Breastfeeding and the Risk of Dental Caries a Systematic Review and Meta-analysis

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Peer-reviewed

Research Article

Breast and Bottle Feeding equally Risk Factors for Dental Caries: A Systematic Review and Meta-Assay

• Walesca 1000. Avila,
• Isabela A. Pordeus,
• Saul M. Paiva,
• Carolina C. Martins

x

• Published: November 18, 2015
• https://doi.org/10.1371/journal.pone.0142922

Figures

Abstract

Understanding the office that breastfeeding and bottle feeding play in the evolution of dental caries during childhood is essential in helping dentists and parents and care providers preclude the affliction, and as well for the evolution of effective public health policies. However, the event is not yet fully understood. The aim of this systematic review and meta-assay was to search for scientific testify in response to the question: Do bottle fed children have more dental caries in primary dentition than breastfed children? Vii electronic databases and grayness literature were used in the search. The protocol number of the study is PROSPERO CRD 42014006534. Two independent reviewers selected the studies, extracted data and evaluated risk of bias by quality assessment. A random effect model was used for meta-analysis, and the summary effect measure were calculated by odds ratio (OR) and 95% CI. 7 studies were included: five cross-exclusive, one instance-control and 1 cohort study. A meta-assay of cantankerous-sectional studies showed that breastfed children were less affected past dental caries than bottle fed children (OR: 0.43; 95%CI: 0.23–0.80). Four studies showed that bottle fed children had more dental caries (p<0.05), while three studies found no such clan (p>0.05). The scientific show therefore indicated that breastfeeding can protect against dental caries in early babyhood. The benefits of breastfeeding until historic period two is recommended by WHO/UNICEF guidelines. Further prospective observational accomplice studies are needed to strengthen the evidence.

Citation: Avila WM, Pordeus IA, Paiva SM, Martins CC (2015) Breast and Bottle Feeding as Chance Factors for Dental Caries: A Systematic Review and Meta-Analysis. PLoS I 10(11): e0142922. https://doi.org/10.1371/journal.pone.0142922

Editor: Tammy Clifford, Canadian Agency for Drugs and Technologies in Health, CANADA

Received: April 10, 2015; Accepted: Oct 28, 2015; Published: November 18, 2015

Copyright: © 2015 Avila et al. This is an open admission commodity distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original writer and source are credited

Data Availability: All relevant data are inside the paper and its Supporting Information files.

Funding: The institutes which provided us funding were: CAPES (Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior), Fapemig (Fundação de Amparo à Pesquisa do estado de Minas Gerais), CNPq (Conselho Nacional de Desenvolvimento Científico east Tecnológico) and PRPq/UFMG (Pró-Reitoria de Pesquisa da UFMG). The funders had no role in study design, data collection and assay, decision to publish, or grooming of the manuscript.

Competing interests: The authors have declared that no competing interests be.

Introduction

Early childhood caries (ECC) are defined as the presence of 1 or more than decayed, missing or filled tooth surface in any primary tooth of children aged nether 71 months [1].

One of the first published reports into dental caries in babies was performed in 1927[two], when doctors noticed that a big number of babies had extensive caries in molar surfaces. Although no enquiry into the function of breastfeeding and bottle feeding in the etiology of ECC existed at this fourth dimension, many studies since then have revealed cryptic results with respect to feeding habits and dental caries [3, 4].

The benefits of breastfeeding for systemic wellness, such as the reduction of morbidity, infectious disease and low weight in newborns [five], are well known. The PROBIT trial emphasized the importance of breastfeeding, as it decreased the hazard of gastrointestinal infections and inflammatory skin conditions [6]. Although it seems the practice does not benefit the development of normal occlusion [7]. Exclusive breastfeeding is recommended by the Earth Health Arrangement (WHO) until the age of half-dozen months, and breastfeeding complemented with nutrient intake is suggested until two years old [8]. Even so, cultural and social factors directly affect knowledge of how long a child should exist breastfed for [nine].

The issue of whether bottle feeding is more cariogenic than breastfeeding remains unresolved even today. Some authors have non found an association between breastfeeding and dental caries [ten–12], while other study have reported the existence of such an association[13]. Some authors have stated that bottle feeding is a run a risk factor for dental caries [xiv–16], while another author did not find such an association [17]. Due to the disagreement between these findings, further studies are needed to clarify the existence of this association [xviii].

A systematic review of studies investigating the relationship betwixt breastfeeding and dental caries was published in 2000 and included xx four case-control studies, three case series and one cohort. The systematic review could not ostend that breastfeeding was a risk factor of dental caries. Withal, information technology did not written report comparisons betwixt breastfeeding and bottle feeding [19]. Another review [20] identified three factors related to breastfeeding and/or bottle feeding as chance factors for dental caries: duration of breastfeeding greater than xviii months, used to feed or stop crying during the night, and to put the child to sleep. However, none of these reviews compared bottle feeding vs. breastfeeding in relation to dental caries, and as such it has non been confirmed whether bottle feeding is more than associated with dental caries in primary dentition than is chest feeding. 15 years afterwards, the issue of whether canteen feeding can contribute to an increased take chances of dental caries compared to breastfeeding remains unclear, every bit none of the reviews aimed to respond this clinical question. Therefore, this systematic review is the offset to compare the rate of caries in different type of feeding practices: breastfeeding and bottle feeding.

Greater understanding of the subject is important, withal, as improved knowledge can assistance dentists provide more appropriate instructions and atomic number 82 to healthier children. The presence of dental caries in babyhood is an important theme, which should be exhaustively discussed and treated as it affects well-existence, growth [21] and quality of life [22]. Despite a subtract in the prevalence of dental caries in both developed [23] and developing countries [24], worldwide prevalence in v-year-old children remains high, with a level of 27.9% in England [25]; 46.vi% in Brazil [26], betwixt xi.0 and 53.0% in the USA [27] and 23% in American children aged ii–3 years sometime [28].

The aim of this study was to systematically review the scientific testify relating to the association between feeding practice (breastfeeding vs. bottle feeding) and dental caries in childhood. The clinical question is (PICO): Patients: children with exclusively master dentition; Intervention / Exposure to risk gene: bottle feeding; Comparison: breast feeding; Outcome: dental caries.

Material and Methods

The present systematic review was undertaken in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [29] (protocol number: PROSPERO CRD 42014006534).

This systematic review included observational cantankerous-sectional, instance-control, and cohort studies, together with clinical trials of children with exclusively master dentition (historic period ≤ 71 months), which compared breastfeeding and bottle feeding in association with dental caries, and included statistical data comparison bottle to breast feeding. Statistical data could be: odds ratio (OR), relative risk (RR), prevalence ratio (PR), confidence intervals (95%CI), p-values, or studies that reported frequency or an absolute number of events/total number of individuals per group.

Vii electronic databases were searched in March 2014: Pubmed (www.pubmed.gov); Cochrane Library (http://www.cochrane.org/index.html); Web of Science (http://world wide web.isiknowledge.com); Controlled-trials Database of Clinical Trials (http://www.controlled-trials.com); Clinical Trials–United states of america National Institute of Health (http://www.clinicaltrials.gov); National Institute for Health and Clinical Excellence (http://www.nice.org.united kingdom); Lilacs (www.bireme.br) without brake of engagement of publication. The search was updated in March 2015.

The following search strategy was used for the Pubmed, Cochrane Library and Spider web of Science databases: ((caries OR dental caries OR dental decay OR decay OR DMF alphabetize OR DMF Indices OR rust-covered teeth OR tooth decay) AND (bottle feeding OR bottlefeedings OR bottlefeed* OR breastfed* OR chest fed OR breastfeeding)).

The controlled-trials Database of Clinical Trials, Clinical Trials, National Establish for Wellness and Clinical Excellence, Lilacs were searched using the following combined keywords: dental caries AND breast feeding AND bottle feeding. A manual search was conducted in the reference lists of the included studies.

The online search identified a full of 1033 papers (Fig 1). After duplicate references were removed, a total of 784 studies were entered in the Reference Manager^® program (Reference Director, Thomson Reuters, version 12.0.3). The list provided by the reference manager was analyzed, and manufactures were selected based on abstracts and/or title by two independent reviewers (WMA and an undergraduate student). The contained reviewers were calibrated in accordance with inclusion/exclusion criteria using a sample of 20% of the retrieved studies, and agreement between reviewers was found to be good (K = 0.79). The inclusion and exclusion criteria were applied independently to the remainder of the studies and whatever disagreement was resolved by consensus with a 3rd reviewer (CCM).

The exclusion criteria were: literature review, letters to the editor, editorials, patient handout, case study or case series, in vitro studies, etiology other than breast or bottle feeding, treatment of dental caries, health promotion, outcome other than dental caries (eg. malocclusion, dental hypoplasia, and others), other feeding habits, study protocol, studies reporting just canteen or breastfeeding, creature studies, studies of quality of life, language other than English.

A total of 667 studies were excluded after title/abstract assay and 117 were selected for total text assay. Where the studies could not be plant, authors were personally contacted by e-mail (for a list of excluded abstracts and/or title, see S1 Appendix). Subsequently full text analysis, 109 studies were excluded (for a listing of excluded studies, encounter S2 Appendix). These studies were excluded for several reasons, such as: investigation of merely i type of feeding practice (only breastfeeding or only canteen feeding), absence of comparison of breastfeeding and canteen feeding, investigation of other issues such every bit dark-fourth dimension feeding or weaning time, absence of statistical data, other etiology, in vitro study, example report, children above 71 months old. Grey literature was searched using abstracts presented in meetings, and a transmission search was conducted from a reference list of included studies.

Data extraction

Descriptive data of clinical and methodological factors such as country, local setting, initial and concluding sample, dental examination, feeding habit evaluation, statistics, outcome and study design were extracted. In case of missing or misunderstood data, the authors were personally contacted by email.

Methodological quality assessment

Quality assessment was performed past using the Newcastle-Ottawa Calibration [thirty], which measures the methodological quality of a study by the number of points the study received. For example-control and cohort studies, the original scale was used. For cantankerous-sectional studies, a modified version of the example-command study scale was used (Fig 2). Run a risk of bias was evaluated for each question. For each question-based entry the judgment was: "Yes, for low run a risk of bias" and a point was allocated (*), and "No, for high risk of bias" and a signal was not allocated [31]. The questions evaluated in each report were based on the following criteria from the Newcastle-Ottawa calibration: exposition/not-exposition and case/command definition; representativeness of the sample (evaluated by the methods of generation of samples, allocation concealment and sample calculation); sample selection (eastward.chiliad., community, hospital, etc.), adjustment for confounders, blindness, acquisition of data on the dependent variable, description of bias, non-response charge per unit (Fig ii).

Fig 2. Newcastle-Ottawa quality assessment summary.

ⁱFor cross-exclusive and case-control studies. ²For case-command study only. ³For cohort study simply. ⁴For all study designs. †This item was allocated a maximum of two points. †† This item was allocated a maximum of 2 betoken for cross-sectional and iii points for cohort and case-command studies. NR = not rated.

https://doi.org/10.1371/journal.pone.0142922.g002

The representativeness criteria was evaluated through the sampling methods. The presence of a random component in the sequence generation was judged as depression adventure of bias. Allocation darkening was besides used every bit a criteria for assessing representativeness. Thus, whatsoever method that precluded participants and researchers from foreseeing assignment was judged as depression risk of bias.

Data synthesis

The Comprehensive Meta-Analysis software programme (version two) was used for meta-assay [32]. Only studies with like designs were included in the forest plot, as meta-analysis tin can provide misleading results if different study designs and studies variations across studies are grouped together [33]. For this reason, in social club to avoid methodological heterogeneity in meta-analysis, only cross-exclusive studies were grouped. Heterogeneity among the studies was evaluated using I^two statistics and a sensitivity examination was used to test consistency of data by removing outliers from time series [33]. 2 outliers acquired statistical heterogeneity and had to exist removed from the forest plot [11, 12]. Fixed consequence model was used for depression heterogeneity and random effect model for high heterogeneity. As values exceeding 50% can be considered to be of notable heterogeneity [34], the random upshot model was used for these cases. [35]. For categorical data, risk measures, odds ratio (OR), 95% confidence intervals (CI) and p-values were calculated in a forest plot.

The studies featured different weaning ages or breastfeeding duration, different study designs and differences in statistical tests. Meta-assay was conducted but for those studies featuring variables that could be grouped [11, 12, 36, 37]. Information technology was not possible to extract data for meta-assay for i cross-exclusive report [16]. Data was extracted for the chiselled variable feeding habit (breastfeeding vs. bottle feeding). For other studies a narrative synthesis of the information was conducted. Publication bias was non quantitatively evaluated past Egger test or funnel plot, as there were not plenty studies to be grouped in a funnel plot [38].

Results

Study characteristics

7 studies were included in this systematic review (two in meta-analysis): five cross-sectional [xi, 12, 16, 36, 37], one example-control [10], and one cohort [15] (Table i). Three studies recruited children from kindergartens [12, 16, 37] and four recruited children from infirmary and health centers [10, 11, 15, 36]. The age of patients ranged from 18 months to sixty months. The sample size of the studies ranged from 218 to 2395 children. Simply ii studies used a representative sample and both collected the sample from kindergartens, i in 1 of the largest cities in Syria [15] and the other in two provinces of Red china [12, 16].

All studies included assessment of feeding habits by questionnaire [15, 37], interview [ten, 11, 16, 36] or both, where an interview was used for the rural population and a questionnaire for the urban population [12]. The sample of the example-control study was fatigued from a main written report group of 1263 children in South African communities [39]. In this written report, children aged 1 to four years were randomly selected from the nascency records of every child of the community, targeting 300 children from each geographical area. Commencement, children with dental caries were segregated from the primary sample, giving a full of 109. These were matched with 109 children without dental caries for age, gender, race and social class.

The cohort written report [15] analyzed children from a hospital from birth to up to 30 months of age. Feeding habits were identified through a questionnaire applied at nascence, and and so over again at half-dozen, 9 and 12 months. After feeding assessment, one clinical examination was conducted past two examiners between 24 and xxx months.

Diagnosis of dental caries

Most studies used WHO criteria[11, 12, 36, 37], ICDAS [15] or specific definition [10] for diagnosis of dental caries, while one written report used iii different criteria (those were ICDAS, WHO and Nyvad) [sixteen]. One author [37] divided the presence of caries presence into three classifications: caries; rampant caries and incisor caries. The "with caries" group was divers according to WHO criteria [40], rampant caries was divers equally two or more than upper deciduous incisors with carious labial or palatal surfaces, while incisor caries considered only this molar group.

Feeding habits

All studies considered categorical data regarding the presence and absenteeism of breastfeeding, bottle feeding or mixed feeding, although the criteria used to ascertain types of feeding differed between studies. One author considered breast feeding or bottle feeding at birth [36]; two authors considered feeding habits up to half dozen months or more [xi, 15], 1 author considered exclusive breastfeeding up to 12 months [10], and others considered feeding habits during infancy [12, 16, 37].

Meta-analysis

Meta-analysis was initially conducted in 4 cross sectional studies [11, 12, 36, 37], which presented categorical variables that could be grouped (breastfeeding vs. canteen feeding). A sensitivity examination was conducted and two outliers were removed [xi, 12]. The final meta-assay included two cantankerous-sectional studies and showed that breast fed children were less affected by dental caries than bottle fed children (OR: 0.43, 95%CI: 0.23-.08, I²: xxx.fourteen%) (Fig 3).

Fig 3. Wood plot of meta-analysis for four cantankerous-sectional studies.

Evaluates bottle or breast feeding practices and dental caries (result: presence of dental caries vs. absence of dental caries). Pooled effect measures [odds ratio (OR) and 95% confidence interval (CI)] indicated no statistically significant departure betwixt chest and bottle fed children. I^two = 33.14%. Fixed effect model used.

https://doi.org/10.1371/journal.pone.0142922.g003

Methodological Quality Assessment

The summary of quality assessment is summarized in Fig two. A high risk of bias was obtained when the particular did not fulfill the Newcastle-Ottawa criteria, and the response given for the item was 'no, the item has high take chances of bias" [31]. Four items were judged every bit having a high risk of bias in a number of studies: failure to adjust for any misreckoning variables [11, 16, 36], representativeness [10, 11, xv, 36, 37] and observation for feeding habits [15]. The confounding variables were searched for in the Methods and Results section and in the tables of the published papers.

Word

Methodological Quality Cess

The diversity of study designs in this review was analyzed using an adapted version of the Newcastle-Ottawa scale for assessing the quality of studies. The process was made circuitous [41] due to the heterogeneity of studies and differences in feeding habits and dental caries classification.

While well-nigh of studies used WHO criteria [11, 12, 16, 36, 37] for diagnosing dental caries, the cohort study [fifteen] used ICDAS criteria. As well the diagnostic criteria, the authors of this report divided the practice of feeding into a gradative scale of exclusively breast/bottle feeding and mixed feeding.

Some studies had high chance of bias for comparability of variables. Adjustment for confounders in cross-exclusive studies was performed only for social class [12, 37]. The case-control written report [10] matched cases and controls for social class, age, gender and race in order to reduce confounding bias. Nevertheless, the study did non accommodate the confounders in a multivariate model. Adjustment was made for social class just in respect of the severity of caries in the accomplice written report. This study defined i of the outcomes (dependent variable) as severity of caries, as the authors used the ICDAS scale to measure severity of dental caries [15]. None analyzed canteen content during bottle feeding. As none of the studies were adjusted for all the confounding factors, all are susceptible to residue confounding. Misreckoning variables tin include social class, hygiene and sugar in canteen content, ethnicity, early on preventive dental visits, water fluoridation and on-demand feeding at night. Some of these variables such as saccharide in bottle content and on-demand feeding at night can contribute to an increase in the risk of dental caries, while others can act as protective factors (water fluoridation, early on preventive dental visits). These variables should be considered during data drove and should be adjusted in proper multivariate models to command the confounders.

Misreckoning factors have the power to mask an association or even falsely indicate an apparent association. The presence of plausible confounding makes it difficult to institute a causal link between a take chances cistron and outcome [42]. This makes evaluation of the role of feeding habits in the etiology of dental caries. Adjustment for major confounders such as social class, hygiene and saccharide in canteen content is extremely of import, as these are known to exist etiological factors of dental caries [43–45].

One common reason for the subtract in quality was the absence of blindness during the ascertainment of bottle/chest feeding in relation to dental caries (exposure/outcome). Only examiners from one study [36] were unaware of the responses of mothers virtually feeding practices when the clinical examination for dental caries was performed. Risk of bias assessment emphasized selection bias considering of inadequate or unclear allocation sequence and concealment. Lack of or unclear blinding statement tin can generate detection bias.

Attrition bias was depression chance as all studies declared the withdrawal of participants, which did not exceed 20% (exposure/event). A low take a chance of reporting bias was observed every bit most of studies adequately reported outcome through a validated dental caries diagnosis index. All the same, observer bias may be present, every bit at that place was a lack of inter- and intra- examiner statistical measurement, such as kappa. Additionally, memory bias is inherent to the ascertainment of feeding habits, as mothers are required to report the nutrient intake of their children. Cohort designs with real time investigation of feeding habits [xv] tin can minimize retention bias.

Only two studies were allocated points for representativeness criteria [12, sixteen]. Both of these used stratified random sampling of kindergartens before randomized sampling was used to select children. The locations for sample selection were kindergartens, which were created for children whose parents worked outside the home [46]. Samples from these locations may favor specific social classes, leading to selection bias. Furthermore, many children may not be enrolled at kindergartens and tin can be cared for at home by a childminder or mother, leading to selecting of the sample. Moreover, at that place was no mention of whether these were public or private kindergartens. For this reason, the generalizability of these studies is express.

Inter- and intra-examiner reproducibility of recordings was not evaluated in all of the studies. Studies evaluated inter-examiner agreement [12, 37]; intra-examiner agreement by Cohen's Kappa Coefficient [15]; or both [10]. Some studies did not report any calibration testing [xi] [16, 36].The lack of a kappa statistic is as well a critical effect in the studies [11 16 36], as this test is considered the well-nigh reliable way to appraise the understanding of researchers during data collection [47, 48]. The absenteeism of this cess may produce bias and produce unreliable data and in consequence, unreliable results.

Data relating to feeding habits was collected through interviews with carers or mothers of children. This type of information collection may be subject to bias due to forgetfulness or inability to provide more precise data, called data bias. All but i of the studies assessed feeding habits through questionnaires or interviews, while the remaining study [15] used a dietary diary for data collection in an endeavor to reduce retention bias. Even so, it is important to clarify that this was simply possible considering it was a cohort study. A dietary diary consists of an individual writing down his or her entire food intake during a twenty-four hours. If this procedure is repeated regularly during a study, it could capture a more realistic view of the subject'south feeding habits.

Information bias could not be measured quantitatively due to the imprecise information regarding feeding habits given by carers. Based on their knowledge of the importance of breastfeeding, mothers may overestimate the duration of breastfeeding. For instance, meta-analysis used the information from the categorical variable "breastfeeding" vs. "bottle feeding". Iii studies reported this categorical variable but did non report fourth dimension data for this question [36, 37, 12]. Mothers were able to answer "yes" for breastfeeding irrespective of the duration of breastfeeding, which could vary from one month for some mothers to 6 months for others. Another study used the categorical variable "breastfeeding for up to six months" [11]. This study was removed in the concluding forest plot all the same, as it was an outlier. It is possible, therefore, that the clinical heterogeneity of this study influenced its statistical heterogeneity [33]. In summary, information bias regarding feeding habits must exist assumed in the meta-analysis. Furthermore, psychological aspects are of import in the determination of when to wean from the breast [49].

Strength of prove

Randomized clinical trials were not found. This was expected because of the upstanding questions related to the issue. 3 cross-exclusive [16, 36, 37] studies and the cohort [15] study showed that breastfed children were significantly less often affected by caries than bottle fed children. While the cross-sectional design features a lower level of evidence and may not requite a cause-and-effect relationship [46], the cohort design may indicate a temporal sequence between exposure and issue and let the incidence of disease to be calculated [47]. Furthermore, such studies accept a higher level of bear witness. Analysis of summary consequence measure out found these studies to be in agreement, revealing that breastfeeding had a protective result against dental caries when compared to bottle feeding. However, some meta-analysis points should be considered: i) the summary effect measure is drawn from cross-sectional studies, which have the lowest strength of evidence; ii) there is a risk of information bias every bit discussed above; 3) there was some statistical heterogeneity; 4) the number of included studies was low; five) it was impossible to adjust for bottle content. Contrastingly, at that place are likewise some positive points every bit both studies included are similar and used WHO criteria to diagnose dental caries [36, 37], demonstrating clinical and methodological homogeneity.

While the majority of studies advise the benefits of breastfeeding for dental caries, two cross-sectional [11, 12] and the case-control study [x] did not notice statistical significance for this association. While case-control studies have an intermediate level of evidence, these studies, together with cohort studies, had a low risk of bias [ten, fifteen].

Meta-assay regarding breastfeeding duration could non be performed due to the impossibility of extracting this data. Studies showed clinical heterogeneity equally the duration of breastfeeding varied from one study to some other. One systematic review aimed to determine the association betwixt duration of breastfeeding and dental caries. Children who were breastfed for longer than 12 months have fewer dental caries than those exposed to breastfeeding for a shorter time. As well, nocturnal breastfeeding longer than 12 months should not be encouraged, as information technology was found to increment the prevalence of dental caries in children [50]. The systematic review pooled data of breast feeding for a 12 month period just, with no other cuts off analyzed and no meta-analysis comparing breast and canteen feeding performed. The present systematic review is the offset attempt to meta-analyze the clan between dental caries and breastfeeding and bottle feeding practices. While both systematic reviews are different their findings are complementary.

This systematic review involved a search of multiple electronic databases, with no year of publication restriction. Efforts were made to endeavour to find unpublished studies through gray literature. Some shortcomings of this systematic review are the presence of many Asian studies, and the exclusion of studies written in other language than English language. These points can imply some publication bias, although the search of grey literature may reduce its touch [44]. These shortcomings limit the global extrapolation of these conclusions, as the concentration of Asian studies may lead to an unrepresentative sample of studies [45].

Current scientific evidence suggests that breastfeeding has a greater protective outcome against dental caries than canteen feeding. This review is the first to attempt to compare the rate of dental caries rate in breastfed and canteen fed children. Breast feeding benefits the systemic health of children [half dozen, 51] and for this reason, exclusive breastfeeding of children for at to the lowest degree six months is prudent [eight].

Conclusion

The available scientific evidence showed that breastfeeding is more effective at preventing dental caries in early childhood than canteen feeding. Although the duration of breastfeeding in the studies analyzed could not be adamant in the present systematic review, breastfeeding should be encouraged as the exclusive feeding method for up to 6 months, followed past complementary breastfeeding for up to ii years of age by all children, in accordance with WHO/UNICEF recommendations. Further prospective cohort studies with follow ups during childhood, blinding during dental examination, and control of confounders are suggested for future studies.

Supporting Data

Author Contributions

Conceived and designed the experiments: WMA SMP IAP CCM. Performed the experiments: WMA CCM. Analyzed the information: WMA CCM. Contributed reagents/materials/assay tools: WMA IAP CCM. Wrote the newspaper: WMA SMP CCM. Conceived the study, developed the study design and protocols, PICO question, manuscript revision: WMA SMP IAP CCM. Performed the data selection, extracted data, quality analysis, and meta-assay: WMA CCM.

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