Open Access Open Badges Research article

Feeding and smoking habits as cumulative risk factors for early childhood caries in toddlers, after adjustment for several behavioral determinants: a retrospective study

Alessandra Majorana1, Maria Grazia Cagetti2, Elena Bardellini1, Francesca Amadori1, Giulio Conti3, Laura Strohmenger2 and Guglielmo Campus24*

Author Affiliations

1 Dental School, Department of Pediatric Dentistry, University of Brescia, Brescia, Italy

2 Department of Health Science, WHO Collaborating Center of Milan for Epidemiology and Community Dentistry, University of Milan, Milan, Italy

3 IRCCS Ca’Granda University of Milan, Milan, Italy

4 Department of Surgery, Microsurgery and Medicine Sciences – Dental School, University of Sassari, I-07100 Sassari, Italy

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BMC Pediatrics 2014, 14:45  doi:10.1186/1471-2431-14-45

Published: 15 February 2014



Several maternal health determinants during the first period of life of the child, as feeding practice, smoking habit and socio-economic level, are involved in early childhood health problems, as caries development. The potential associations among early childhood caries, feeding practices, maternal and environmental smoking exposure, Socio-Economic Status (SES) and several behavioral determinants were investigated.


Italian toddlers (n = 2395) aged 24–30 months were recruited and information on feeding practices, sweet dietary habit, maternal smoking habit, SES, and fluoride supplementation in the first year of life was obtained throughout a questionnaire administered to mothers. Caries lesions in toddlers were identified in visual/tactile examinations and classified using the International Caries Detection and Assessment System (ICDAS). Associations between toddlers’ caries data and mothers’ questionnaire data were assessed using chi-squared test. Ordinal logistic regression was used to analyze associations among caries severity level (ICDAS score), behavioral factors and SES (using mean housing price per square meter as a proxy).


Caries prevalence and severity levels were significantly lower in toddlers who were exclusively breastfed and those who received mixed feeding with a moderate–high breast milk component, compared with toddlers who received low mixed feeding and those exclusively fed with formula (p < 0.01). No moderate and high caries severity levels were observed in an exclusively breastfed children. High caries severity levels were significantly associated with sweet beverages (p < 0.04) and SES (p < 0.01). Toddlers whose mothers smoked five or more cigarettes/day during pregnancy showed a higher caries severity level (p < 0.01) respect to those whose mothers did not smoke. Environmental exposure to smoke during the first year of life was also significantly associated with caries severity (odds ratio =7.14, 95% confidence interval = 6.07-7.28). No association was observed between caries severity level and fluoride supplementation. More than 50% of toddlers belonging to families with a low SES, showed moderate or high severity caries levels (p < 0.01).


Higher caries severity levels were observed in toddlers fed with infant formula and exposed to smoke during pregnancy living in area with a low mean housing price per square meter.

Early childhood caries; Toddler; Feeding practice; Smoking exposure; Socio-Economic Status