A randomized trial of the effectiveness of home visits in preventing early childhood caries

Maternal health during pregnancy and oral health of 4-year-olds: a birth cohort study from Brazil

Data were collected by trained interviewers at primary healthcare units and hospitals during pregnancy and childbirth, and by trained dentists when the children were 4 years old. A total of 3,644 mothers and 3,645 babies were included in the study, which evaluated the association between systemic diseases, maternal physical activity, weight gain during pregnancy, and the oral health of four-year-old children enrolled in the 2015 Pelotas Birth Cohort (Brazil). Exposure variables included systemic diseases, maternal physical activity, and gestational weight gain. Outcome variables were dental caries and caries experience in four-year-old children, assessed using the ICDAS index. Statistical analyses were performed using the Stata 15 software, and they included Pearson's chi-square test and Poisson regression to estimate prevalence ratios and their respective 95% confidence intervals. Excessive weight gain during pregnancy was associated with a higher risk of dental caries in children (PR: 1.12; 95%CI: 1.01-1.23). Maternal physical activity before or during pregnancy was considered a protective effect against dental caries in the unadjusted analysis ([RP: 0.82; 95%CI: 0.71-0.93] [RP: 0.60; 95%CI 0.44-0.81]), respectively, but this association was no longer significant after adjusting for confounding factors. The presence of maternal systemic diseases during pregnancy was not associated with childhood caries. In conclusion, maternal systemic diseases during pregnancy were not associated with dental caries in children. On the other hand, an excessive increase in maternal weight during pregnancy was associated with poorer oral health among children.

Impact of Oral Health Chatbot With and Without Toothbrushing Training on Childhood Caries

OBJECTIVES

Standalone oral health chatbots targeting young children's oral health are rare. The aim of this research was to compare the effectiveness of a standalone chatbot and a combination chatbot with in-person toothbrushing training for caregivers in improving young children's oral health.

METHODS

A randomised, parallel, 2-group pretest-posttest design was employed with 320 caregiver-child pairs (aged 6-42 months). Group I (160 pairs) used the 21-Day FunDee (modified) chatbot along with in-person toothbrushing training, whilst Group II (160 pairs) used only the 21-Day FunDee Plus chatbot. Oral examination assessed plaque levels and caries, whilst a self-administered questionnaire evaluated oral hygiene care, dietary practices, and oral health perceptions based on the protection motivation theory (PMT). Data were analysed using 2-way repeated-measures analysis of variance, a t test, and chi-square measures for group comparisons.

RESULTS

The majority of caregivers were Muslim mothers. No significant differences were observed between groups at the baseline, 3-month, and 6-month follow-ups in mean dmft (Group I: 4.16, 4.64, and 5.30 vs Group II: 4.30, 5.54, and 5.82), mean plaque scores (Group I: 0.72, 0.53, and 0.55 vs Group II (0.84, 0.52, and 0.59), and most dietary habits. However, significant improvements were found within groups from baseline to follow-ups in plaque reduction, toothbrushing practices, overall knowledge score, PMT perceptions, proper tooth brushing, fluoride toothpaste usage, and dietary behaviours (frequency of bottle feeding, frequency of nocturnal bottle feeding, proportion of children who went to bed without consuming anything after cleaning their teeth before bedtime). The significant differences between groups were found in self-efficacy at all time points, but only at the 6-month evaluation for percentage of fluoride toothpaste and overall PMT perceptions.

CONCLUSIONS

Both interventions were comparable in preventing caries, reducing plaque, improving feeding practices, increasing parental involvement in tooth brushing, and enhancing knowledge. The standalone chatbot 21-Day FunDee Plus presents a viable alternative for promoting oral health in young children.

Exploring barriers and facilitators to water availability and accessibility, and potential strategies for improving water accessibility and children's intake in family childcare homes: a qualitative study

Background

Children in the U.S. drink too little water and too much juice and sugar sweetened beverages. Inadequate access to drinking water in locations where children spend substantial time, like family childcare homes (FCCH) could play a role in low child water intake. The aim of this qualitative study was to explore barriers and facilitators to water availability and accessibility in FCCH, and determine potential strategies for facilitating water accessibility and children's intake in FCCH.

Methods

We conducted virtual interviews, in Spanish and/or English, with family child care providers (FCCP) from Rhode Island, Connecticut, and Massachusetts. Interviews were conducted by University of Connecticut graduate students, including two who were fluent in Spanish and English. These were audio-recorded, transcribed verbatim, and translated to English. We conducted a deductive analysis using a priori themes. Additional codes were developed and applied to capture emerging themes from the qualitative data.

Results

Twenty FCCP (100% identified as female; 50% as Latina) participated in the interviews. FCCP barriers to water availability at FCCH included focus on other beverages, e.g., milk; confusion with the Child and Adult Care Food Program (CACFP) guidelines regarding water, and concerns about: water quality, mess, children eating enough food/milk, bathroom accidents, and cost for filters/bottled water. Barriers to children drinking water included: children not liking or preferring water, parental preferences/role modeling, and parental concerns about water quality. Suggested potential strategies to facilitate water access and intake included water filters to ensure safe water access, self-serving stations and water bottles to encourage autonomy among children, and incorporating water into daily routines. Participants also favored materials and activities to educate and encourage children to drink water and to keep track of their intake.

Conclusion

These findings suggest that interventions to increase water consumption at FCCH should provide resources to guarantee safe water access to children, encourage children to drink water, and help clarify misperceptions and confusion around CACFP beverage guidelines. Future research should evaluate the effectiveness of interventions to provide education and water access resources to FCCP and families on improving child water access, availability and intake.

Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries

BACKGROUND

Dental caries, a common chronic disease of childhood, is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC). This review updates one published in 2019.

OBJECTIVES

To assess the effects of interventions undertaken with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years).

SEARCH METHODS

We searched Cochrane Oral Health's Trials Register, Cochrane Pregnancy and Childbirth's Trials Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL EBSCO, the US National Institutes of Health Ongoing Trials Register (clinicaltrials.gov) and WHO International Clinical Trials Registry Platform (apps.who.int/trialsearch). The latest searches were run on 3 January, 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing interventions with pregnant women, or new mothers and other primary caregivers of infants in the first year of life, against standard care, placebo or another intervention, reporting on a primary outcome: caries presence in primary teeth, dmfs (decayed, missing, filled primary surfaces index), or dmft (decayed, missing, filled teeth index), in children up to six years of age. Intervention types include clinical, oral health promotion/education (hygiene education, breastfeeding and other dietary advice) and policy or service.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence (GRADE).

MAIN RESULTS

We included 23 RCTs (5 cluster-randomised), involving 25,953 caregivers (mainly mothers) and their children. Fifteen trials assessed oral health education/promotion interventions against standard care. Six trials assessed a clinical intervention for mother dentition, against placebo, or a different type of clinical intervention. Two trials assessed oral health/education promotion plus clinical intervention (for mother's dentition) against standard care. At most, five trials (maximum of 1326 children and 130 mothers) contributed data to any comparison. Enamel-only caries were included in the diagnosis of caries in some studies. For many trials, the risk of bias was unclear due to lack of methodological details reported. In thirteen trials, participants were socioeconomically disadvantaged. No trial indicated receiving funding that was likely to have influenced their results. Oral health education/promotion interventions Child diet and feeding practice advice versus standard care: We observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a slightly lower mean dmfs (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, the evidence is very uncertain regarding the difference between groups in mean dmft (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence). Breastfeeding promotion and support versus standard care: We observed little or no difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence) and in mean dmft (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). dmfs was not reported. Child diet advice compared with standard care: We are very uncertain about the effect on the risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). dmfs and dmft were not reported. Oral hygiene, child diet and feeding practice advice versus standard care: The evidence is very uncertain about the effect on the risk of caries presence in primary teeth (RR 0.73, 95% CI 0.50 to 1.07; 5 trials; 1326 participants; very low-certainty evidence) and there maybe little to no difference in mean dmfs (MD -0.87, 95% CI -2.18 to 0.43; 2 trials; 657 participants; low-certainty evidence) and mean dmft (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; low-certainty evidence). High-dose versus low-dose vitamin D supplementation during pregnancy: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.99, 95% CI 0.70 to 1.41; 1 trial; 496 participants; very low-certainty evidence). dmfs and dmft were not reported. Clinical interventions (for mother dentition) Chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo: We are very uncertain regarding the difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment for mother dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trial reported dmfs or dmft. Xylitol compared with CHX antimicrobial treatment: We are very uncertain about the effect on caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence), but we observed there may be a lower mean dmft with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence). No trial reported dmfs. Oral health education/promotion plus clinical interventions (for mother dentition) Diet and feeding practice advice for infants and young children plus basic dental care for mothers compared with standard care: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.44, 95% CI 0.05 to 3.95; 2 trials, 324 participants; very low-certainty evidence) or on mean dmft (1 study, not estimable). No trial reported dmfs. No trials evaluated policy or health service interventions.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very-low certainty and is insufficient for determining which, if any, other intervention types and features may be effective for preventing ECC, and in which settings. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine the effects and relative effects of different interventions and inform practice. We have identified 13 ongoing studies. Future studies should consider if and how effects are modified by intervention features and participant characteristics (including socioeconomic status).

A randomized controlled trial of 6-month dental home visits on 24-month caries incidence in preschool children

OBJECTIVES

This paper reports on the effect of 6-month dental home visits compared to no dental home visits on 24-month caries incidence in 5- to 6-year-olds.

METHODS

5- to 6-year-olds attending kindergartens were randomized to receive either 6-month dental home visits and education leaflets (Intervention group) or education leaflets alone (Control group) over 24 months. To detect a 15% difference in caries incidence with a significance level of 5% and power of 80%, 88 children were calculated to be needed in the Intervention group and 88 in the Control. Baseline clinical data included oral examinations at the kindergartens. Follow-up visits were made on the 6th, 12th and 18th month. At the end of the 24 months, both the Intervention and Control groups were visited for oral examinations. The primary outcome was caries incidence, measured by the number and proportion of children who developed new caries in the primary molars after 24 months. The secondary outcome was the number of primary molars that developed new caries (d-pms). Frequency distributions of participants by baseline socio-demographic characteristics and caries experience were calculated. The chi-square test was used to test differences between the caries experience in the Intervention and Control groups. The t test was used to compare the mean number of primary molars developing new caries between the Intervention Group and the Control Group. The number of children needed to treat (NNT) was also calculated.

RESULTS

At the 24-month follow-up, 19 (14.4%) developed new caries in the Intervention Group, compared to 60 (60.0%) in the Control Group (p = .001). On average, 0.2 (95% CI = 0.1-0.3) tooth per child in the Intervention Group was observed to have developed new caries compared to 1.1 (95% CI = 0.8-1.3) tooth per child in the Control Group (p = .001). The number of children needed to treat (NNT) to prevent one child from developing new caries was 2.2.

CONCLUSIONS

The present study has demonstrated that 6-month home visits to families of 5- to 6-year-olds are effective in caries prevention in 5- to 6-year-olds of low-income families in a middle-income country where access to health services, including oral health promotion services, is limited.

Increasing the Awareness of Pediatric Nurses about the Protection and Continuity of the Oral and Dental Health of Children

Objectives: To provide pediatric nurses with knowledge and skills on oral and dental health and to increase their awareness. Material and Methods: In the first phase of the study, pre-tests were given to pediatric nurses in Trabzon and Rize central and district hospitals. A Whatsapp group was created with the nurses who completed the tests, and the training video prepared by the researcher was shared. In the second phase of the study, the same questions were applied again as the post-test. Jamovi (Version 1.0.4) software was used for statistical analysis. P < 0.05 was accepted as statistically significant in all analyses. Results: Of the 91 nurses who completed both the pre-test and the post-test, 83 (91.2%) were female and 8 (8.8%) were male. In all sections in the test category consisting of six different sections (Tooth Decay, Risk Factors in Dental Caries, Prevention of Dental Caries, Oral and Dental Injuries, Children with Special Care Needs, What to Do - How to do?), the success rate was significantly higher in the post-test ( p < 0.001). Conclusion: Research emphasizes that neonatal nurses, pediatric nurses and health professionals working in community health centers should be activated and empowered in order to prevent oral and dental health problems of children, and awareness should be increased with scientifically valid educational guidelines. The results of the present study support these views and emphasize the importance of education by showing significant improvement with the training provided to nurses who had insufficient knowledge and awareness about the subject. Amaç: Pediatri hemşirelerine ağız ve diş sağlığı konusundaki bilgi ve beceriyi kazandırmak ve onların farkındalıklarını artırmaktır. Gereç ve Yöntemler: Araştırmanın birinci aşamasında, Trabzon ve Rize merkez ve ilçe hastanelerindeki pediatri servis hemşirelerine ön test soruları verildi. Testi cevaplayan hemşirelerle oluşturulan Whatsapp grubunda, tarafımca hazırlanan eğitim videosu paylaşıldı. İkinci aşamada; ön test sorularının aynısı, son test olarak tekrar uygulandı. İstatistiksel analiz için Jamovi (Sürüm 1.0.4) yazılımı kullanıldı. İstatistiksel anlamlılık için olasılık seviyesi p = 0,05 olarak belirlendi. Bulgular: Hem ön test hem de son testi cevaplayan 91 hemşirenin 83’ ü (91.2%) kadın, 8’i (8.8%) erkekti. Altı farklı bölümden oluşan test kategorisindeki tüm bölümlerde ( Diş Çürüğü, Diş Çürüklerinde Risk Faktörleri, Diş Çürüğünün Önlenmesi, Ağız ve Diş Yaralanmaları, Özel Bakım İhtiyacı Olan Çocuklar, Ne Yapmalı - Nasıl Yapılır?) eğitim sonrası yapılan son testteki başarı oranı anlamlı ölçüde artmıştı (p

Oral Health Coaches at Well-Baby Clinics to Promote Oral Health in Preschool Children From the First Erupted Tooth: Protocol for a Multisite, Pragmatic Randomized Controlled Trial

Background

Early childhood caries is considered one of the most prevalent diseases in childhood, affecting almost half of preschool-age children globally. In the Netherlands, approximately one-third of children aged 5 years already have dental caries, and dental care providers experience problems reaching out to these children.

Objective

Within the proposed trial, we aim to test the hypothesis that, compared to children who receive usual care, children who receive the Toddler Oral Health Intervention as add-on care will have a reduced cumulative caries incidence and caries incidence density at the age of 48 months.

Methods

This pragmatic, 2-arm, individually randomized controlled trial is being conducted in the Netherlands and has been approved by the Medical Ethics Research Board of University Medical Center Utrecht. Parents with children aged 6 to 12 months attending 1 of the 9 selected well-baby clinics are invited to participate. Only healthy children (ie, not requiring any form of specialized health care) with parents that have sufficient command of the Dutch language and have no plans to move outside the well-baby clinic region are eligible. Both groups receive conventional oral health education in well-baby clinics during regular well-baby clinic visits between the ages of 6 to 48 months. After concealed random allocation of interventions, the intervention group also receives the Toddler Oral Health Intervention from an oral health coach. The Toddler Oral Health Intervention combines behavioral interventions of proven effectiveness in caries prevention. Data are collected at baseline, at 24 months, and at 48 months. The primary study endpoint is cumulative caries incidence for children aged 48 months, and will be analyzed according to the intention-to-treat principle. For children aged 48 months, the balance between costs and effects of the Toddler Oral Health Intervention will be evaluated, and for children aged 24 months, the effects of the Toddler Oral Health Intervention on behavioral determinants, alongside cumulative caries incidence, will be compared.

Results

The first parent-child dyads were enrolled in June 2017, and recruitment was finished in June 2019. We enrolled 402 parent-child dyads.

Conclusions

All follow-up interventions and data collection will be completed by the end of 2022, and the trial results are expected soon thereafter. Results will be shared at international conferences and via peer-reviewed publication.

Trial Registration

Netherlands Trial Register NL8737; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8737

International Registered Report Identifier (IRRID)

DERR1-10.2196/39683

Attitude of Midwives towards Fluoride Recommendations and Oral Prevention in Infants and Young Children

Early childhood caries is a challenge. Early dental screening flanked by multidisciplinary preventions by pediatricians, dentists, and midwives (MWs) may be helpful. New recommendations for dental screening in children (FUs) and fluoride have been introduced in Germany. The aim of this study was to investigate whether midwives consider FUs useful and implement early childhood caries prevention, as well as fluoride recommendations. The survey was conducted using an online questionnaire. Demographic data, including 11 items on early childhood dental prophylaxis and fluoride, were requested. Agreement was recorded using Likert scales. The data were analyzed descriptively. Two hundred and seventeen female MWs participated (age: 44.1 (11.04) years). One hundred and four (47.9%) participants knew about the FUs. Of the MWs, 30.7% found a referral from the first tooth to be very important (important/neutral/unimportant: 27%/27.9%/14.4%), compared with 84.8% for the entire primary dentition (11.8%/2.8%/0.5%). Of the MWs, 41.7% always recommended fluoride toothpaste from the first tooth (often/occasionally/rarely/never: 22.7%/12.4%/7.9%/15.3%) and 48.1% completely rejected fluoride-free toothpaste (always/often/occasionally/rarely: 9.8%/8.9%/17.3%/15.9%). In addition, 54.8% never recommended the use of fluoride tablets (always/often/occasionally/rarely: 9.2%/7.4%/10.2%/18.4%). The FUs are not yet well-known among MWs, and only less than one-third recommended dental check-ups, starting with the first tooth. This contrasts with the high uptake of fluoridated toothpaste. More educational work should be carried out to convince more MWs of the benefits of the FUs.

Dental care utilization during pregnancy by Medicaid dental coverage in 26 states: Pregnancy risk assessment monitoring system 2014-2015

OBJECTIVE

To examine the association between Medicaid dental coverage for adult pregnant women with dental care utilization during pregnancy.

METHODS

Pregnancy risk assessment monitoring system (PRAMS) data (2014-2015) and the Medicaid-SCHIP state dental association (MSDA) national profiles (2014-2015) were used in this study. The study sample included 16,612 Medicaid-enrolled women, for a weighted number of 965,046 women from 26 states and New York City. State Medicaid dental coverage was categorized into (1) no coverage for the dental cleaning, (2) coverage for dental cleaning and fillings, (3) extended dental coverage. The adjusted prevalence ratios (aPR) for dental visits for cleaning during pregnancy were examined by Medicaid dental coverage level.

RESULTS

Medicaid-enrolled women in states with no dental coverage were less likely to visit dentists for cleaning during pregnancy (26.7%) compared with women in states with either limited dental coverage (36.6%) or extended dental coverage (44.9%). Compared with women in state without dental coverage, Medicaid-enrolled women in states with extended dental coverage (aPR = 1.20, 95% CI [1.16-1.23]) and women in states with limited coverage (aPR = 1.10, 95% CI [1.06-1.14]) were more likely to visit dentists for cleaning during pregnancy when adjusted for other sociodemographic variables and adequacy of prenatal care. A similar pattern of association was observed for a dental visit to address dental problems during pregnancy.

CONCLUSIONS

This study highlights the importance of Medicaid dental coverage for adult pregnant women related to dental service utilization during pregnancy.

Community interventions and strategies for caries control in Latin American and Caribbean countries

Dental caries remains highly prevalent in Latin American and Caribbean countries (LACC). However, this disease can be controlled through interventions that implement evidence-based strategies in an affordable manner and that target all population groups instead of the most affluent only. Therefore, the aim of this report was to summarize the main scientifically documented community interventions and strategies based on restriction of sugars consumption, use of fluoride, and the use of occlusal sealants for caries control in LACC. A critical literature review was carried out in a systematic manner that included defined search strategies, independent review of the identified publications, and compilation of results in this report. Three systematic searches were conducted using the PubMed, LILACS, and SciELO databases to identify studies related to community interventions and strategies for caries control in LACC. Of the 37 publications identified, twenty-six focused on fluoride use, eight on occlusal sealant use, and three on the restriction of sugar consumption. Documented community interventions for sugars restriction were scarce in the region and were based on food supplementation, sugar replacement, and education. Thus, local and/or national policies should prioritize investment in upstream, coherent, and integrated population-wide policies such as taxes on sugary drinks and stronger regulation of advertising and promotion of sugary foods and drinks mainly targeting children. The main fluoride-based strategies used drinking water, refined domestic salt, cow milk, toothpaste and, to a lesser extent, mouth-rinses, acidulated phosphate fluoride (APF) gels, and varnishes to deliver fluoride to the population. Evidence of fluoride use was seen in Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. Studies reporting the use of occlusal sealants were mainly located in Brazil, Chile, Colombia, Costa Rica, Peru, Mexico, and Venezuela. Community interventions restricting sugar consumption should be implemented at the individual level and through public policies. The use of fluoride must be monitored at the local, regional, and national levels so as to achieve maximum anti-caries effect while also minimizing the risk of dental fluorosis. Moreover, fluoridated water and salt programs, used as a mutually exclusive community level strategy for caries control, should expand their benefits to reach non-covered areas of the LACC while also simultaneously providing adequate surveillance of the fluoride concentration delivered to the population. Regulating the concentration of soluble fluoride (for anti-caries effect) in dentifrice formulations is also necessary in order to provide the population with an effective strategy for disease control. Targeting culturally appropriate, economically sustainable caries control interventions to rural populations and native ethnic groups such as indigenous people, quilombolas (African-origin), and riverside Amazonian people remains a crucial challenge.

Protocol for a family-centered behavioral intervention to reduce early childhood caries: the MySmileBuddy program efficacy trial

BACKGROUND

Although largely preventable through diet management and topical fluoride use, early childhood caries (ECC) often progresses to severity that necessitates surgical repair. Yet repair often fails to mitigate caries progression. Needed is an effective behavioral intervention to address underlying behavioral causes.

METHODS

This randomized controlled trial will evaluate the efficacy of a behaviorally focused, family-centered intervention, the MySmileBuddy Program (MSB Program), to reduce ECC progression in high-risk preschoolers in New York City. Recruitment will target 858 children ages 24-71 months with ECC and their parents from primary care medical and dental clinics. The study aims to assess the MSB Program's efficacy to: (1) decrease ECC progression measured 12-months post-randomization; and (2) enhance adoption of a low cariogenic diet and twice-daily fluoridated toothpaste use compared to control group. Potential causal pathways (mediators and moderators) will be explored. The MSB Program equips community health workers (CHWs) with an app that facilitates multilevel risk assessment and provides motivational interviewing-based counseling to inform parents about the caries process, develop personalized goals, and create family-level action plans to achieve targeted behaviors. Social support from CHWs (4 interactions during the 6-month intervention, supplemented by up to 4 in-person/remote contacts throughout the 12-month study period, based on need) is bolstered by automated text messages. Participants will be randomized to a Control Group (paper-based educational handout plus toothbrushes and fluoridated toothpaste for the child) or Intervention Group (MSB Program, two tooth-brushing observations with feedback and instruction, and toothbrushes and toothpaste for the entire family). All children will receive visual ICDAS dental examinations and parents will complete study measures at baseline and 12-months. An incentive up to $150 plus round-trip transit cards ($5.50 value) will be provided.

DISCUSSION

This study hypothesizes that the MSB Program can reduce ECC progression in a high-risk population. Sufficient incentives and a focus on establishing rapport between participants and CHWs are anticipated to mitigate recruitment and retention challenges. If successful, this study will advance the long-term goal of reducing pediatric oral health disparities by demonstrating the efficacy of an acceptable and feasible intervention that shifts attention from dental repair to behavioral risk mitigation.

TRIAL REGISTRATION

Trial registration was completed on 4/13/2021 through the U.S. National Library of Medicine ClinicalTrials.gov website (Identifier: NCT04845594).

Randomized trial of a photography-aided behavioural intervention to reduce risk factors for caries and malocclusion in high-risk infants

OBJECTIVE

To assess the efficacy of a photography-aided behavioural intervention in reducing risk factors for dental caries and malocclusion in high-risk infants.

MATERIALS AND METHODS

In this randomized trial conducted in a maternity hospital, 55 mothers of recently born infants at high risk of developing oral diseases were allocated to either the intervention (n = 28) or usual care (n = 27). The intervention arm received the same usual care plus an enhanced, behaviour-oriented, photography-aided, two-stage (0 and +6 months) educational programme addressing nutritional, behavioural, lifestyle and familial factors that affect child's oral health. The primary outcome was the proportion of children classified as being at a 'low risk' of developing dental caries at the age of 12 months using a modified score based on the Caries-risk Assessment Form of the American Academy of Pediatric Dentistry. Secondary outcomes included risk factors for malocclusion, such as duration of exclusive breastfeeding, pacifier use and bottle-feeding and/or sippy cup usage.

RESULTS

At 12 months, the proportion of children considered at low risk for dental caries was significantly higher in the intervention group compared to usual care (71% vs 15%, respectively, relative risk = 4.82, 95% confidence interval = 1.89-12.3, p < 0.001). The median duration of exclusive breastfeeding in the intervention group was 1.7 times higher than in the control arm (5 months vs 3 months, p = 0.03).

CONCLUSION

Altogether, our findings provide evidence that a low-cost, two-stage preventive strategy using photographs to deliver a stronger visual impact might significantly reduce the incidence of risk factors for dental caries and malocclusion in 12-month-old children.

Oral Health Birth Cohort Studies: Achievements, Challenges, and Potential

Birth cohorts are those among observational studies that provide understanding of the natural history and causality of diseases since early in life. Discussions during an International Association for Dental Research symposium in London, United Kingdom, in 2018, followed by a workshop in Bangkok, Thailand, in 2019, concluded that there are few birth cohort studies that consider oral health and that a broader discussion on similarities and differences among those studies would be valuable. This article aims to 1) bring together available long-term data of oral health birth cohort studies from the low, middle, and high-income countries worldwide and 2) describe similarities and differences among these studies. This work comprises 15 studies from all 5 continents. The most studied dental conditions and exposures are identified; findings are summarized; and methodological differences and similarities among studies are presented. Methodological strengths and weaknesses are also highlighted. Findings are summarized in 1) the negative impact of detrimental socioeconomic status on oral health changes over time, 2) the role of unfavorable patterns of dental visiting on oral health, 3) associations between general and oral health, 4) nutritional and dietary effects on oral health, and 5) intergenerational influences on oral health. Dental caries and dental visiting patterns have been recorded in all studies. Sources of fluoride exposure have been documented in most of the more recent studies. Despite some methodological differences in the way that the exposures and outcomes were measured, some findings are consistent. Predictive models have been used with caries risk tools, periodontitis occurrence, and permanent dentition orthodontic treatment need. The next steps of the group's work are as follows: 1) establishing a consortium of oral health birth cohort studies, 2) conducting a scoping review, 3) exploring opportunities for pooled data analyses to answer pressing research questions, and 4) promoting and enabling the development of the next generation of oral health researchers.

Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries

BACKGROUND

Dental caries is one of the most common chronic diseases of childhood and is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC).

OBJECTIVES

To assess the effects of interventions with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years of age).

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 January 2019), Cochrane Pregnancy and Childbirth Group's Trials Register (to 22 January 2019), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Register of Studies, to 14 January 2019), MEDLINE Ovid (1946 to 14 January 2019), Embase Ovid (1980 to 14 January 2019) and CINAHL EBSCO (1937 to 14 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing one or more interventions with pregnant women, mothers, or other caregivers of infants in the first year of life (intervention types included clinical, oral health education/promotion such as hygiene education, breastfeeding and other dietary advice, and policy or health service), versus standard care or placebo or another intervention. For inclusion, trials had to report at least one caries outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 17 RCTs (4 cluster-randomised), involving 23,732 caregivers (mainly mothers) and their children. Eleven RCTs assessed four oral health education/promotion interventions against standard care: child diet advice, child diet and feeding practice advice, breastfeeding promotion and support, and oral hygiene with child diet and feeding practice advice. Six trials assessed clinical interventions in mother's dentition, four trials chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo, and two trials xylitol against CHX or CHX + xylitol. At most, three trials (maximum of 1148 children and 130 mothers) contributed data to any comparison. For many trials, risk of bias was judged unclear due to lack of methodological details reported, and there was high risk of attrition bias in some trials. None of the included trials indicated receiving funding that is likely to have influenced their results. The trials were performed in high-, middle- and low-income countries. In nine trials, participants were socioeconomically disadvantaged. For child diet and feeding practice advice versus standard care, we observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a lower mean dmfs (decayed, missing, filled primary surfaces) score (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, we are uncertain regarding the difference between the groups in mean dmft (decayed, missing, filled teeth) score (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence). For breastfeeding promotion and support versus standard care, we observed that there may be little or no a difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence), or mean dmft score (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). Dmfs was not reported for this comparison. We are uncertain whether child diet advice only compared with standard care reduces risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). Dmfs and dmft were not reported for this comparison. For oral hygiene, child diet and feeding practice advice versus standard care, we observed little or no reduced risk of caries presence in primary teeth (RR 0.91, 95% CI 0.75 to 1.10; 2 trials; 365 participants; low-certainty evidence), and are uncertain regarding difference between the groups in mean dmfs score (MD -0.99, 95% CI -2.45 to 0.47; 1 trial; 187 participants; very low-certainty evidence) and dmft score (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; very low-certainty evidence). We observed there may be little or no difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment in mother's dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trials assessing this comparison reported dmfs or dmft. For xylitol compared with CHX antimicrobial treatment, we observed there may be a lower mean dmft score with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence); however, we are uncertain regarding the difference between groups in caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence). Neither trial evaluating this comparison reported dmfs. No trials assessed a health policy or service intervention.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very low certainty and is insufficient for determining which, if any, other interventions types and features may be effective for preventing ECC. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine effects and relative effects of different interventions and inform practice. We have identified 12 studies currently in progress. Those designing future studies should describe the intervention components, setting and participants, consider if and how effects are modified by intervention features and participant characteristics, and adopt a consistent approach to measuring and reporting ECC.

Effectiveness of preventive dental programs offered to mothers by non-dental professionals to control early childhood dental caries: a review

BACKGROUND

Early childhood caries is a common chronic childhood disease and maternal oral health is a risk factor. Improving the oral health behaviours of pregnant women/young mothers can positively influence the oral health of children and reduce their caries risk. Such preventative strategies have been undertaken by non-dental professionals producing mixed results encompassing various interventions across the perinatal period. However, no comprehensive review of these studies has been undertaken. The aim of this review was to assess the effectiveness of maternal oral health programs undertaken during the antenatal and/or postnatal period by non-dental health professionals to reduce early childhood caries.

METHODS

A systematic search of five databases was undertaken using key search terms. Studies were included if they (a) involved quantitative study designs with a control; (b) were published in English; (c) reported on interventions delivered by non-dental professionals (d) delivered the intervention to expectant mothers or mothers with young infants up to 24 months; (e) measured outcomes when the child was under 5 years; (f) measured changes in oral health outcomes of children clinically and oral health behaviours of mothers or children. No restrictions were placed on the study quality and setting.

RESULTS

Nine studies met the inclusion criteria and involved interventions delivered by diverse non-dental professionals across the antenatal (n = 1), postnatal (n = 6) and perinatal period (n = 2). Most studies were of low methodological quality (n = 6). The interventions focussed on oral health education (n = 8), dental referrals (n = 3) and oral health assessments (n = 1). Interventions conducted in either the postnatal or antenatal periods showed meaningful improvements in children's clinical and mother's behavioural oral health outcomes. The outcomes appear to be sustained when a suite of interventions were used along with referral reminders. There were mixed results from interventions across the perinatal period.

CONCLUSIONS

Non-dental professionals can promote maternal oral health by providing oral health education, risk assessment and referrals. Combining these interventions could provide a sustained improvement in oral health outcomes for children although current evidence is weak. More high-quality studies are needed to confirm these findings and determine whether the antenatal and/or postnatal period is best suited to deliver these interventions.

Systematic Review of Evidence Pertaining to Factors That Modify Risk of Early Childhood Caries

INTRODUCTION

A systematic review of evidence on the impact of modifiable risk factors on early childhood caries (ECC) was conducted to inform recommendations in a World Health Organization manual on ECC prevention.

OBJECTIVES

To systematically review published evidence pertaining to the effect of modifiable risk factors on ECC.

METHODS

Twelve questions relating to infant feeding, diet, oral hygiene, and fluoride were addressed, as prioritized by a World Health Organization expert panel. Questions pertaining to the use of fluoride toothpaste were excluded due to its proven efficacy. The target population was children aged <72 mo. Data sources included Medline, Embase, CINAHL, and PubMed, and all human epidemiologic studies were included. The highest level of evidence was used for evidence synthesis and, where possible, meta-analysis. The review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement, with evidence assessed via the GRADE method.

RESULTS

Of the 13,831 papers identified, 627 were screened in duplicate; of these, 139 were included. The highest-level evidence indicated that breastfeeding ≤24 mo does not increase ECC risk but suggested that longer-duration breastfeeding increases risk (low-quality evidence). Low-quality evidence indicated increased risk associated with consumption of sugars in bottles. Only 1 study had data on the impact of sugars in complementary foods, which increased risk. Moderate-quality evidence showed a benefit of oral health education for caregivers (odds ratio, 0.39; 95% CI, 0.19 to 0.80, P = 0.009). Meta-analysis of data on the impact on ECC from living in a fluoridated area showed a significant effect (mean difference, -1.25; 95% CI, -1.24 to -0.36; P = 0.006). Limited moderate- and low-quality data indicated a benefit of fluoride exposure from salt and milk, respectively.

CONCLUSION

The best available evidence indicates that breastfeeding up to 2 y of age does not increase ECC risk. Providing access to fluoridated water and educating caregivers are justified approaches to ECC prevention. Limiting sugars in bottles and complementary foods should be part of this education.

KNOWLEDGE TRANSFER STATEMENT

This research is being used by the World Health Organization in developing a toolkit on the prevention and management of early childhood caries. The information will guide 1) governments in developing national oral health plans and 2) clinicians when providing preventive advice, including that regarding infant feeding practices. It will help ensure that advice is in line with current World Health Organization guidelines and the best available evidence.

Early Childhood Caries

Early childhood caries (ECC) is a common childhood disease with highest prevalence found in poor, socially disadvantaged, and minority groups. The main risk factors for ECC are frequent sugar consumption, lack of tooth brushing, and enamel hypoplasia. Contributory factors include environmental and psychosocial stresses that modify caregiver behaviors. Strategies for prevention include preventing mutans streptococci transmission, restricting dietary sugars, tooth brushing, topical fluoride applications, and early dental examinations. This article provides an overview of ECC based on current understanding of its cause, prevention, and management.

Integrated Interventions Delivered in Health Systems, Home, and Community Have the Highest Impact on Breastfeeding Outcomes in Low- and Middle-Income Countries

Background: Improving breastfeeding rates is critical. In low- and middle-income countries (LMICs), only subtle improvements in breastfeeding rates have been observed over the past decade, which highlights the need for accelerating breastfeeding promotion interventions.Objective: The objective of this article is to update evidence on the effect of interventions on early initiation of and exclusive (<1 and 1-5 mo) and continued (6-23 mo) breastfeeding rates in LMICs when delivered in health systems, in the home or in community environments, or in a combination of settings.Methods: A systematic literature search was conducted in PubMed, Cochrane, and CABI databases to identify new articles relevant to our current review, which were published after the search date of our earlier meta-analysis (October 2014). Nine new articles were found to be relevant and were included, in addition to the other 52 studies that were identified in our earlier meta-analysis. We reported the pooled ORs and corresponding 95% CIs as our outcome estimates. In cases of high heterogeneity, random-effects models were used and causes were explored by subgroup analysis and meta-regression.Results: Early initiation of and exclusive (<1 and 1-5 mo) and continued (6-23 mo) breastfeeding rates in LMICs improved significantly as a result of interventions delivered in health systems, in the home or community, or a combination of these. Interventions delivered concurrently in a combination of settings were found to show the largest improvements in desired breastfeeding outcomes. Counseling provided in any setting and baby-friendly support in health systems appear to be the most effective interventions to improve breastfeeding.Conclusions: Improvements in breastfeeding practices are possible in LMICs with judicious use of tested interventions, particularly when delivered in a combination of settings concurrently. The findings can be considered for inclusion in the Lives Saved Tool model.

Do Preschools Offer Healthy Beverages to Children? A Nationwide Study in Poland

Background: Children’s beverage consumption patterns have received increased attention in light of the obesity epidemic in this group. In day care centers (DCCs), children spend up to 10 h a day, and typically consume half to three quarters of their daily food intake. The purpose of the study was to investigate what beverages are typically served to children in preschools in Poland, and to evaluate the practices associated with adding sugar and other sweetening agents to beverages. Methods: Direct interviews with preschools staff were conducted with a questionnaire regarding offered beverages and adding sugar and other sweetening agents. The menu of 10 consecutive days and inventory reports were analyzed to verify information. Results: A total of 720 preschools were included in the study. Cocoa and milk coffee substitute were served in 95% of preschools, followed by compote (92%), tea (84%), fruit/herbal tea (73%) and water (69%). Water was the only beverage available between meals (93% DCCs). 86% of preschools added sugar to tea/cocoa/coffee substitute drinks, and 74% to compote. Conclusions: In the majority of preschools, beverages which are not recommended were offered. Such an assortment of beverages and common practice of sweetening can increase the amount of added sugar in a children diet. Nutrition education and legal regulations concerning the assortment of beverages served in preschools are urgently needed.

WITHDRAWN: Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Integrating Maternal and Children's Oral Health Promotion into Nursing and Midwifery Practice- A Systematic Review

BACKGROUND

Globally, oral diseases contribute to major disease problems and oral health disparities persistently exist amongst vulnerable population groups. Two contributory factors to these challenges are the shortage of dental practitioners and the characteristic separation between the medical and dental professions. Nurses and midwives, in particular, are in a potentially excellent position to assist in basic oral health services such as dental health education and intraoral screening. We aimed to assess the effectiveness of integrating promotion of oral health of young children and their mothers into nursing and midwifery practice.

METHODS AND FINDINGS

Seven electronic databases including CENTRAL, EMBASE, MEDLINE, GLOBAL HEALTH, CINHAL, Scopus, and Web of Science were systematically searched whereas conference proceedings and theses were retrieved via PROQUEST. Only randomized, non-randomized trials and observational studies on preventive oral health programs delivered by nurses or midwives in healthcare settings or through home visits were included. Two investigators reviewed full-text articles independently to decide on eligibility for inclusion. Quality assessment was done using Cochrane tool for risk of bias for randomized trials and Downs and Black assessment tool for all other studies. Out of 3162 retrieved records, twenty one trials on oral health interventions incorporated into standard nursing practice were reviewed. Eighteen programs reported significant positive outcomes including reduction in caries experience, better oral hygiene and dietary habits and increased rates of dental visits amongst young children as reported by their caregivers.

CONCLUSIONS

Incorporating oral health promotion into nursing practice is a promising initiative for reducing oral health disparities by contributing to a downward trend in caries experience and increased access to dental care especially amongst the poor disadvantaged communities.

Dental knowledge of educators and healthcare providers working with children with autism spectrum disorders

OBJECTIVES

To evaluate dental knowledge and attitudes toward oral health care among healthcare providers and educators working with children with autism spectrum disorders (ASD) in central Saudi Arabia.  

METHODS

 There were 305 questionnaires distributed to 7 special-needs centers between September and November 2014. A total of 217 questionnaires were collected with a response rate of 71.1%. The study took place in the College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia. 

RESULTS

Approximately 50.2% of the participants did not offer any toothbrushing advice, and 73.3% never recommended dental checkup visits to parents, and 75.6% never performed dental examinations to children under their care. Ten percent thought that children should have their first dental visit after 6 years of age. Almost all participants agreed that children should practice oral hygiene, and 60.4% think they should brush twice per day. In general, the participants choose toothbrushes and toothpaste as the main tools to perform oral hygiene. There were 35% of participants who believed that parents should be responsible for the children's oral hygiene, and a few participants mentioned teachers and therapists to be responsible. Most of the participants (71.4%) did not receive any dental information from dental professional resources, only 14.3% of participants believed bacteria to be the cause of dental cavities.  

CONCLUSION

There is a clear lack of dental knowledge and attitudes, and its practical application among the participating group of healthcare providers working with children with ASD in Riyadh.

Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Factors affecting children's adherence to regular dental attendance: a systematic review

BACKGROUND

Parents' adherence to regular dental attendance for their young children plays an important role in improving and maintaining children's oral health. The authors conducted a systematic review to determine the factors that influence parental adherence to regular dental attendance for their children.

TYPE OF STUDIES REVIEWED

The authors searched nine electronic databases to May 2013. They included quantitative and qualitative studies in which researchers examined factors influencing dental attendance in children 12 years or younger. The authors considered all emergency and nonemergency visits. They appraised methodological quality through the Health Evidence Bulletins Wales methodological quality assessment tool.

RESULTS

The authors selected 14 studies for the systematic review. Researchers in these studies reported a variety of factors at the patient, provider and system levels that influenced dental attendance. Factors identified at the patient level included parents' education, socioeconomic status, behavioral beliefs, perceived power and subjective norms. At the provider level, the authors identified communication and professional skills. At the system level, the authors identified collaborations between communities and health care professionals, as well as a formal policy of referring patients from family physicians and pediatricians to dentists.

PRACTICAL IMPLICATIONS

Barriers to and facilitators of parents' adherence to regular dental attendance for their children should be identified and considered when formulating health promotion policies. Further research is needed to investigate psychosocial determinants of children's adherence to regular dental visits.

Monitoring of caries disease by risk assessments and activity

ABSTRACT Dental caries is a non-communicable disease and is considered a public health problem. For diagnosis and correct treatment, the study of risk assessment and caries activity is necessary. The caries risk assessment is a way to formalize the balance and imbalance of predictably disease to diagnose dental caries. Therefore, the caries risk assessment is performed through different evaluation systems. Another parameter of great importance to be studied is the activity of caries, because through it is done the correct treatment decision for the patient. The objective of this article is to inform the reader about: the concepts and caries risk factors; the different caries risk assessment systems described in the literature; and which systems are validated. In addition, this literature review provides for identification and evaluation of risk factors and activity of caries lesions in order to enable greater objectivity in the diagnosis and facilitate the decisions of a successful treatment.

Role of saliva proteinase 3 in dental caries

Salivary analysis can be used to assess the severity of caries. Of the known salivary proteins, a paucity of information exists concerning the role of proteinase 3 (PR3), a serine protease of the chymotrypsin family, in dental caries. Whole, unstimulated saliva was collected from children with varying degrees of active caries and tested using a Human Protease Array Kit and an enzyme-linked immunosorbent assay. A significantly decreased concentration of salivary PR3 was noted with increasing severity of dental caries (P<0.01); a positive correlation (r=0.87; P<0.01; Pearson's correlation analysis) was also observed between salivary pH and PR3 concentration. In an antibacterial test, a PR3 concentration of 250 ng·mL⁻¹ or higher significantly inhibited Streptococcus mutans UA159 growth after 12 h of incubation (P<0.05). These studies indicate that PR3 is a salivary factor associated with the severity of dental caries, as suggested by the negative relationship between salivary PR3 concentration and the severity of caries as well as the susceptibility of S. mutans to PR3.

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis

AIM

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

METHODS

Of 23977 titles identified through a systematic literature search in PUBMED, Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the pooled relative risk and corresponding 95% confidence intervals as our outcome estimate. In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-regression and applied random effects model.

RESULTS

Intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

CONCLUSION

To promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment concurrently.

Breastfeeding and the risk of dental caries: a systematic review and meta-analysis

AIM

To synthesise the current evidence for the associations between breastfeeding and dental caries, with respect to specific windows of early childhood caries risk.

METHODS

Systematic review, meta-analyses and narrative synthesis following searches of PubMed, CINAHL and EMBASE databases.

RESULTS

Sixty-three papers included. Children exposed to longer versus shorter duration of breastfeeding up to age 12 months (more versus less breastfeeding), had a reduced risk of caries (OR 0.50; 95%CI 0.25, 0.99, I(2) 86.8%). Children breastfed >12 months had an increased risk of caries when compared with children breastfed <12 months (seven studies (OR 1.99; 1.35, 2.95, I(2) 69.3%). Amongst children breastfed >12 months, those fed nocturnally or more frequently had a further increased caries risk (five studies, OR 7.14; 3.14, 16.23, I(2) 77.1%). There was a lack of studies on children aged >12 months simultaneously assessing caries risk in breastfed, bottle-fed and children not bottle or breastfed, alongside specific breastfeeding practices, consuming sweet drinks and foods, and oral hygiene practices limiting our ability to tease out the risks attributable to each.

CONCLUSION

Breastfeeding in infancy may protect against dental caries. Further research needed to understand the increased risk of caries in children breastfed after 12 months.

Evaluation of a feasible educational intervention in preventing early childhood caries

Early childhood caries (ECC) in the primary dentition of preschoolers remains high. Young children have limited access to oral healthcare, and oral health education (OHE) measures can be a valuable tool to prevent caries in this population. The aim of this study was to evaluate the impact of an early educational intervention on ECC prevention. The study group (SG) comprised 271 children aged 0-12 months and their mothers, who attended 12 selected public health centers (PHC). The SG received oral health instructions from a pamphlet and by verbal explanation of some topics. One year later, a similar sample of children from another 12 PHCs were selected to serve as the control (CG; n = 251). The children were examined to determine their caries status: decayed = cavitated and/or white spot lesion (maxillary anterior surface); missing; and filled surface index > 0. There was a one-year follow-up. Socioeconomic and demographic information was collected. Logistic regression was used to estimate the effects of the educational intervention on the ECC odds. A sample of 445 (SG = 194 and CG = 251) children remained to the end of the study and were examined. The prevalence of caries was 12.9% in the SG and 17.9% in the CG. The odds of caries were 80% higher in the CG than in the SG (p = 0.037). The strategy of providing OHE from a pamphlet and with a brief verbal instruction to mothers during their child's first year of life can constitute a valuable tool for ECC prevention.

Evaluating the effectiveness of oral health education program among mothers with 6-18 months children in prevention of early childhood caries

Background:

Mothers play a key role as transmitters of oral health behavior for their children. Hence increasing their knowledge about positive attitude toward desirable oral health behaviors regarding their children will lead to the better oral health of the children.

Aim:

The aim was to evaluate the effectiveness of oral health education program among mothers with 6-18 months old children in the prevention of early childhood caries.

Materials and Methods:

A total of 480 mothers with 6-18 months old children were selected using cluster randomization of the primary health center. The allocated mothers were assigned into three groups: Motivation group (group A), traditional health education group (group B) and control group (group C). Clinical examination was carried out to record the dental decay of the child.

Statistical Analysis:

The data was analyzed using SPSS 13. Evaluation of statistical significance between groups was made using the Chi-square test, ANOVA and Kruskal-Wallis.

Results:

Mean number of decayed teeth was 0.23 + 0.58 in group A that was significantly less as compared to 0.39 + 0.79 and 1.17 + 1.32 in group B and C, respectively.

Conclusion:

Motivational intervention was more effective in reducing dental decay in the children as compared to the other two groups.

Knowledge and behaviour of parents in relation to the oral and dental health of children aged 4-6 years

AIM

To evaluate baseline knowledge and behaviour of parents with regard to the oral and dental health of their young children.

METHODS

Following ethical approval, six urban and rural schools were identified. Questionnaires were distributed to the parents of pupils (children aged 4-6 years). The questionnaire included several questions evaluating parental knowledge and behaviour of oral and dental health issues in their children. Each question was assigned a score of either 0 or 1 being inconsistent or consistent with current paediatric guidelines giving a maximum score of 6 for knowledge and 7 for behaviour. Chi-square analysis was used to analyse associations among variables.

RESULTS

Parental knowledge varied widely among parents and across questions; however, 70.2 % of parents had scores greater than 3 (range 0-6). The majority of parents (65.8 %) also had scores greater than 3 (range 0-7) for behaviour. Deficiencies were noted in oral hygiene practices; very few parents brushed their child's teeth and were not aware of the recommended age of the first dental visit at 1 year (Age 1 visit). Parents without free medical care demonstrated high levels of knowledge (P < 0.05). Almost half of the parents thought that the information available to them on the oral health of their young children was insufficient.

CONCLUSION

Parents appeared to have limited knowledge regarding the dental and oral health of their young children. This study indicates a need for improved education for parents, particularly in toothbrushing behaviour and use of toothpaste. Education strategies tailored to the Irish population should be explored.

Babies, soft drinks and snacks: a concern in low- and middle-income countries?

Undernutrition in infants and young children is a global health priority while overweight is an emerging issue. Small-scale studies in low- and middle-income countries have demonstrated consumption of sugary and savoury snack foods and soft drinks by young children. We assessed the proportion of children 6-23 months of age consuming sugary snack foods in 18 countries in Asia and Africa using data from selected Demographic and Health Surveys and household expenditures on soft drinks and biscuits using data from four Living Standards Measurement Studies (LSMS). Consumption of sugary snack foods increased with the child's age and household wealth, and was generally higher in urban vs. rural areas. In one-third of countries, >20% of infants 6-8 months consumed sugary snacks. Up to 75% of Asian children and 46% of African children consumed these foods in the second year of life. The proportion of children consuming sugary snack foods was generally higher than the proportion consuming fortified infant cereals, eggs or fruit. Household per capita daily expenditures on soft drinks ranged from $0.03 to $0.11 in three countries for which LSMS data were available, and from $0.01 to $0.04 on biscuits in two LSMS. Future surveys should include quantitative data on the purchase and consumption of snack foods by infants and young children, using consistent definitions and methods for identifying and categorising snack foods across surveys. Researchers should assess associations between snack food consumption and stunting and overweight, and characterise household, maternal and child characteristics associated with snack food consumption.

Primary care nurses' awareness of and willingness to perform children's oral health care

BACKGROUND

The majority of young children receive no early dental examination while attending primary health care for routine check-ups. Our aim was to study primary care nurses' knowledge of oral health care (OHC) and their attitudes toward delivering OHC, as well as to assess their willingness to obtain OHC information.

METHODS

We conducted a cross-sectional survey of all primary-care nurses working in the public health centres of Tehran city. An anonymous self-administered questionnaire queried their knowledge in paediatric-, general and medicine-related areas of dentistry, providing knowledge scores for three domains. The nurses' attitudes toward OHC and their willingness to obtain OHC information underwent evaluation with statements utilizing a five-point Likert scale. Altogether 680 nurses took part in the survey. The Chi-square test, t-test, one-way ANOVA and logistic regression model served for statistical analyses.

RESULT

The mean score for the paediatric dentistry domain (3.6, SD: 1.5) was lower than for the medical (4.4, SD: 2.3) and dental domains (5.8, SD: 1.5). Obtaining higher scores in the paediatric (OR = 1.2) and dental (OR = 1.3) domains, and a greater willingness to receive OHC information (OR = 5.3), were associated with a positive attitude toward OHC. Nurses with a lower education (OR = 1.9) and better oral health behaviour (OR = 1.1) as well as those working in a non-affluent region (OR = 1.6) had a more positive attitude toward OHC.

CONCLUSION

Primary care nurses' low level of knowledge in OHC and their positive attitude and willingness to obtain more information point to the need for appropriate OHC training and encouragement for the nurses to promote oral health and prevent dental diseases.

An exploratory trial implementing a community-based child oral health promotion intervention for Australian families from refugee and migrant backgrounds: a protocol paper for Teeth Tales

INTRODUCTION

Inequalities are evident in early childhood caries rates with the socially disadvantaged experiencing greater burden of disease. This study builds on formative qualitative research, conducted in the Moreland/Hume local government areas of Melbourne, Victoria 2006-2009, in response to community concerns for oral health of children from refugee and migrant backgrounds. Development of the community-based intervention described here extends the partnership approach to cogeneration of contemporary evidence with continued and meaningful involvement of investigators, community, cultural and government partners. This trial aims to establish a model for child oral health promotion for culturally diverse communities in Australia.

METHODS AND ANALYSIS

This is an exploratory trial implementing a community-based child oral health promotion intervention for Australian families from refugee and migrant backgrounds. Families from an Iraqi, Lebanese or Pakistani background with children aged 1-4 years, residing in metropolitan Melbourne, were invited to participate in the trial by peer educators from their respective communities using snowball and purposive sampling techniques. Target sample size was 600. Moreland, a culturally diverse, inner-urban metropolitan area of Melbourne, was chosen as the intervention site. The intervention comprised peer educator led community oral health education sessions and reorienting of dental health and family services through cultural Competency Organisational Review (CORe).

ETHICS AND DISSEMINATION

Ethics approval for this trial was granted by the University of Melbourne Human Research Ethics Committee and the Department of Education and Early Childhood Development Research Committee. Study progress and output will be disseminated via periodic newsletters, peer-reviewed research papers, reports, community seminars and at National and International conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12611000532909).

Middle school student attitudes about school drinking fountains and water intake

OBJECTIVE

To describe middle school student attitudes about school drinking fountains, investigate whether such attitudes are associated with intentions to drink water at school, and determine how intentions relate to overall water intake.

METHODS

Students (n = 3211) in 9 California middle schools completed surveys between 2009 and 2011. We used multivariate linear regression, adjusting for school sociodemographic characteristics, to examine how attitudes about fountains (5-point scale; higher scores indicating more positive attitudes) were associated with intentions to drink water at school and how intentions to drink water at school were related to overall water intake.

RESULTS

Mean age of students was 12.3 (SD = 0.7) years; 75% were Latino, 89% low income, and 39% foreign born. Fifty-two percent reported lower than recommended overall water intake (<3 glasses/day), and 30% reported that they were unlikely or extremely unlikely to drink water at school. Fifty-nine percent reported that school fountains were unclean, 48% that fountain water does not taste good, 33% that fountains could make them sick, 31% that it was not okay to drink from fountains, and 24% that fountain water is contaminated. In adjusted analyses, attitudes about school drinking fountains were related to intentions to drink water at school (β = 0.41; P < .001); intentions to drink water at school were also associated with overall water intake (β = 0.20; P < .001).

CONCLUSIONS

Students have negative attitudes about school fountains. To increase overall water intake, it may be important to promote and improve drinking water sources not only at school but also at home and in other community environments.

Effect evaluation of an oral health promotion intervention in preschool children

OBJECTIVE

This study evaluates the effectiveness of a multi-component oral health intervention in preschool children in a non-randomized intervention study with a complementary baseline control.

METHODS

Participants in the main study were 2137 children born between October 2003 and July 2004 in Flanders, Belgium. In the intervention group (50.5% of participants), an oral health education program was added to a standard preventive care program during the first 3 years of life. Oral health examinations were performed by trained dentists when the children were 3 (2007) and 5 (2009) years old. Data on dietary habits, oral hygiene habits and dental attendance were obtained through structured questionnaires. Regression analyses were applied to compare the results of the intervention and control group with baseline measurements obtained before the intervention (2003) in other cohorts of 3- (N = 1291) and 5-year-olds (N = 1325) living in the same regions.

RESULTS

The prevalence of caries experience was generally lower in the main study compared with the baseline cohorts, with little differences between the intervention and control group. For the oral health-related behaviours, the control group scored mostly better. Nevertheless, compared with baseline, limited differences were observed in dental attendance, tooth brushing, helping with tooth brushing and consuming in-between drinks (P < 0.05).

CONCLUSION

The study illustrates that a multi-component, theory-based intervention at community level had only a limited and temporary effect on oral health-related behaviours in the community under study. Further research is needed to determine how oral health in young children can be improved in the long term.

Cluster-randomized trial of infant nutrition training for caries prevention

The objective of this study was to estimate the caries impact of providing training in infant feeding guidelines to workers at Brazilian public primary care clinics. In a cluster-randomized controlled trial (n = 20 clinics), health care workers either were trained in guidelines for infant nutrition, stressing healthful complementary feeding, or were assigned to a 'usual practices' control, which allowed for maternal counseling at practitioner discretion. Training occurred once; the amount of counseling provided to mothers was not assessed. Eligible pregnant women were enrolled to follow health outcomes in their children. Early childhood caries (ECC) was measured at age three years (n = 458 children). The overall reductions in ECC (relative risk, 0.92; 95%CI, 0.75, 1.12) and severe ECC (RR, 0.87; 95%CI, 0.64, 1.19) were not statistically significant. There was a protective effect among mothers who remained exclusively at the same health center (S-ECC RR, 0.68; 95%CI, 0.47, 0.99) and among those naming the health center as their principal source of feeding advice (S-ECC RR, 0.53; 95%CI, 0.29, 0.97). Health care worker training did not yield a statistically significant reduction in caries overall, although caries was reduced among children of mothers more connected to their health centers.

The Parental Dental Concerns Scale (PDCS): its development and initial psychometric properties

OBJECTIVES

To assess the validity and reliability of a Parental Dental Concerns Scale (PDCS) to identify parents unable to access preventive dental care for their children.

METHODS

Two studies were conducted. In Study One, a purposive convenience sample of 399 Scottish parents answered questions on going to the dentist, family life and demographics. Parents were retested eight weeks later. In Study Two, 574 Scottish parents participating in a preventive oral health programme were posted the same questionnaire. Information on child dental attendance was gained from dental records. Data were analysed using exploratory (EFA) and confirmatory (CFA) factor analysis. Internal consistency and test-retest correlations provided reliability estimates. Validity was assessed with confirmatory factor analysis, correlations and independent t-tests.

RESULTS

EFA indicated that the PDCS had a four factor structure, supported by a subsequent CFA. The PDCS and its four subscales had good internal consistency, concurrent validity and test-retest reliability. Further work is required to confirm the scale's predictive validity in discriminating between children and parents who did and did not attend the dental practice.

CONCLUSIONS

The PDCS is a reliable scale, which demonstrates good construct validity. Further testing is required to confirm its predictive validity.

Peer support and exclusive breastfeeding duration in low and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To examine the effect of peer support on duration of exclusive breastfeeding (EBF) in low and middle-income countries (LMICs).

DATA SOURCES

Medline, EMBASE, and Cochrane Central Register for Controlled Trials were searched from inception to April 2012.

METHODS

Two authors independently searched, reviewed, and assessed the quality of randomized controlled trials utilizing peer support in LMICs. Meta-analysis and metaregression techniques were used to produce pooled relative risks and investigate sources of heterogeneity in the estimates.

RESULTS

Eleven randomized controlled trials conducted at 13 study sites met the inclusion criteria for systematic review. We noted significant differences in study populations, peer counselor training methods, peer visit schedule, and outcome ascertainment methods. Peer support significantly decreased the risk of discontinuing EBF as compared to control (RR: 0.71; 95% CI: 0.61-0.82; I(2) =92%). The effect of peer support was significantly reduced in settings with >10% community prevalence of formula feeding as compared to settings with <10% prevalence (p=0.048). There was no evidence of effect modification by inclusion of low birth weight infants (p=0.367) and no difference in the effect of peer support on EBF at 4 versus 6 months postpartum (p=0.398).

CONCLUSIONS

Peer support increases the duration of EBF in LMICs; however, the effect appears to be reduced in formula feeding cultures. Future studies are needed to determine the optimal timing of peer visits, how to best integrate peer support into packaged intervention strategies, and the effectiveness of supplemental interventions to peer support in formula feeding cultures.

A community-randomized controlled trial against sugary snacking among infants and toddlers

OBJECTIVES

We evaluated the impact of educational interventions on sugary snacking in infants and toddlers in Tehran, Iran.

METHODS

A 6-month intervention was integrated into health staff duties. We assigned 12- to 15-month-olds (n = 242) and their mothers attending the vaccination offices of 18 randomly selected public health centers into the following groups: pamphlet and reminder (A), pamphlet only (B), and one control group (C). The mothers were interviewed at baseline and after follow-up. We recorded the frequency of sugary snacking for both the children and their mothers and calculated changes over 6 months. A reduction in the children's snacking frequency indicated a positive outcome. The family's residential area (affluent/nonaffluent) indicated its socioeconomic level. Associations between the children's and their mothers' snacking frequency were assessed by means of Spearman correlation. The outcomes of each intervention group were compared separately to those of the control group by means of the Mann-Whitney test. In addition, we performed intention to treat analysis. Factors related to a positive outcome were explained by means of logistic regression models.

RESULTS

In all groups, the child's and mother's snacking at baseline correlated (r = 0.4). A positive outcome was found for 62% of the children in group A and for 49% and 32% in groups B and C, respectively. In group A, a reduction in the children's snacking frequency was found despite their residential area (P < 0.05). Controlling for intervention effects, the logistic regression model showed that residential area was unrelated to the positive outcome.

CONCLUSIONS

Oral health education with reminders provided to mothers by general health staff is a valuable tool for reducing sugary snacking in infants and toddlers in a country with developing oral health systems.