By Burton L. Edelstein, D.D.S., M.P.H.
Columbia University College of Dental Medicine

The U.S. medical community agrees that breastfeeding is best for babies and toddlers. This includes public health officials, doctors who take care of babies, and doctors who deliver them. The American Academy of Pediatrics (AAP) says breast milk is "uniquely superior for infant feeding." It says mothers should breastfeed unless they can't do so because of significant medical conditions.

Breastfeeding's many benefits may include its effects on the teeth. Breast milk has been found to contain high levels of protective chemicals. It also produces relatively little acid in the mouth. These facts suggest that breastfed infants should have an advantage when it comes to having healthy teeth.

Yet reports and studies have raised concern that breastfeeding — particularly prolonged breastfeeding — may lead to Early Childhood Caries (ECC). Other dental studies, however, show no link between tooth decay and breast milk or breastfeeding.

ECC is a devastating form of tooth decay. It destroys teeth rapidly. ECC typically shows up as brown, broken, painful teeth well before the third birthday. This early decay also can set up a child for a lifetime of dental woes.

The top front teeth typically are affected first. Often, decay occurs on the back, or tongue side of the tooth, which can't be seen easily. The top teeth in the back of the mouth are affected next, then the bottom back teeth. The lower front teeth usually do not become involved.

So what does it mean that breastfeeding has been associated with tooth decay in some children? Is this just "guilt by association," as some have suggested? Or is it scientific evidence that breastfeeding increases the risk of tooth decay? And what is a parent to do?

To answer these questions, we first consider some of the scientific evidence that explains the decay process. Then we look to the American Academy of Pediatric Dentistry for guidance.

• Tooth decay requires direct interaction between the bacteria that cause decay and a food or drink that bacteria can turn into acid. Children usually acquire these bacteria from their mothers around the time of their first tooth.



• Tooth decay is a disease that has periods of "attack" and "repair" of teeth. Several studies show that breast milk itself is not a good food for the bacteria that cause cavities. Chemical buffers like those found in breast milk help to turn off the attack and speed the repair.



• Tooth decay is made worse by frequent eating of foods that contain sugar. Eating many times a day also can speed up tooth decay. This is true even if the food is not one that especially helps tooth decay bacteria to make acid. Tooth decay occurs earlier and is more severe in children who are allowed to eat or drink frequently, with little break between snacks.



• Tooth decay speeds up the most at night. That's because saliva flow slows down at night and during sleep. Saliva helps to protect teeth against decay. Any food or drink, including breast milk, consumed just before sleep or during sleep can stimulate the decay process.

Clearly, breastfeeding puts most children at very minimal risk of cavities and is protective for many children. But under certain and very specific conditions breastfeeding may push the limits of a child's capacity to ward off tooth decay. This may occur when breastfeeding:

• Is very frequent
• Occurs repeatedly throughout the night
• Is not followed by cleaning the baby's mouth

This complexity explains why the American Academy of Pediatric Dentistry has developed a carefully stated position on breastfeeding. The academy fully supports breastfeeding. But it cautions that, "the risk of potentially devastating … decay exists for the breast-fed child as it does for the bottle-fed child."

The statement adds that breastfeeding a child throughout the night "should be avoided after the first primary tooth begins to erupt." The first primary tooth can appear at any point from 3 to 12 months of age. About 6 months of age is typical.

You can take steps to protect your child's teeth through proper care:

• Clean your baby's teeth and gums with a damp cloth or a soft toothbrush after each feeding.
• Take your baby for his or her first visit to the dentist as soon as the first tooth erupts.
• Teach your baby to drink from a cup by his or her first birthday.
• Make sure your baby is getting the right amount of fluoride. If your town does not have fluoride in its drinking water, ask your pediatric dentist or pediatrician about fluoride supplements.

You can give your child the benefits of breast milk and help avoid tooth decay if you follow these guidelines:

• Breastfeed your baby for at least a year, as recommended by the AAP.
• As your child begins to have other liquids and solids, limit how often he or she consumes foods that contain sugar. This is one of the most important things you can do to reduce the risk of cavities for your child.
• Establish sleep routines early in your baby's life. According to the AAP, by age 6 to 8 weeks babies should learn how to get to sleep on their own without being rocked or fed. By age 6 months, most babies should be able to sleep through the night.
• Avoid long periods of breastfeeding, particularly when your child is very sleepy or falling asleep at the breast.

In short, parents should be aware of factors that lead to ECC and assure that their breastfeeding practices provide all the benefits and none of the risks to their children's oral health.

Burton L. Edelstein, D.D.S., M.P.H., a pediatric dentist, is professor and chairman of social and behavioral sciences at Columbia University College of Dental Medicine and professor of clinical health policy and management at the Mailman School of Public Health. He is also founding director of the Children's Dental Health Project, a non-profit organization that advances policies to improve children's oral health. Burt practiced pediatric dentistry in Connecticut and taught at the Harvard School of Dental Medicine for 21 years before committing to full time health policy practice.