It feels like everyone’s got an opinion and personal outlook regarding breastfeeding. While many are very open and accepting of your “plan” others are silently(?!) judging. I’m going to be honest/human with you for a moment: I’m not even following my own recommendations that I’m about to propose. As a working mom, it is truly a challenge to continue breastfeeding in the literal sense, as well as pumping in the logistical sense. Compared to other countries, we are far lacking in supportive systems. I have been combination feeding since leaving the hospital; breastfeeding when I can, and supplementing with formula and pumped milk. However, as time passes, the proportion of formula feeding continues to rise as my breastfeeding capability declines. I’ve been trying to accept and make peace with letting my baby dictate the fact that I may likely not be able to breastfeed much longer as it has been recently difficult for me to maintain a consistent supply. However, knowing what I know as an orthodontist, it does tear at me a little bit. I was bottle-fed with formula after one week and I turned out fine (phew!).
As I try to seek a balance, I remind myself that my son is well-fed and thriving, which is most important. However, for peace of mind, I chose to expand on what I’ve already known about the general benefits and possible risks (believe it or not) of breastfeeding. I will review breastmilk compared to formula, breastfeeding compared to bottle feeding as well as orofacial correlations.
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding as the optimal form of infant nutrition for the first six months and to continue for one year. However, this is pretty much impossible for a working mom! A mother’s food choices will affect the nutritional profile of human breastmilk, as well. As Erick (1) notes, only when a mother is adequately nourished she may provide optimal nourishment for a metabolically active and developing brain, both in utero and post-partum. There are a few common nutritional deficiencies that begin in utero that may present as adult deficiencies. Iodine deficits reduce fetal/neonatal IQ, iron deficiencies lead to cognitive and physical compromises, and folic acid deficiency leads to neural tube defects.
In this sense, let’s review the “conditional” benefits of breastmilk. According to Erick (1), breastmilk is highly nutritive, providing immunological and growth factors. Breastmilk has been shown to prevent infection, enhance neurodevelopmental outcomes, decrease obesity likelihood, allergies, and celiac disease. The bioactivity of breastmilk peptides is anti-inflammatory and anti-microbial, and helps regulate gastrointestinal function. The World Health Organization (WHO) additionally notes a decreased development of obesity, type II diabetes and cardiovascular disease. Furthermore, breastfeeding allows for improved maternal-infant bonding, postpartum weight loss, and protection for the mother against ovarian, breast and endometrial malignancies. Benefits are economical, as well (breastmilk is free!).
According to Holmes (2), many (including myself) will supplement with formula, which causes a decrease in supply, as demand for breastmilk decreases. Exclusively breastfed (EBF) children are at a lower risk for obesity between ages 2-6, compared to formula or combo-fed children. Holmes (2) notes that combo-feeding is often done based on the perception that infants will receive the “best of both” – health benefits and vitamins in formula. I can understand and resonate with that, and since I knew I would eventually be working I wanted to make sure my son was comfortable with both nutrition options. Holmes (2) additionally cites that multiple studies demonstrate that EBF offers greater protection from illnesses and infant mortality.
However, breastmilk has also been shown to be low in certain nutrients such as Vitamin D, iodine, iron and Vitamin K. My pediatrician gave me a liquid Vitamin D supplement for the baby. Yet supplement compliance generally is poor (2-19%). I admit that I forgot to use it a few times at first! Furthermore, poorly developed countries show additional deficiencies in Vitamins A, B12, B1, and zinc. For these reasons, Erick (1) states: “…isn’t it more accurate to describe breast milk as ‘conditionally perfect’?” Meanwhile, infant formulas are fortified with vitamins, minerals, proteins, fatty acids, and nucleic factors. They are monitored for quality control and are consistent, unlike breastmilk. Any nutrient deficiencies during pregnancy are also transferred to the baby via lactation. A woman cannot transfer nutrients via breastmilk that she does not have. A well-balanced diet is essential, therefore, during both pregnancy and breastfeeding stages to ensure providing optimal nutrition.
Erick (1) considers malnutrition during pregnancy and afterwards an unrecognized “skeleton in the closet”. Eating disorders and bariatric surgery are two examples where nutrition needs to be properly managed. Maternal Crohn’s or celiac disease, or restrictive diets such as veganism may need to adhere to nutritional protocols or supplementations.
Tangential to breastfeeding challenges and as an orthodontic specialist, I would like to touch upon tongue ties. Tongue-ties (TT) are a commonly missed barrier to breastfeeding. TT in infants is cited as a significant cause of difficulty to continue breastfeeding, according to Billington and colleagues (3). Early treatment and support may help improve breastfeeding conditions, and allow for infants to obtain the nutritional and development benefits. A tongue-tie is defined as a congenital, shortened and thickened “frenulum”, which limits tongue movement. Wait, what’s a frenulum? A Frenulum/frenum is a muscular band of tissue that binds the tongue to the floor of mouth essentially. Billington and colleagues (3) quote an estimated incidence of TT between 3-11%. That’s pretty significant. While usually asymptomatic, a TT will create a barrier to establish breastfeeding as it contributes to a poor latch, air swallowing, restlessness while feeding, and maternal pain/discomfort. Mothers on average wait 11 days to have their children be seen (3), and will be recommended a frenectomy procedure to free this tissue attachment. But, the sooner the better; knowledge is power! A TT may also contribute to inadequate tongue muscular support for optimal palatal growth and development, as well. This may contribute to mouth-breathing and a high-vaulted palate, of which I’ve discussed the sequelae before in my previous blog posts.
While on the topic of growth and development, I will review the benefits of breastfeeding and its dental/orofacial implications. Orofacial/dental growth and development begin prenatally actually. The primary dentition usually begins to erupt around six months old and up to about three years old. According to Anyanechi and colleagues (4), 89.3% mothers are not educated or aware of the relationship between breastfeeding and dental development. Yikes! Dogramaci and colleagues (5) performed a systematic review and meta-analysis of seven studies correlating malocclusions and breastfeeding. Breastfeeding for under 12 months was strongly associated with the development of an anterior open bite (3.58x risk) and a Class II canine relationship (1.65x risk). There was some evidence that posterior crossbite risks were increased, as well. However, it’s important to note that breastfeeding exposure cannot affect a genetic predisposition towards a skeletal malocclusion. For this reason, we cannot say that breastfeeding will eliminate the needs for orthopedic and/or surgical orthodontic treatments later in life. Peres and colleagues (6) found that babies are 72% less likely to have crooked teeth if exclusively breastfed for six months. For those of us that cannot do this, I’m here to help later on ;)
Dogramaci and colleagues (5) illustrate that non-nutritive sucking behaviors (NNSB) are also associated with a higher risk of malocclusions when compared to suboptimal breastfeeding. In particular, pacifier use (i.e. non-nutritive sucking) accounted for class II development. Children who had NNSBs (particularly digit-sucking) had 10x risk of anterior open bite, while children who did not breastfeed nor had these behaviors had a 1.46x relative risk. Lower lip sucking habits were associated with severe overjet relationships.
Finally, I’d like to review findings relating to breastfeeding/bottle-feeding and dental decay. CNN in 2017 cited a study noting that children who are breastfed for 2+ years were 2.4x more likely to have dental cavities. In this study 23.9% had severe decay, while 48% had at least one affected tooth surface. Wong and colleagues (7) similarly demonstrated that dental decay (caries) risk increases with an increased duration of breastfeeding. The risk particularly increases after two years, to 2.75x, in their study. Why? These children are being fed at a higher frequency and on-demand at night, as well, making it difficult to clean teeth. The teeth are constantly being exposed to sugars that disrupt the intraoral pH balance. Even breastmilk has sugar(!) Children from families of lower education and economic status also are at a higher risk of having severe cavities. Conversely, strict breastfeeding may decrease the risk of “baby bottle tooth decay,” which occurs when babies are put to bed with a bottle. The bottle is being used as a pacifier, however also exposing babies’ teeth to sugary drinks (such as milk or juice) for extended periods of times.
In terms of infant oral hygiene, it is important to wipe down the baby’s gums after eating with a moist cloth. Teeth, once they come in, should be brushed twice a day. A rice grain-sized amount of fluoride toothpaste is recommended. When should a child see the dentist? As soon as that first tooth comes in! Parents need to be diligent with their own oral hygiene too, especially if they start sharing a spoon with their child. This, along with cleaning a pacifier/toy with one’s own saliva is one of the most common ways a child is introduced to cavity-causing bacteria. This is done more commonly than you’d think, I don’t recommend it!
While on the topic of hygiene, unfortunately, there isn’t much information or literature regarding breast-pumping “hygiene” or technique, and most studies simply cite the lack of information and/or investigate breastmilk compare to formula, and don’t stratify between direct breastfeeding or bottling pumped milk. In my early stages of giving pumping a “go” and discussing with friends, I was surprised to find no protocol or standardized information about cleaning/sterilizing parts. Maybe I’m missing something! I have noticed a new surge of post-partum products and discussions relating to the minimal support and information for new moms. So I’m sure developments will be forthcoming.
At the end of the day, as everyone says, “fed is best.” There are definitely conditional risks and benefits to breastfeeding, bottle feeding with breastmilk, and formula feeding. Hopefully this will offer some solace; if you’re a mother, whatever you end up doing is perfect, keep up the great work!
1. Breast milk is conditionally perfect. Erick M. Med Hypotheses. 2018 Feb;111:82-89.
2. Combination feeding of breast milk and formula: evidence for shorter breast-feeding duration from the National Health and Nutrition Examination Survey. Holmes AV, Auinger P, Howard CR.
J Pediatr. 2011 Aug;159(2):186-91.
3. Long-term efficacy of a tongue tie service in improving breast feeding rates: A prospective study. Billington J, Yardley I, Upadhyaya M. J Pediatr Surg. 2018 Feb;53(2):286-288.
4. Parturients' Awareness and Perception of Benefits of Breast Feeding in the Prevention of Infant and Childhood Oral and Dental Diseases. Anyanechi CE, Ekabua KJ, Ekpenyong AB, Ekabua JE. Ghana Med J. 2017 Jun;51(2):83-87.
5. Malocclusions in young children: Does breast-feeding really reduce the risk? A systematic review and meta-analysis. Doğramacı EJ, Rossi-Fedele G, Dreyer CW. J Am Dent Assoc. 2017 Aug;148(8):566-574.e6.
6. Exclusive Breastfeeding and Risk of Dental Malocclusion. Peres KG, Cascaes AM, Peres MA, Demarco FF, Santos IS, Matijasevich A, Barros AJ. Pediatrics. 2015 Jul;136(1):e60-7.
7. Total Breast-Feeding Duration and Dental Caries in Healthy Urban Children. Wong PD, Birken CS, Parkin PC, Venu I, Chen Y, Schroth RJ, Maguire JL; TARGet Kids! Collaboration. Acad Pediatr. 2017 Apr;17(3):310-315.