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Review Article

Infant Formula and Early Childhood Caries

Abstract Saudamini Girish

The prevalence of early childhood caries  (ECC) is increasing worldwide. Impaired oral health More,
could have a negative impact on the overall health of infants. ECC can continue to deteriorate the Roopali
growth and development of the child in preschool stage. Feeding practices largely influence the
occurrence of ECC. Infant formula is commonly used as supplements or substitutes for breast milk Sankeshwari,
up to the first 2  years of age. The dietary sugars such as lactose and sucrose, present in the infant Pratibha A. Patil,
formula, could act as a favorable substrate and change the oral microflora. Infant formula constitutes Sagar S. Jalihal,
of various minerals which are known to affect tooth mineralization including iron, fluoride, and Anil V. Ankola
calcium. A  number of in  vitro, animal, and human studies have been conducted to understand their Department of Public Health
effect on oral environment and microbiota. Exploring the scientific literature for different types of Dentistry, KAHE’s KLE VK
infant formula and their role in the etiopathogenesis of dental caries could give us an insight into the Institute of Dental Sciences,
cariogenic potential of infant formula. Furthermore, this could be source of information for health Belagavi, Karnataka, India
practitioners as they are the ones who are first sought by parents for advice related to infant feeding.

Keywords: Dental caries, infant formula, infant oral health, sucrose

Introduction and infant formulas act as favorable

Early childhood caries  (ECC) is considered
to be the most prevalent disease and
contributes to unmet health needs among
children.[1] ECC is defined as the presence
of one or more decayed  (noncavitated
or cavitated), missing due to caries, or
filled tooth surfaces in any primary tooth
in a child aged 71  months or younger.[2]
Dental caries is a disease of multifactorial
etiology.[3] The key microorganisms
causing ECC is mutans streptococci  (MS)
which comprise Streptococcus mutans and
Streptococcus sobrinus while the other
microorganisms include Lactobacillus and
Streptococcus sanguis.[4] Other common
factors for causing ECC include feeding
during the night, frequency of exposure
to foods, and foods having higher sucrose
content.
The World Health Organization has
recommended feeding infants with human’s
milk and infant formulas up to the age of
2 years. Bovine milk can only be introduced
after 6  months of age.[5] However, there
exists a discrepancy of opinion between
pediatricians and dentists regarding the
duration of infant feeding.[6] This is mainly
substrate for initiation of dental caries.
Hence, this review compiles the literature
about infant formula and its possible
contribution in dental caries formation.
Methodology
A literature search was carried out on infant
formula and its role in the causation of
ECC. PubMed/Medline and Google Scholar
databases were searched using the following
keywords: “infant formula,” “dental caries,”
“early childhood caries,” and “infant
feeding.” A total of ten articles which
were found relevant from January 1993 to
October 2017 are included in the review.
Infant Oral Microbiota
Address for correspondence:
The microbiota inhabiting in the oral cavity Dr. Saudamini Girish More,
Department of Public Health
and other parts of the gastrointestinal  (GI)
Dentistry, KAHE’s KLE VK
tract develops from sterility at birth into the Institute of Dental Sciences,
most heavily colonized parts of the human Belagavi ‑ 590 010,
Karnataka, India.
body.[7] Different environmental conditions
E‑mail: drsaudamini90@gmail.
can lead to distinct bacterial communities com
at the different anatomical niches of the GI
tract. There are over  700 taxa which have
been identified in the colon and mouth. Access this article online
However, minimal species overlap between
the two sites.[7]
Website: www.jdrr.org

because the sugars present in breast milk DOI: 10.4103/jdrr.jdrr_11_18

Establishment of stable bacterial Quick Response Code:
This is an open access journal, and articles are distributed ecosystems in the GI tract, including the
under the terms of the Creative Commons Attribution-
NonCommercial-ShareAlike 4.0 License, which allows others mouth, evolves during a period of microbial
to remix, tweak, and build upon the work non-commercially,
as long as appropriate credit is given and the new creations How to cite this article: More SG, Sankeshwari R,
are licensed under the identical terms. Patil PA, Jalihal SS, Ankola AV. Infant formula and
For reprints contact: reprints@medknow.com early childhood caries. J Dent Res Rev 2018;5:7-11.

© 2018 Journal of Dental Research and Review | Published by Wolters Kluwer ‑ Medknow 7

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More, et al.: Infant formula and early childhood caries
variation chiefly during the first 2 years of life.[8] The initial
colonizers are facultatively anaerobic in genera, such as
streptococci and Actinomyces. These are succeeded by
more strictly anaerobic genera, such as Bifidobaterium in
the gut and Veillonella in the mouth.[4]
Infant Formula
It is an alternative to breast milk for feeding the child
and is obtained from other human  (surrogate mothers) or
another mammal. The most frequently used sources include
the cow, sheep, and goat.[9]
Numerous health organizations, including the World
Health Organization  (2002), the American Academy
of Pediatrics  (1997), the American Academy of
Family Physicians  (2003), and various others, promote
breastfeeding as the ideal form of nutrition for infants
during the 1st  year of life. Even so, a vast majority of
infants in various parts of the world are fed human’s milk
substitutes since the age of 6  months.[9] Even though these
food sources are inferior to human’s milk in multiple
respects, it promotes more efficient growth, development,
and nutrient balance than commercially available cow’s
milk. It is recommended that infants who are not breastfed
should consume iron‑fortified infant formulas rather
than cow’s or goat’s milk until 12  months of age by the
American Academy of Pediatrics.[8]
Infant formulas can be used as substitutes or supplements
for human’s milk. Infant formulas are commonly
recommended in low birth weight babies, cases of
malnutrition, emergency situations such as famines,
vulnerable groups, HIV‑positive mother, and lactose
intolerant babies.[8]
Infant formulas are of two types: cow’s milk‑based
formulas and noncow’s milk‑based formulas. Table 1 shows
the history and development of infant formula.[8]
By the early 20th  century, it was clear that cow’s milk was
most likely the best animal‑milk base to work with but
that certain modifications were needed to make it safe and
palatable for human infants. These modifications included
removing animal fat and substituting vegetable oils,
diluting the protein content for the newborn’s relatively
immature renal tubular system, and adding or balancing
minerals and vitamins  (e.g., adding iron, adjusting the
calcium:phosphorus ratio).[8]
Essential Composition
Infant formula is a milk‑based product obtained from cows
or other animals or a mixture of other ingredients which
have been proven to be suitable for infant feeding. All
ingredients and food additives should be gluten free. Infant
formula prepared ready for consumption in accordance
with instructions of the manufacturer should contain per
100  ml not  <60 kcal  (250 kJ) and not  >70 kcal  (295 kJ)
8 Journal of Dental Research and Review | Volume 5 | Issue 1 | January-March 2018
Table 1: History of the development of milk formulas
Year Constituents added to infant formula
Cow’s milk‑based formulas
1867 Formula contained wheat flour, cow’s milk, malt
flour, and potassium bicarbonate
1915 Formula contained cow’s milk, lactose, oleo oils,
and vegetable oils in a powdered form
1935 Protein content of formula was taken into
consideration
1959 Formula fortified with iron
1960 Formula was concentrated to reduce the renal load
1962 Whey: Casein ratio was made similar to human’s
milk
1984 Taurine fortification introduced
Late 90s Nucleotide fortification was done
Early 2000s Long‑chain polyunsaturated fatty‑acid fortification
introduced
Noncow’s milk‑based formulas
1929 Introduction of commercially available soy
formula (soy flour)
Mid 1960s Isolated soy protein introduced
of energy.[9] The composition of infant formulas includes
protein, lipid, carbohydrate, linoleic acid, vitamins, and
minerals in standardized ranges. When prepared according
to the label directions for use, the product should be free
of lumps and of large coarse particles and suitable for
adequate feeding of young infants. The ingredients should
be clean, of good quality, safe and suitable for ingestion by
infants. Furthermore, the normal quality requirements, such
as color, flavor, and odor, are assessed. Various thickeners
and acidity regulators are also added to it. The product and
its component should not have been treated by ionizing
irradiation. Thus, the nutritional safety and adequacy of the
formula should be scientifically demonstrated to support
growth and development of infants.[9]
The carbohydrate content in infant formula is
predominantly distributed among lactose, sucrose, maltose,
or glucose. Formulas highest in sucrose are alternatives
to lactose‑containing milk‑based formulas. The grams of
total sugars per serving ranged from 1.28 to 11.16 g. Some
products are found to be containing 12  g of sugar per
serving.[10]
Various in vitro studies conducted on rat teeth [Table 2] and
human teeth [Table 3] have tried to evaluate the cariogenic
potential of infant formulas. Some in vivo studies [Table 4]
have also tried to compare the cariogenic potential of
commercially available infant formulas.
Breast milk provides nutrition for the infant and
is a source of lactobacilli, Bifidobacteria, and
streptococci.[21,22] However, components of breast
milk inhibit growth and attachment of the cariogenic
bacteria, S. mutans in particular.[22] A study conducted by
Holgerson et al.[23] revealed that the Lactobacillus counts
in the oral cavity were higher in breastfed as compared to
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More, et al.: Infant formula and early childhood caries

Table 2: Studies conducted on rats

Study
Bowen and Pearson, 1993[11]
Bowen et al., 1997[12]
Erickson et al., 1998[13]
Peres et al., 2002[14]
Bowen and Lawrence, 2005[15]
Peres et al., 2009[16]
SDW: Sucrose added to sterile distilled water
Materials compared Inferences
10% sucrose and cow’s milk 10% sucrose significantly more cariogenic than
cow’s milk
5% sucrose, cow’s milk, Lactofree, Isomil, Highest caries ‑ sucrose water
carnation follow‑up, Gerber with soy, Similac Have significant cariogenic potential ‑ Gerber Baby
low iron, Gerber low iron, ProSobee, Nursoy, formula with soy, Gerber Baby formula low‑iron,
Nutramigen and Similac low‑iron infant formula
High amounts of sulcal and smooth surface caries
observed in low‑iron formulas
Lowest scores: Carnation follow‑up (carnation),
ProSobee (Mead Johnson Nutritional), Lactofree
(Mead Johnson Nutritional), 2% milk, and water
groups
Control solutions: Water, sucrose cow’s whole milk The carbohydrate content of all the infant formulas
Iron‑containing formulas was higher than cow’s whole milk
Low‑iron formulas Caries progression in dentin and pulp significantly
higher than cow’s whole milk
Soy‑based formulas
Maximum calcium dissolution seen with soy‑based
Special formulas
formulas
Protein formulas
5% sucrose, cow’s milk, and Cariogenic potential: Sucrose water > Ninho > Nan
commercially available infant formulas 2 > cow’s milk
(Nan 2, Nestogeno 2, Ninho growth supporting)
10% sucrose, cow’s milk, and human’s milk Cariogenic potential: 10% sucrose > human’s milk
> cow’s milk
5% SDW, cows’ milk, human’s milk, and Ninho Cariogenic potential: Ninho formula, 5% sucrose
formula reconstituted with SDW water > human’s milk > cow’s milk

Table 3: In vitro studies conducted on human teeth

Study Parameters assessed Methods Inferences
Hinds et al., 2016[17] S. mutans cultured in TSB 11 commercially available infant formula Cariogenic potential: Sucrose‑based
and biofilm formation at 9 dilutions: 1:5, 1:10,1:20, 1:40, 1:80, formulas > lactose based > formulas
1:160,1:320, 1:640, and 1:1280 containing ferric chloride
Sucrose, lactose, and ferric chloride at Cariogenic potential: Low‑iron formulas
representative concentrations > normal iron containing at dilution of
1:5 adding Fe further did not reduce
the S. mutans biofilm formation
TSB: Tryptic Soy Broth without Dextrose, S. mutans: Streptococcus mutans

Table 4: Studies on human participants

Study
Munshi et al., 2001[18]
Masih et al., 2010[19]
Raju et al., 2012[20]
Methods
Test: 7 regular infant formulas and 7 special
infant formulas (lactose free)
Control: Whole bovine milk
Plaque pH drop after 5, 20, and 30 min
Five commercially available infant formulas
compared: Farex, Lactodex, Lactogen,
Nestogen, and Nan with sucrose
Inferences
11 infant formulas show significant reduction of pH than
prerinse
Lactofree formulas produced plaque pH changes below critical
pH
Sucrose and corn syrup formulas more cariogenic
Cariogenic potential: Sweetened milk > Amulspray > Lactogen
2 > Lactodex 2 > Plain milk
No significant differences with respect to mean postrinse plaque
pH after 1 h
Least buffer capacity by Nestogen and highest by
lactose‑containing formulas

formula‑fed infants. They also concluded that lactobacilli that formula‑fed infants were at higher risk of developing
species had an inhibitory effect on MS. This suggested dental caries. A  systematic review compared various

Journal of Dental Research and Review | Volume 5 | Issue 1 | January-March 2018 9

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More, et al.: Infant formula and early childhood caries
commercially available infant formulas; however, limited
evidence was found regarding the cariogenic effect of
infant formulas.[24]
Effect of Fluoride
Fluoride has been established as a caries‑preventing
agent when used in systemic or topical formulations.
Evidence from studies conducted in the USA, Australia,
and Brazil suggests that there is a higher concentration
of fluoride in infant formulas.[25,26] Some studies
have also reported that formula fed infants had lesser
caries prevalence as compared to nonformula fed.[27,28]
However, in a study conducted by Peres et  al.,[14] the
MS counts were higher in Wistar rats which were given
fluoride‑supplemented infant formulas as compared to
human’s or cow’s milk. This was mainly attributed to
higher concentration of sucrose and reducing sugars
present in the infant formulas. A  study has shown that
the fluoride level in infant formulas available in India
is slightly less than the optimal fluoride requirement in
milk.[29]
Cariogenic Potential of Human’s Milk and
Cow’s Milk
The prevalence of dental caries caused by cow’s milk is
relatively low as compared to human’s milk. In comparison
with cow’s milk, breast milk has a low mineral content,
higher concentration of lactose  (7% vs. 3%), and lower
protein content (1.2 g/100  ml vs. 3.3 g/100  ml).[30] Thus,
cow’s milk could have a better remineralization potential
of teeth.
Cariogenic Potential of Infant Formulas
Carbohydrates used in formula are mainly sucrose and
lactose. Sucrose is considered to be the most cariogenic
dietary carbohydrate, fermentable by the oral bacteria.
This process results in reduction of pH in the oral cavity
causing dental caries. It also acts as a substrate for the
formation of extra‑  and intra‑cellular polysaccharides
in dental plaque. These biofilms have more cariogenic
potential. Lactose is less readily fermented by S. mutans
as compared to sucrose.
Conclusions
Various studies conducted showed that infant formulas
containing sucrose and/or corn syrup solids are
more acidogenic and hence more cariogenic than
lactose‑containing formulas. Furthermore, in the study
conducted by Erickson et  al.[13] which compared the
cariogenic potential of different infant formulas, sucrose
water, and bovine milk, it revealed that bovine milk was
least cariogenic. Formulas containing casein are proven to
be less cariogenic than others. Low‑iron formulas can cause
increase in the S. mutans biofilm formation as compared to
normal iron containing at dilution.
10
Recommendations
Health practitioners should take into consideration the
composition of infant formula before recommending them.
Since pediatricians and dentists are more likely to see
infants and toddlers, they are in a better position to advice
parents regarding early initiation of oral hygiene practices
for the prevention of ECC.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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