24months. Maternal demographic data was collected on a prestructured and validated Performa. All infants` were subjected for the oral mucosal examination to determine the level of good or bad oral health. The information regarding the practices of breastfeeding at the time of study was collected. Exclusive and predominant breastfeeding were observed to determine the association with infants ‘oral health status. Mothers were informed about the study objectives and benefits for the infants to determine the different strategies in future within the resource constraints situation in the rural area. Motherswere counselled for the time of introduction of solid food and its implication on oral health of infants may lead to early dental carries in infants` life. Main outcome measures were infants ‘oral health quality (Good/Bad) and different types of exclusive and predominant breastfeeding practices. Mothers were given appropriate information and oral informed consent was obtained before inclusion in the study of 910 pair ofmother and infant in the Gadap Town, Karachi. The study was conducted from January- June 2011. All the data were collected by community health workers in the town. The data was checked for the quality control before the analysis. The data was entered and analysed on SPSS windows version 15. The mean and standard deviations were calculated for numeric variable e.g. maternal and infants` age. The frequency and percentages of categorical variables e.g. booking status, educational levels, occupation, socioeconomic status, maternal body mass index, type of exclusive and predominant breastfeeding practices and infants` oral health status were also determined through SPSS. The association of the categorical variables as risk factorswere cross tabulated by Chi-square to determine the significance level at less than 0.5. The most significant and strong association were obtained against the major outcome ( good or bad) oral hygiene of infants.


The study was conducted on 910 pairs of mother and infant. The oral health examination of infants had resulted in 539(59.2%) good oral hygiene.Breastfeeding practices were observed as exclusive 400(44 %) and predominant 360(39.6%).Mothers had at least 3 andmore visits during the observed index pregnancy in 403(44.3%) cases. Only 164(18%) of mothers had family income of more than 8000/ PakRupees per month. Mostly mothers had no education 619(68%), 648(71.2%) were working women and 584(64.2%) belong to low socio economic class in the society. Body mass index of Pakistani women was assumed 24 as an average value affecting the pregnancy outcome in villages. The degree of body mass index revealed that normal BMI at 18-23.5 Kg/m2 were 150(40.4%), under nutrition 51(13.7%),overweight 138(37.2%) and obesity 32(8.6%) associated with bad oral health of infants in a rural population.Maternalmean age ±SDwas 27.64± 6.3years andmeanweight±SD63.88 ± 8.34 Kg at the time of baby’s` birth. The characteristics ofmother and infant pairs have been shown in Table I.

A chi square test was performed to determine the association between oral health (Good/ Bad) and breastfeeding practices pattern in exclusive and predominant methods from 6-24 months among pairs of mothers and infant in villages of Gadap town, Karachi, Pakistan shown in Table II. The study found a significant association between oral hygiene and exclusive and predominant breastfeeding practices with p-value <0.05. The risk factors associated were socioeconomic status, Infant`s age, male gender, maternal body mass index, exclusive and predominant breastfeeding.

* Significance Level= <0.05


The access to protect, promote, and support exclusive breastfeeding for the first six months of life and introduction of solid food at 6 months and continuation of breast feeding upto 24 months is recommended globally. The infants ‘oral health status and current breastfeeding practices is the main focus of this study. Breastfeeding is recognized as the preferred method of feeding infants` particularly from birth to 24 months of life by all oral health experts. The high infant death rate in Pakistan, 78 deaths per 1,000 live births has not been reduced for several decades and very slow improvements have been observed in rural communities of Pakistan. There has been minimum data for the research with respect to oral health and recommended exclusive and predominant breastfeeding practices. The value of breastfeeding for oral health to both practitioners and the public has not been established in Pakistan thus require an analysis of the impact of exclusive and predominant breastfeeding practices on oral health from 6-24 moths of infants life In Pakistan over 5million children are born each year. About 9 % do not survive until the end of the first year of life. About 0.45Million die each yearwithin the first year of life, nearly half of these deaths occur in the firstmonth. There is a paucity of data both at the national and provincial level in Pakistan. The only nationally representative data in this regards are from the Pakistan Demographic and Health Survey (PDHS 2010), which focuses on maternal and child health care. The risk of neonatal death due to infections is 10 times higher in the firstmonth of life than in subsequentmonths of infancy There were 378 (70.1%) male infants with good oral hygiene compared to 161(29.9%) female on exclusive breastfeedingwhich show a normcustomin the lowsocial groups where male infants are given better care and food compared to female infants. The good oral health was observed in 312(57.9%) of infants from 6-12 months and 227 (42.1%) from 13-24 months of age. The socioeconomic status of mothers were good oral hygiene inmiddle 266(49.4%) and lower 273(50.6%) social group with Pvalue (<.00001) in this study.The lowsocial class is a risk factor for bad oral hygiene as mother were working women ,mostly not educated and had lowincome. The Centers for Disease Control and Prevention report that caries is perhaps the most prevalent infectious diseases in children. Early childhood caries (ECC) developing on smooth surfaces have detrimental impact on the dentition. Although this disease affects the general population but is 32 times more likely to occur in infants who are of lowsocioeconomic status,whosemothers have a low education level, and start solid foods earlier in their lives. In the current study 420(77.9%) were erm babies with good oral hygiene compared to 119(22.1%) preterm babies which shows that pretermbabies aremore prone to bad oral hygiene due to low immunity and predominant feeding with the introduction of solid food enhances bad oral hygiene. This analysis indicates that for preterm babies particularly exclusive breastfeeding is important to avoid early dental caries in infants in low social class of Pakistan. The benefits of exclusive breastfeeding on maternal health have been studied widely. The social and economic benefits include saving on health care costs particularly in the villages of Pakistan can be achieved by the exclusive breastfeeding practices for first six months of life. According toWorld Health Organization "Exclusive" breastfeeding is defined as no other food or drink, not even water, except breast milk for at least 4 and if possible 6 months of life, but allows the infant to receive drops and syrups (vitamins, mineral s and medicines). "Predominant" breastfeeding means that the infant's predominant source of nourishment has been breast milk. However, the infant may also have received water and water-based drinks (sweetened and flavoured water, teas, infusions, etc), fruit juice, orORS solution. Exclusive Breastfeeding practices in Pakistan is (37.1 %) only, inspite of national nutrition an d Baby Friendly hospital initiatives by World Health Organization and UNICEF since 1991 in Pakistan the impact on mother and infant pairs have not been successfully achieved in last few decades in all the provinces of Pakistan. The preventive national initiatives for dental carries in early infancy have not been in practice in Pakistan Several researches have shown that the immune factors in human milk include antimicrobial (Oligosaccharides, lactoferrin, fatty acids, lysozyme) immunoglobulin (bifidus factor, complement, mucins,lactoperoxidase),anti- Cytokines( long-chain polyunsaturated fatty acids),inflammatory growth factors( lactoferrin, hormones),Immune system (Macrophages, cytokines, lymphocytes, long-chain promotion/ polyunsaturated fatty acids, nucleotides)growth development factors( hormones, neutrophils). The recommended breastfeeding practices help reducing the infection rate and infant mortality because of the benefits of the above immune factors in brestmilk. The current data showed bad oral hygiene in 150 (40.4%) infants of mothers with normal body mass index 18-23.5 Kg/m2 which indicates that the health of mother and exclusive breastfeeding practices have a significant impact on the oral health of infants in villages of Pakistan. This study was conducted to assess the current oral health and dental caries related to exclusive and predominant breastfeeding practices in the first 6-24 months of infants. The method of breastfeeding and oral hygiene status in early life will determine the time of dental caries in childhood.An adequate data on oral health status and methods of feeding (exclusive or partial breastfeeding) is scarce in the literature therefore this study was conducted to analyse and develop guided principles and practices to prevent early dental carries in the children in rural community. Dental caries is a complex disease caused by an imbalance in physiologic equilibrium between tooth mineral and a biofilm of normal oral bacteria. Dental Caries occur due to the multiplication of specific organisms present in human oral flora. An early oral health risk assessment and preventive intervention provided by a dentist in all breastfed infants to identify high risk infants and multiple risk factors is needed at the community level in Pakistan. Mothers must be counselled for oral hygiene care, exclusive breastfeeding till six months and predominant feeding till 24 months in, preterm babies specifically. The connection between prolonged breastfeeding and caries is a great controversy. Bad oral health is a serious public health problem and its control should be considered on a priority basis. Pretermbirths, predisposes to high levels of streptococcal colonization and maternal infection, metabolic disorders (hypoxemia, nutritional disorders, hypocalcaemia). The booking status with infants` good oral hygiene was found only in 255(47.3%) in this study.Therefore, the antenatal care required to counsel mothers during their visits for exclusive breastfeeding practices for early six months. Health promotion strategies need to be targeted to mothers in less advantaged backgrounds.Messages about infant breast feeding should emphasise that the method is beneficial to the oral health of the children if appropriately used Limitation of the Study In this study the good oral health is associated with exclusive breastfeeding in 289(53.6%) compared to 250(46.4%) infants not on exclusive breastfeeding. Therefore, this is the limitation of the study because the data is from only one town; a national data is required to support the association of oral health and breastfeeding in deprived villages of Pakistan.


The good oral hygiene was found in two third of breastfeeding infants’ between 6-24 months and the associated risk factors for bad oral hygiene in low social class include infants` age, male infants, low socioeconomic status, lowmaternal body mass index, and pretermbabies.


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